Category Archives: Flight Safety

Safety Corner: September

Safety Corner

Warren Le Grice

Mid Air Collisions

A mid-air collision is probably a pilot’s worst nightmare, and is the main reason that air traffic
control exists. Mid-airs are the result of a loss of situational awareness on the part of one, or both of the pilots involved. These accidents are often preceded by either a breakdown in
communication or a total absence of it.

I will relate two of my own near-miss experiences, in this article, and discuss two fatal
accidents in which I knew the pilots involved.

Incident #1

The first close call that I experienced, was at Penticton in the spring of 1969. I was flying a Champion Tri-Traveller with my younger brother as my back seat passenger. We had just landed CF-XNE on runway 34. I needed to taxi back to the Penticton Flying Club hangar where the airplane was tied down, so we moved over to the left side of the runway and I did a 180 degree turn to taxi back towards the runway threshold.

Now in 1969 there was no such thing as a MF (Mandatory Frequency). That would come as a result of the PWA crash at Cranbrook  1989.  Pentiction  Aeradio, where I worked at the time,  provided an airport advisory service on 122.2 mhz. I had called in and announced my intentions and received the airport advisory, I did not hear any other aircraft on the frequency. We at the Aeradio Station, were well aware of a mid-air collision that had occurred in April of 1963, when eight people were killed in a mid-air between an  Aero Commander Twin, and a Cessna 140 over Skaha Lake, while both aircraft were on approach to runway 34.

As I taxied towards the threshold of runway 34, I noticed a Stinson Voyager about a mile final, and above him and slightly behind, was a Cherokee, which was owned by the same flying school as the airplane I was flying. I said to my brother “look at those guys on final”. As the Stinson was starting to round out for its landing, the Cherokee’s right gear leg contacted the Stinson’s starboard wing, and I noticed  bits of fabric being torn off  and the Stinson contacted the pavement quite firmly. The Stinson pilot was able to maintain control of his machine and continued to taxi straight ahead. The Cherokee pilot, who as it turned out, was a student pilot on his first solo, then turned  to the left and added power in order to do a go around. This action took him on a heading towards our airplane. I turned right towards the VASIS lights located on the grass, left of the runway, to avoid being hit.

The student pilot then banked right and climbed away and did another successful circuit and landed with a bent right undercarriage. The Stinson had major damage to the right wing and the pilot luckily was not injured.  It was a classic high-wing, low-wing situation, compounded by the fact that nether pilot was aware of the other aircraft, as there was no radio communication.  I believe the student pilot never came back for any more lessons, both aircraft would be written off in later years and the flying school crashed themselves out of business within two years.

Incident # 2

Approximately ten years later, I was now a Terminal Controller at the VR ACC. I was flying my Arrow CF-UKE, the aircraft I mentioned in a previous article. I was giving instrument dual to my friend Rick Quiring, who had been my OJI ( On Job Instructor) in Terminal. We had filed IFR and were going to Victoria to do and ILS on runway 26 ( the movement of the magnetic north pole, would necessitate renumbering the runway several years later), then a missed approach back to Vancouver, where we kept the machine. It was a summer evening and the weather at Victoria  was about 1800 feet broken and 20 miles visibility, very stable air and no precipitation.

We had flown the transition from the Victoria VOR over to the Victoria NDB which was at that time located on Sidney Island, about 4 miles on final for RWY 26. We received our approach clearance from Vancouver Terminal. Just prior to procedure turn, we were changed over to YJ tower, and on initial contact with the Tower there was no mention made of any other aircraft. As we were intercepting the localizer inbound, we broke out at the bottom of cloud base. The next thing I saw were three bright lights climbing up towards us.

I took the controls from Rick said “ I have control” and we did a right descending turn. Once we got sorted out again and back the ILS, I told the Tower we had just passed a jet going the opposite direction.  The tower had departed the aircraft on runway 08, unbelievable! The reply I got was “ Oh, he is VFR going for an approach”. I replied that the aircraft which turned out to be a British Midlands 737 couldn’t have been VFR as we were IMC during procedure turn. Very dangerous  behaviour on the part of the tower controller and of the pilot of the 737. You cannot make this kind of stuff up!

Had we not broken clear of cloud when we did, we would have collided for sure. Now days that type of incident would have resulted in a TSB investigation and action by Transport Canada.   There were three of us on board that evening, as we also had another VR Terminal controller with us, so had the 737 got us, it would have taken out about 15% of the VR Terminal staff in one fell swoop.

