Recommendation A16-08

Assesssment of the response to Aviation Safety Recommendation A16-08

Night visual flight rules regulations

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On 31 May 2013, at approximately 0011 Eastern Daylight Time, the Sikorsky S-76A helicopter (registration C-GIMY, serial number 760055), operated as Lifeflight 8, departed at night from Runway 06 at the Moosonee Airport, Ontario, on a visual flight rules flight to the Attawapiskat Airport, Ontario, with 2  pilots and 2 paramedics on board. As the helicopter climbed through 300 feet above the ground toward its planned cruising altitude of 1000 feet above sea level, the pilot flying commenced a left-hand turn toward the Attawapiskat Airport, approximately 119 nautical miles to the northwest of the Moosonee Airport. Twenty-three seconds later, the helicopter impacted trees and then struck the ground in an area of dense bush and swampy terrain. The aircraft was destroyed by impact forces and the ensuing post-crash fire. The helicopter's satellite tracking system reported a takeoff message and then went inactive. The search-and-rescue satellite system did not detect a signal from the emergency locator transmitter (ELT). At approximately 0543, a search-and-rescue aircraft located the crash site approximately 1 nautical mile northeast of Runway 06, and deployed search-and-rescue technicians. However, there were no survivors.

The Board concluded its investigation and released report A13H0001 on 15 June 2016.

TSB Recommendation A16-08 (June 2016)

In this occurrence, the pilots took off on a night visual flight rules (VFR) flight in conditions that did not permit them to safely maintain visual reference to the surface. Although the Canadian Aviation Regulations (CARs) indicate that night VFR requires a pilot to maintain visual reference to the surface, they do not adequately define the visual references required for compliance. For example, the regulations do not define the cultural/ambient light requirements, nor do they provide for an alternate means of compliance when this cannot be achieved. During the investigation, it was determined that many pilots who conduct night VFR operations believe that it is acceptable to do so at night, regardless of lighting conditions, as long as the reported weather conditions (i.e., ceiling and visibility) meet the minimums specified by regulation. These differences in the ways in which the regulations are being interpreted significantly increase the risk to those who travel on VFR aircraft at night. Further, there is no regulatory requirement, as there is in some countries, for commercial operators to demonstrate to Transport Canada (TC) that their night VFR routes can be reasonably carried out by relying on cultural or ambient lighting, or by alternative means such as night vision goggles (NVG), before they receive TC approval of their night VFR routes.

Night VFR flights are routinely conducted across Canada. In heavily populated areas, it may be easy for pilots to maintain visual reference to the surface using cultural lighting. However, flights are often conducted in remote locations of Canada, where there may be little to no cultural lighting available to help pilots maintain visual reference to the surface without some type of alternative means, such as NVGs. The risks associated with conducting night VFR operations in conditions where pilots are unable to maintain visual reference to the surface are well documented in TSB investigation reports. In a TC study, the regulator identified a number of instances in which flights were conducted under the auspices of night VFR, but with inadequate cues to maintain reference to the surface. Strong evidence therefore exists to suggest that the current night VFR regulations should be re-examined and amended to clearly establish the conditions required to meet the intent of the regulation. For example, in the United States, the Federal Aviation Regulations (FARs) state that no person shall operate a helicopter under VFR at night unless that person has "visual surface light reference, sufficient to safely control the helicopter."

Without clearly defined night VFR requirements that establish unaided visual reference/lighting considerations or alternative means of maintaining visual reference to the surface (i.e., night-vision imaging systems), it is highly likely that accidents such as this one will continue to occur:

Therefore, the Board recommended that

The Department of Transport amend the regulations to clearly define the visual references (including lighting considerations and/or alternate means) required to reduce the risks associated with night visual flight rules flight.
TSB Recommendation A16-08

Transport Canada's response to Recommendation A16-08 (September 2016)

Transport Canada agrees with this recommendation.

TC will address this recommendation in two steps; first with safety promotion and education activities as early as fall 2016; and secondly, by initiating a regulatory amendment project in 2017 including consultation with our key stakeholders. Safety promotion and education will leverage TC's recently published Advisory Circular No. 603-001 — Use of Night Vision Imaging Systems.

Board assessment of Transport Canada's response to Recommendation A16-08 (December 2016)

In its response, TC indicated that it will take a two-fold approach to address this recommendation to reduce the risks associated with night visual flight rules flights. In the short term, TC will conduct safety promotion/education activities, which will be followed in 2017 by a regulatory amendment project. The Board is pleased that TC is taking action to address this safety deficiency.

However, until specific details about the proposed regulatory changes are fully known, the TSB cannot evaluate if these actions will fully address the safety deficiency associated with visual flight rules flights.

Therefore, the response to Recommendation A16-08 is assessed as Satisfactory Intent.

Next TSB action

The TSB will monitor the progress of TC's actions to mitigate the risks associated with the safety deficiency identified in Recommendation A16-08.

This deficiency file is Active.