CAA: Airport News, "When the system breaks down"

["Stephen Irwin" <stepheni@cwnet.com>]

Saturday, June 10, 2000

When the system breaks down
Safety board files show 41 'incidents' at Ottawa airport in past two years
By Ian MacLeod
Canada - The Ottawa Citizen


The Canadian Airlines 737 passenger jet was en route to Ottawa from Toronto
when the captain spotted a wisp of smoke in the cockpit. Moments later, more
smoke and -- at an altitude of 23,000 feet -- the faint but unnerving smell
of something burning.

The flight crew radioed air traffic controllers about 160 kilometres away in
Ottawa and declared an emergency while the cabin crew warned passengers of
the situation.

The big jet got down safely. Later, maintenance inspectors found a burned
circuit board near the first officer's seat.

Just 14 days later, on April 20, 1999, it happened again. A Royal airlines
737 was preparing to land at Ottawa when three cockpit alarms warned of a
fire in the jet's auxiliary power unit.

The flight crew again declared an emergency, discharged a fire extinguisher
into the unit and ordered the flight attendants to prepare passengers for a
possible evacuation on landing.

Again, the plane landed without further incident. Evidence of a small fire
was found near the power unit.

The emergencies were among 41 "reportable incidents" at Ottawa's
Macdonald-Cartier International Airport in 1999 and 1998, Transportation
Safety Board files released to the Citizen show. Most of the more serious
incidents have never been made public.

They include a controller allowing a runway to be used for an incoming
flight without realizing an airport vehicle was parked on the runway.
Another controller spotted the danger and ordered the approaching commuter
jet to abort its landing.

Another time, an air traffic controller mistakenly directed two inbound
commuter jets too close to one another.

In two cases, the pilots of small planes and jets accidentally taxied onto
active runways or took off without permission.

And once, an Air Canada Airbus 320 accelerating for takeoff at more than 200
kilometres an hour was forced to slam on the brakes after plowing into a
flock of seagulls on the runway. Once the brakes cooled -- there was no
other damage -- the airplane continued on its journey.

While some of the incidents were certainly hazardous, none was officially
considered critical. If anything, aviation experts stress, they show how
well Canada's aviation safety procedures work.

Many airlines encourage pilots, even if the problem is relatively minor, "to
go ahead and declare an emergency, ask for priority (landing), get the
(rescue) equipment on standby, just to be extra -- extra safe," says Mike
Stacey, the safety board's Ontario regional manager.

"In general, the air carriers and the other commercial operators and
everybody that works in the aviation industry basically looks at reportable
occurrences and knows that by reporting them, they're only going to help
enhance safety in the long run."

Still, many of the situations reported in Ottawa were potential accidents,
he admits.

"It means something has broken down. We know that a minor occurrence can
turn into a major occurrence fairly quickly -- if a whole bunch more things
happened, as things tend to have a domino effect, it potentially could have
led to an accident.

"We pay particular attention to things like smoke or fire or loss of
separation (between planes in the air) because the worst result is a mid-air
collision.

"You can't say, 'Well, that really wasn't anything significant because they
missed each other by two miles.'

"The system somehow broke down, somebody made a mistake, as humans tend to
do occasionally, and we try to dig into it," to prevent a recurrence.

There were 20 reportable incidents, typically engine and equipment failures
or suspected malfunctions, involving flights at Ottawa airport in 1998,
which recorded 181,861 takeoffs and landings that year. The airport has
never had a crash of a major commercial carrier on a regular flight.

Last year, with almost 4,200 more takeoffs and landings than in 1998, there
were 21 reportable incidents. By comparison, there were 52 such incidents at
Vancouver International last year and 67 in 1998.

And across the country, though planes spent more time in the air last year,
the air accident rate among Canadian-registered aircraft decreased to 8.3
accidents for every 100,000 flying hours compared with 9.6 in 1998.

The 1999 Ottawa occurrences include a March 22 incident in which an air
traffic controller instructed an inbound Air Alliance de Havilland Dash 8
commuter aircraft to hold at 10,000 feet and 3.9 nautical miles from the
threshold of runway 07.

Around the same time, an inbound Air Canada Canadair regional jet was to
hold at 9,000 feet, 10 nautical miles from runway 07. Both flight crews were
told of each other's position.

When the Dash 8 reached the outer limit of the holding area, the pilot
banked right to circle back and was instructed to descend to 5,000 feet. But
the controller had mistaken the position of the Air Canada jet.

Instead of being separated by at least three nautical miles laterally or
1,000 feet vertically, as required in that airspace, the two planes found
themselves separated by 1.8 miles and just 600 feet. Traffic collision
avoidance systems in both planes sounded. The controller quickly intervened
and separated the aircraft.

In Vancouver last year, a departing Canadian Airlines 767 mistook air
traffic control instructions and came within 60 metres vertically and one
nautical mile (1,853 metres) laterally of an arriving Delta Canadair jet.

"In most cases, a controller recognizes the error and takes the corrective
action before there's an actual risk of collision," says Sharron Ellis, a
spokeswoman for Nav Canada, the company responsible for the nation's air
traffic control and civil air navigation services.

"That envelope around the plane had been breached, but as soon as it was
breached, action was taken. And the reason why they have those large
separations is to have a safety zone."

Critical losses of separation, where emergency evasive action has to be
taken, are rare, less than one for every million aircraft movements (takeoff
and landings) in 1999, according to Nav Canada records.

"Any time there's a loss of separation, it doesn't always mean there was a
risk of collision," says Mr. Stacey. "Often times, the air traffic
controller may have just made a minor error -- he was monitoring the two
airplanes, he knew one was going to pass behind the other one, he thought he
was going to have the required separation, five or six miles, and one guy
slowed down or was going a little faster than he expected and he broke the
bubble ... But it's still a reportable incident."