Incident # 3

The mid-air collision which occurred on November 20, 1999, in CYA125(T)  is well documented as report  # A99P0168 by the TSB. The mid-air involved a C152 operated by Pacific Flying Club and a privately owned Aircoupe owned and flown by one of  my two friends Alvin and Stan out of Langley. Alvin was an instructor at BCIT in Burnaby, and Stan was a retired CP Air engineer. The C152 had a young instructor on board and a 15 year student pilot who was working on his recreational license.

CYA125(T) was a Class F special use airspace, located over  Surrey, and the north portion of that airspace infringed on the localizer for runway 26 at Vancouver. It was capped at 2000 feet, which meant as terminal controllers we couldn’t come below 2500 feet with light and medium weight IFR aircraft, and 3000 feet for heavy jets. This certainly affected operations when Rwy 26 was active at Vancouver.  The airspace was a bit of a nuisance from an IFR perspective, and we used to comment on the number of aircraft, that we observed, jammed into that airspace on a good VFR day. It really was an accident waiting to happen.

I remember the day of the accident well. It occurred late in afternoon on a November weekend. It was the first day of reasonable weather, following a dismal week, of almost constant rain. The weather improvement created an opportunity for many pilots to finally go flying. Transport Canada was aware of the elevated risk,  that CYA125 posed to VFR aircraft. Numerous flying training aircraft, were squeezed into only really 1500 feet of vertical airspace. Following the accident, in which all four persons were killed, Transport Canada eliminated the special use airspace, and PFC installed flashing landing lights on all their aircraft.

Incident # 4

The last accident occurred over Nairn  Falls Provincial Park, four miles SW of the Pemberton Airport on June 29, 2013. The aircraft involved were a Stemme S10 motor glider and a C150. The motor glider was being flown by a friend of mine Rudy, who was my one of my instructors, when I was flying gliders at Pemberton, a number of years ago. Rudy was operating his motor glider operating scenic flights on the day of the accident. Rudy was an experienced glider and powered aircraft pilot, with over 3,000 hrs of flight time.

Weather permitting, the scenic flights involved taking passengers, one at a time, out west of the airport and over the Ipsoot Glacier, to an altitude of 8400 feet, a really spectacular flight.  The engine would be shut down at altitude and the propeller stowed and the aircraft would become a sailplane for the descent and landing.

Rudy’s business, Pemberton Soaring, was a real grass roots operation, he slowly built up his glider fleet from one Blanik L33 and a Bellanca Scout towplane, into several sailplanes. Over the few years, rental pilots and one of his own tow pilots wrote-off  most of his aircraft, to the point where he was only operating the Stemme motor glider.

A sailplane requires rising air, in order that the flight become anything other than a sled ride. In the Pemberton area, that would require flying relatively close to terrain, in search of rising boundary layer air. Rudy would likely have been using that method on his descent to the airport. As he rounded the mountain side above the Nairn Falls Park, he encountered opposite direction traffic.

The Cessna 150 which was on a VFR flight plan, from Lillooet to Nanaimo had on board a man, his wife and their dog. The pilot had a Private License and 127 hours of flight time. There is an ATF frequency at Pemberton on 123.2 mhz. Rudy had made a radio call inbound to the field, which was heard by witness, but the witness did not recall hearing the Cessna pilot make any transmissions.

The sailplane when viewed head on, would have presented a very small profile to the C150 pilot. The long nose of the sailplane, combined with the view from the semi reclining seats in the sailplane, would have made it difficult to see the Cessna below. Both pilots likely thought they had the sky to themselves. The collision resulted in both aircraft shedding a wing each  and the wreckage spiralling down amongst people  in the campsite below. None of the four people in the two aircraft, survived the accident.

Back at the airport, the other two members of the family of the young boy, who was the passenger in the motor glider, were waiting for their turn at a scenic flight.

Rudy left a wife and two teenage sons. There is plaque located in the picnic grounds on the Pemberton Airport, which was placed in honour of Rudy.

Mid-air collisions remain a very threat, however we can mitigate risk by a number of means.

  • Effective communication is essential, ensuring you are on the correct frequency, particularly at uncontrolled airports.
  • When flying cross country, get into the ATC system as soon as possible, you can do so by requesting flight following, and getting the benefit of radar traffic.
  • Keep your eyes outside as much as possible in VMC, and don’t get distracted by Ipads and such. Avoid non-essential conversations. Sterile cockpits exist for a reason.
  • Just because you don’t hear other traffic on the frequency and don’t see anyone, doesn’t mean you are all alone out there. Be aware of special use airspace.

 

Fly professionally and make good decisions.

Fuel contamination and why take the chance?

