aviation occurrence report collision with terrain cessna 188 … · 2019. 4. 1. · cessna 188...

AVIATION OCCURRENCE REPORT

COLLISION WITH TERRAIN

CESSNA 188 AGWAGON C-GYUDMARENGO, SASKATCHEWAN 2 mi S

29 JUNE 1994

REPORT NUMBER A94C0119

MANDATE OF THE TSB

The Canadian Transportation Accident Investigation and Safety Board Actprovides the legal framework governing the TSB's activities. Basically, theTSB has a mandate to advance safety in the marine, pipeline, rail, andaviation modes of transportation by:

! conducting independent investigations and, if necessary, publicinquiries into transportation occurrences in order to make findings asto their causes and contributing factors;

! reporting publicly on its investigations and public inquiries and on therelated findings;

! identifying safety deficiencies as evidenced by transportationoccurrences;

! making recommendations designed to eliminate or reduce any suchsafety deficiencies; and

! conducting special studies and special investigations ontransportation safety matters.

It is not the function of the Board to assign fault or determine civil or criminalliability. However, the Board must not refrain from fully reporting on thecauses and contributing factors merely because fault or liability might beinferred from the Board's findings.

INDEPENDENCE

To enable the public to have confidence in the transportation accidentinvestigation process, it is essential that the investigating agency be, and beseen to be, independent and free from any conflicts of interest when itinvestigates accidents, identifies safety deficiencies, and makes safetyrecommendations. Independence is a key feature of the TSB. The Boardreports to Parliament through the President of the Queen's Privy Council forCanada and is separate from other government agencies and departments.Its independence enables it to be fully objective in arriving at its conclusionsand recommendations.

The Transportation Safety Board of Canada (TSB) investigated this occurrence for thepurpose of advancing transportation safety. It is not the function of the Board to assign faultor determine civil or criminal liability.

Aviation Occurrence Report

Collision with Terrain

Cessna 188 Agwagon C-GYUDMarengo, Saskatchewan 2 mi S29 June 1994

Report Number A94C0119

Synopsis

The pilot of the Cessna 188 Agwagon was en route to a private airstrip after completing an aerialapplication of herbicide on a cereal crop south of Marengo, Saskatchewan. When the aircraft did notarrive at the airstrip, a search was conducted, and the wreckage was located in a field near Marengo. The pilot had sustained fatal injuries and the aircraft was destroyed.

The exact cause of the accident could not be determined. While en route to his destination, the pilotmost likely became incapacitated to such a degree that he allowed the aircraft to enter a descending turnand strike the ground. The pilot's incapacitation may have been caused by an inner ear disorder. Possible contributing factors were fatigue, resulting from the pilot's work schedule, and the effects ofagricultural chemicals.

Ce rapport est également disponible en français.

TABLE OF CONTENTS

TRANSPORTATION SAFETY BOARD iii

Table of ContentsPage

1.0 Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 History of the Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2 Injuries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.3 Damage to Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.5 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.6 Aircraft Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

1.8 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

1.9 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1.10 Flight Path . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1.11 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.12 Medical Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.13 Inner Ear Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.14 Organizational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.15 Pilot's Work Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

1.16 Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

1.17 Safety Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2.0 Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

2.1 Flight Path . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

2.2 Medical Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

2.3 Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

2.4 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

3.0 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

3.1 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

3.2 Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

4.0 Safety Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

5.0 AppendicesAppendix A - Map of Area Showing Last Observed Flight Path . . . . . . . . . . . . . . . . . . . . . . . 13

Appendix B - List of Supporting Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

TABLE OF CONTENTS

iv TRANSPORTATION SAFETY BOARD

Appendix C - Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

FACTUAL INFORMATION

TRANSPORTATION SAFETY BOARD 1

1.0 Factual Information

1.1 History of the Flight

The pilot of the privately registered Cessna 188aircraft was returning to his base at a privateairstrip two miles south of Marengo,Saskatchewan, from a herbicide applicationflight. The flight was conducted in accordancewith visual flight rules (VFR)1. When theaircraft failed to return to the airstrip, a searchwas conducted, and the wreckage was locatedin a field about one mile southwest of theairstrip. The pilot, the sole occupant, hadsustained fatal injuries.

The accident occurred about 0930central standard time (CST)2, during daylighthours, at latitude 51°27'N and longitude109°47'W.