In another Ottawa incident, on June 30, 1999, the pilot of a Beech A100,
operated by the federal department of transport, rolled down taxiway F for
departure off runway 25. The crew planned to backtrack down the runway for
takeoff after completing pre-flight checks.

The controller cleared the plane to backtrack on the runway and be ready to
receive takeoff clearance as soon as they turned around. An Air Canada
Airbus A319 was on its final approach to the same runway. Instead, the pilot
of the Beech simply took off from his position near taxiway F, perhaps
wanting to save time. Still, he was never cleared for flight by the tower,
one of the aviation industry's cardinal rules.

"The whole issue is there was confusion between the pilot and the
controller," says Mr. Stacey. "The pilot

didn't follow the instructions by the controller -- pilots should never take
off until they hear the words 'you're cleared for takeoff.' "

Other Ottawa incidents include:

Nov. 26, 1999: The crew of a Fokker F28, operated by Canadian Regional
Airlines, was taxiing on runway 07, when a navigation instrument
malfunctioned and the flight crew headed back to the ramp. But while taxiing
back, they reported smoke in the aircraft cockpit and galley area and
announced they would be evacuating passengers. Emergency response services
(ERS) were dispatched and passengers evacuated. There were no injuries.

Nov. 12: In cruising flight, the crew of a British Aerospace 146-200
reported hearing a loud noise followed by a complete loss of thrust from the
No. 3 engine. The crew shut down the engine and requested ERS stand by for
the uneventful landing in Ottawa.

Aug. 11: A government of Canada Beech 300 aircraft was en route to Ottawa at
28,000 feet. When Ottawa controllers requested the pilot descend to 22,000
feet, he stated he could not because he was running low on fuel. Flying at
lower altitudes burns more fuel. The flight was near Saranac Lake, New York,
at the time. The pilot requested priority handling and was cleared direct to
the Ottawa airport. He later declared an emergency and was instructed to
make a straight-in approach to runway 32, where ERS was waiting. The
aircraft landed without incident.

Aug. 5: The crew of an Air Canada DC-9, with 92 people onboard, was
extending the landing gear as they prepared to land in Ottawa when they
realized a main landing gear door was jammed in the down position. The crew
performed a fly-by of the control tower and tower personnel confirmed the
left main landing gear door was extended. The flight crew declared an
emergency and landed with the ERS on standby.

Dec. 17, 1998: At 4,000 feet after take off from Montreal, the No. 4 engine
on an Air Nova BAE 146-200 jet failed. The flight crew declared an emergency
and diverted to Ottawa from the destination of Saint John, New Brunswick.
The aircraft landed at Ottawa with three engines operating and with ERS
standing by.

Oct. 10: After takeoff, the power output from the No. 1 engine of an Air
Canada Airbus 320 began to surge. The surge continued through all power
settings with all other engine parameters normal. The surge was audible to
crew and passengers. The flight returned to Ottawa and landed on runway 07
with ERS standing by.

Oct. 2: An Air Canada DC-9 was cruising from Ottawa to Winnipeg. About 80
nautical miles northwest of Ottawa and while climbing from 28,000 to 31,000
feet, the cabin altitude climbed to 11,000 feet and the passenger oxygen
masks deployed. The crew initiated an emergency descent into Ottawa and
landed without further incident.

Sept. 8: A Jetstream jet, operated by Samaritan Air Service, was taxiing on
taxiway B into position for takeoff on runway 32. As the plane approached
the turn for taxiway E, the pilot was focused on his pre-flight briefing and
he missed the turn. Instead, he entered taxiway C, continued across the
"Hold" line and onto the active runway. He immediately turned around. But at
the same time, a federal department of transport Beech 200 had just landed
on runway 32. Luckily, the plane's roll out speed was low and the two
aircraft didn't collide.

Aug. 29: About 60 nautical miles southeast of Ottawa, a cockpit indicator on
an Air Canada 767 out of Toronto signalled a fire in the forward cargo hold.
The crew carried out a "quick reference handbook drill," discharged
automatic fire extinguishers in the hold and declared an emergency. The
plane landed safely. There was smoke but no fire in the cargo bay.

July 16: The crew of a Beech A100 King Air, operated by the federal
department of transport, was unable to obtain a locked indication for the
right main landing gear. The plane landed on runway 25. As it rolled on the
runway, the right landing gear collapsed and the plane went off the right
side of the runway. No one was seriously hurt.

June 25: An Air Canada DC-9 with 90 passengers was preparing to land in
Ottawa when the flight crew was unable to confirm the nose landing gear was
properly locked in position. About 100 feet from the ground, the flight from
Toronto aborted its first landing attempt. Passengers were told to prepare
for the worst. Just before landing on a second attempt, a flight attendant
shouted to passengers to "keep your heads down and brace yourselves." The
plane touched down without incident.

Feb. 23: The flight crew of a Bradley Air Services Boeing 727 watched as the
No. 3 engine exhaust-gas temperature indicator approached the maximum
operating limits shortly after takeoff from Ottawa. The crew reduced power
on the No. 3 engine but the engine's thrust lever jammed at the one-third
power position. The crew shut down the No. 3 engine and returned to Ottawa
for landing with ERS standing by.

Jan. 27: A Cessna 172M, operated by Torres Aviation, was taxiing south on
taxiway A and passed behind a Boeing 747 stopped on taxiway DD, with engines
operating, and awaiting clearance onto the de-icing pad. The blast from the
jet's engines tipped the Cessna on to its right wing tip and propeller.

Attached Graphic: Ottawa Macdonald-Cartier International Airport

ottawa.gif