From BoldMethod:

https://www.boldmethod.com/learn-to-fly/systems/fuel-sump-contamination-engine-failure/?fbclid=IwAR0hyv-RiGdeniONTTvwySYaU5BmSHxA52VdtJ-oZLKUv0u7bRrQUhiySBc

Contaminated fuel on the ground can lead to a serious problem in the air

Pulled from a 2017 NASA ASRS Report, the following events occurred when a student pilot and instructor experienced an engine failure on rotation during takeoff…

During a “long cross country” training flight to meet the experience requirements for a Private Pilot Certificate an engine failure occurred at the moment of rotation. Our takeoff was aborted and the aircraft was safely taxied off the runway using remaining energy. After examination of the aircraft, a large amount of water was removed from the gascolator. Both fuel tank sumps produced no water at all.

During the previous 4 weeks, it had been raining unusually in the area. The incident aircraft had been parked in a steeply inclined parking space (nose down) for the previous 4 days without being flown. Two weeks prior to this incident, I was conducting an initial flight lesson for a new student in a C152. While sumping the gascolator, the sample did not have the blue color of 100LL fuel, and the fuel smell was slightly less than usual. It was only after a very careful inspection which lasted more than 20 seconds (and by sumping an additional sample from a known-good fuel tank) that it was determined the sample cup initially contained only water.

According to a secondary report, “while it was initially determined that the student pilot and instructor failed to notice the water contamination and the lack of blue dye in the sample cup, hours later it was realized that the samples were taken while the aircraft was parked nose-down on a steep incline. It is highly possible that the water was located in the forward portion of the fuel tanks and did not enter the fuel system until the aircraft was moved to level ground.”
What Happens When Fuel Mixes With Water?

According to Dror Artzi, an experienced 40-year aeronautical engineer, aircraft engines will tolerate a small amount of free water (read his entire presentation published by AOPA here). When water concentration is 30ppm, that’s 30 grams per 1000 Kg. This is usually considered to be the maximum an engine can handle.

Your engine may not fail right away when running on contaminated fuel. The first indications will likely be sputtering and a generally rough-running engine. Once enough water is mixed with fuel, combustion is no longer possible. Water is the most common contaminant in aviation fuel. Because water it’s denser than 100LL, you’ll find water settling to the lowest part of the tank. Here’s what it may look like in your sump cup…

How Can Water Get Into Your Fuel Tanks?

There are a few common reasons you may notice water in your fuel system. Here are the top causes:

Contaminated Fuel Source: The tanks where avgas, or 100LL, are stored are susceptible to water contamination. Poor storage in fuel farms, trucks, or self-serve tanks could lead to water appearing in your fuel.
Condensation: Over a period of time with temperature fluctuations, condensation inside your fuel tanks will develop water droplets. With enough time and the right conditions, you could end up with substantial amounts of water in your tanks.
Improper Fuel Tank Seals: When the filler neck of a fuel tank isn’t sealed properly by a fuel cap, water can seep in quite quickly. After heavy rain, you could find literally gallons of water in your tanks if you have bad

What You Can Do.

If you find water contamination in your fuel, keep sumping the tanks until the fuel is the correct color and water-free. Try gently rocking the wings or raising/lowering the tail to move excess water to the drain points. And when you do your engine run-up, take extra time to make sure your engine is running smoothly.

Never skip sumping your fuel tanks during preflight. If your plane sits on a steep slope, move the aircraft to level ground, wait around 10 minutes, and re-sump the fuel. If you notice excessive contamination, it might be time to get a certified mechanic involved.

Safety Corner: Plan Continuation Bias

“ Plan continuation bias”, by Warren Le Grice

Welcome to the “ Safety Corner”. I used to write a similar column, when I was a member of the Boundary Bay Flying Club. I have been involved in the promotion of flight safety for many years and will continue to do so with the AFC.

In the early 1990s, when the ATC system was still operated by Transport Canada, I had an opportunity to participate in a 20 month secondment with System Safety Branch, as a Regional Safety Officer . At the time I was working as a Course Director in our Regional Training School at the VR ACC.

I was fortunate enough to work with an excellent mentor, during my time with System Safety, Vince Edwards, an experienced fixed wing and helicopter pilot. During my time with the Safety Branch, I developed a keen interest in human factors and why pilots make the decisions they make. I was tasked with delivering the PDM ( Pilot Decision Making) course to Flying Schools and Flying Clubs around  B.C. A side benefit to the secondment was the opportunity to receive dual on both Transport’s amphibious  Beaver C-FDTI and the Jet Ranger C-GCGQ.

With the preceding narrative as some background, I can now relate the story of my first aircraft partnership, what happened to the aircraft and one of my partners.

