TSB Canada releases final report on Bombardier Global 5000 accident
published: November 10, 2009, 16:59 UTC
by Harro Ranter, ASN
Citing ineffective oversight by the Canadian Business Aviation Association (CBAA), the Transportation Safety Board of Canada (TSB) has released its final report into the 2007 landing accident in Fox Harbour, Nova Scotia. The accident injured 10 people when the Bombardier Global 5000 private jet skidded off the runway, stopping 1000 feet from its initial touchdown point, close to neighbouring homes.
In its investigation, the TSB reported that private operators regulated by the CBAA were not held to the same standard that Transport Canada (TC) implemented for commercial operators. TC regulations require commercial airline companies to implement safety management systems (SMS) in stages, on a fixed timeline, while the CBAA was free to implement SMS for its operators on its own terms with no fixed timeframe.
In 2003, TC transferred regulatory responsibility for some aviation operators to the CBAA but prior to this accident failed to exercise effective oversight of the CBAA programs.
In two key recommendations, the Board calls for the CBAA to set SMS implementation milestones for its certificate holders and for TC to ensure the CBAA has an effective quality assurance program in place to audit its certificate holders.
In the course of the investigation, the TSB also found that many pilots were not aware of the limitations of the visual guidance systems used to conduct safe approaches and landings. These guidance systems, known as visual glide slope indicators (VGSI), use ground-based light beams to show pilots when they are too high or too low on approach but many pilots don't realize that some VGSI should not be used when flying larger aircraft.
Information on the distance between the cockpit and the landing gear (eye-to-wheel height) is needed to know which VGSI to use but the Board revealed this information is not readily available to pilots.
To address these issues, the Board made two additional recommendations requiring TC to make eye-to-wheel height information available to pilots, and that better training also be provided to them on VGSI so they have the information they need to land safely. (TSB)
» TSB Report A07A0134
In its investigation, the TSB reported that private operators regulated by the CBAA were not held to the same standard that Transport Canada (TC) implemented for commercial operators. TC regulations require commercial airline companies to implement safety management systems (SMS) in stages, on a fixed timeline, while the CBAA was free to implement SMS for its operators on its own terms with no fixed timeframe.
In 2003, TC transferred regulatory responsibility for some aviation operators to the CBAA but prior to this accident failed to exercise effective oversight of the CBAA programs.
In two key recommendations, the Board calls for the CBAA to set SMS implementation milestones for its certificate holders and for TC to ensure the CBAA has an effective quality assurance program in place to audit its certificate holders.
In the course of the investigation, the TSB also found that many pilots were not aware of the limitations of the visual guidance systems used to conduct safe approaches and landings. These guidance systems, known as visual glide slope indicators (VGSI), use ground-based light beams to show pilots when they are too high or too low on approach but many pilots don't realize that some VGSI should not be used when flying larger aircraft.
Information on the distance between the cockpit and the landing gear (eye-to-wheel height) is needed to know which VGSI to use but the Board revealed this information is not readily available to pilots.
To address these issues, the Board made two additional recommendations requiring TC to make eye-to-wheel height information available to pilots, and that better training also be provided to them on VGSI so they have the information they need to land safely. (TSB)
11 NOV 2007, 14:34 Bombardier BD-700-1A11 Global 5000
C-GXPR - Jetport Inc.
0 / 10
Fox Harbour Airport, NS (Canada)
Executive flight, during Landing
Global 5000 C-GXPR departed Hamilton (YHM) at 11:53 EST on a flight to the Fox Harbour private airst... (more)
FINDINGS AS TO CAUSES AND CONTRIBUTING FACTORS:
1. The crew planned a touchdown point within the first 500 feet of the runway to maximize the available roll-out. This required crossing the threshold at a height lower than the manufacturer's recommended threshold crossing height (TCH).
2. The flight crew members flew the approach profile as they had done in the past on the smaller Bombardier Challenger 604 (CL604), with no consideration for the Global 5000 greater aircraft eye-to-wheel height (EWH), resulting in a reduced TCH.
3. The abbreviated precision approach path indicator (APAPI) guidance, although not appropriate for this aircraft type, would have assured a reduced main landing gear clearance of eight feet above threshold. At 0.5 nm, the pilot flying (PF) descended below the APAPI guidance, further reducing the TCH.
4. The pilot used the wing-low crosswind technique, increasing his workload and resulting in pilot-induced oscillations.
5. Both pilots' low experience on the Global 5000, combined with the PF's high workload, affected their ability to recognize the unsafe approach path and take appropriate corrective action.
6. With the aircraft in a low energy state, the pitch up to 10.6º without an associated thrust increase could not correct the flight profile, resulting in the impact with the sloped surface before the runway threshold.
7. The impact with the sloped surface initiated a sequence resulting in the collapse of the right main gear, a loss of directional control, the eventual departure from the runway surface, substantial damage to the aircraft, and some injuries.
8. Contrary to the manufacturer's recommended practices, Jetport's standard operating procedures (SOPs) sanctioned descent under electronic or visual glide slope guidance, with a view to extending the landing distance available as acceptable and good airmanship; this contributed to the aircraft landing short of the runway.
9. The lack of an effective transition from traditional safety management to a functional safety management system (SMS) as required by Jetport's private operator certificate (POC) prevented an adequate risk assessment of the introduction of the Global 5000 into its operations and contributed to the accident.
10. An inappropriate balance of responsibilities for oversight between the regulator, its delegated agency, and the operator resulted in Jetport's inadequate risk assessment not being identified.