I controlled  at Vancouver Tower from 1971 to 1979, a very interesting airport to control  during that time period. My first aircraft partnership was in a 1968 Piper Arrow, CF-UKE. My four other partners and I purchased the airplane in 1979. I was able to build up my IFR experience in the airplane over the next couple of years and was able to give one of my partners, Dave, most of the dual he needed to get his instrument rating.

We had one good cross country from Carson City, Nevada, back to Vancouver, in the Arrow, as one of the partners got weathered in, and wisely decided to return to VR by airlines. Dave and I were able to  practice all the IFR approaches in the lower mainland and southern Vancouver Island, including Nanaimo. Now in the early 1980s Nanaimo had only one NDB approach which terminated at the YCD NDB, if you didn’t see the airport from the beacon inbound, you carried out the missed approach, so obviously the limits were quite high, probably about 1000 feet and 3 miles.

I do remember advising Dave to take it easy, and be careful as he built up his experience, after he achieved his instrument rating. The Arrow had only 2 VOR/ILs receivers, no DME and no de-icing capability was really just a fair weather IFR airplane. Unfortunately as he got more experience in the airplane, he would take on IFR flights that I wouldn’t attempt, and once told me about an icing experience he had going into Port Hardy.

In 1981 when the mortgage rate went to 19 ¼ on our home in Burnaby, I decided it was time to sell my share in the airplane. It would be approximately a year later when I heard on the news, that UKE had crashed into a mountain, south west of the Nanaimo airport. My first thought was, what was the airplane doing going into Nanaimo at night? We kept the airplane on the south ramp at Vancouver, so I couldn’t figure out what reason there would be for flying into Nanaimo at night, on that fall evening. I concluded the pilot must have been Dave, as he was the only IFR rated partner at the time.

I got the full story a couple of weeks later, from one of my ex partners who was an electronics  tech with Transport Canada. Dave was a keen bird hunter and had flown over to Alberta with his youngest daughter, to shoot geese and ducks around Brooks, Alberta. He had asked permission of a farmer to shoot on his property, and after the hunt was invited in for coffee. The farmer’s sister –in –law, was visiting from Port Alberni, having travelled out by Greyhound. When Dave was told she would be returning soon, he volunteered to fly the lady back as far as Nanaimo as he had a spare seat.

The aircraft was on an IFR flight plan to CD, and as is often the case, the weather was deteriorating in the lower mainland, as the flight progressed from Alberta. Dave was likely anticipating doing an approach in VFR conditions upon his arrival. Now we had never done a night landing at Nanaimo as part of training, and I don’t know if Dave had ever done one once he was on his own. As the flight progressed through the Vancouver Terminal airspace, and was approaching Nanaimo, UKE was cleared to the Nanaimo airport for an approach, radar service was terminated and a the frequency change to Nanaimo radio was given. During the early 1980s VR Terminal controlled both CD and YJ airports as well as VR as there wasn’t anywhere near the IFR traffic there is today.

The last communication from the aircraft to Nanaimo Radio was, “are the runway lights on? ” The aircraft failed to arrive and was located a day or so later, having flown into the side of a mountain located a few miles south west of the airport. The aircraft was in level flight, likely in cloud and hit a large tree almost head on, killing all three occupants instantly.

The accident was a classic CFIT ( Controlled Flight Into Terrain) situation, likely brought on by pilot fatigue, stress and not being prepared to do a non precision approach, following a long day.

There is an interesting side note to this story. A couple of years later at the Area Control Center, I was facilitating a series of  human factor workshops for all Transport Canada control and FSS staff in the province. The subject was “ Situational Awareness”, and the first question I asked each class was, had they ever had an experience where  loss of situational awareness had lead to an accident or incident? On different workshops, the Terminal controller who cleared UKE for the approach that night, and the Nanaimo FSS who last spoke to the aircraft, related their stories. The FSS member had the family of the passenger who was headed for Port Alberni, waiting at the counter in the FSS, for word of their family member. It was a tragic experience for all involved.

So what can we take away from this accident?

NASA has recently come up with a new term “ Plan Continuation Bias”. The premise is when the pilot has somewhere to get to, he or she ignores the environment. The more the person has invested in the plan, the less likely they are to change that plan. Another way of putting it would be to say when a journey is almost over, people tend to go into auto-pilot, ignore changing and potentially dangerous environmental factors.

Had my ex-partner decided as they approached his home base in Vancouver, “gosh I am tired, let’s just do the ILS onto runway 08  and we’ll put the lady in the back seat ,on a ferry tomorrow”, I have already saved her a very long bus ride”. Had that been the case, his wife would have grown old with her husband and younger  daughter and the older daughter would have had a Dad and a younger sister.

Know your aircraft’s limitations and more importantly know your own.

Fly professionally and make good decisions.