1.2 Injuries to Persons

Crew Passengers Others Total

Fatal 1 - - 1Serious - - - -Minor/None - - - -Total 1 - - 1

1 See Glossary for all abbreviations and acronyms.

2 All times are central standard time (Coordinated UniversalTime (UTC) minus 6 hours) unless otherwise stated.

1.3 Damage to Aircraft

The aircraft was destroyed by the impact forces.

1.4 Other Damage

There was some damage to a cereal crop in thefield where the wreckage was located.

1.5 Personnel Information

Pilot

Age 24Pilot Licence CPLMedical Expiry Date 01 FEB 1995Total Flying Time 578 hrTotal on Type 220 hrTotal Last 90 Days 123 hrTotal on Type Last 90 Days 123 hrHours on Duty Prior to Occurrence 5 hrHours off Duty Prior to Work Period 7 hr

The pilot was certified and qualified forthe flight in accordance with existingregulations.

1.6 Aircraft Information

Manufacturer Cessna Aircraft CompanyType 188 AgwagonYear of Manufacture 1967Serial Number 188-0302Certificate of Airworthiness (Flight Permit) ValidTotal Airframe Time 2,860 hrEngine Type (number of) Continental O-470-R (1)Propeller/Rotor Type McCauley 2A34C66N (number of) constant speed (1)Maximum Allowable Take-off Weight 3,800 lbRecommended Fuel 80/87 or 100/130 aviation Type(s) gasolineFuel Type Used Farm grade automotive gasoline

The aircraft was a single-place,low-wing, conventional-gear monoplane. Itwas equipped with a hopper, mounted in thefuselage forward of the cockpit, and wing-

FACTUAL INFORMATION

2 TRANSPORTATION SAFETY BOARD

mounted spray booms for agricultural chemicalapplication. The aircraft was not equipped witha breathing air filtration system for the pilot. Not all agricultural application aircraft areequipped with such a system, nor is it requiredby regulation. The Pilot's Operating Handbookfor the aircraft lists its normal cruising speed at2,500 feet above sea level (asl) as between 103and 125 miles per hour (mph)3 depending onpower setting and configuration.

3 Units are consistent with official manuals, documents,reports, and instructions used by or issued to the pilot.

The aircraft's aileron control cableswere past due for replacement based on "timein service." New cables were on order at thetime of the accident, and arrangements hadbeen made for the cables to be replaced. Theaircraft's technical records indicate that, exceptfor the control cables, the aircraft was certifiedand maintained in accordance with existingregulations. The aircraft's weight and centre ofgravity were within prescribed limits at the timeof the accident.

1.7 Meteorological Information

The area forecast predicted scattered cloudbased at 10,000 feet asl, with variable brokencloud based at 12,000 feet asl.

The 0900 weather observation atKindersley, Saskatchewan, about 30 nauticalmiles (nm) east of the accident site, was thinscattered cloud based at 1,500 feet aboveground level (agl), another thin scattered layerof cloud based at 4,000 feet agl, visibility15 miles, temperature 15 degrees Celsius, andwinds from the east at 8 knots.

Witnesses describe the weather on themorning of the accident as generally clear, withlight winds.

1.8 Flight Recorders

The aircraft was not equipped with a flight datarecorder or a cockpit voice recorder, nor waseither required by regulation.

1.9 Wreckage and Impact Information

The aircraft struck the ground on asouthwesterly heading in a 40-degreenose-down and 15-degree right-wing-lowattitude, at a speed in the normal cruising range. Some of the aircraft instruments wererecovered and submitted to the TSBEngineering Branch Laboratory. The engineinstruments indicated that the engine wasproducing normal cruise power at the time ofimpact. Examination of the vertical speedindicator revealed that it was indicating3,000 feet per minute (fpm) down at the time ofimpact (Engineering Branch ReportLP 110/94).

The left wing flap cables failed at thepulley inside the fuselage and the left aileroncable failed in the vicinity of the aileron cableswage ball fitting. The failed aileron and flapcables were also submitted for examination tothe TSB Engineering Branch Laboratory. Thecable failures were determined to be the resultof loading in excess of the cables' specifiedbreaking strength and most probably occurredduring the crash impact (Engineering BranchReport LP 109/94).

The engine and propeller were taken tothe TSB Regional wreckage examinationfacility. Propeller damage was consistent withpower being produced at the time of impact. Examination of the

4See diagram of the area and the aircraft's last observed flightpath in Appendix A.

FACTUAL INFORMATION


engine did not reveal any pre-existing defects. Internal damage in the engine indicated that itwas producing power at the time of impactwith the ground.

The aircraft was extensively damagedby the force of the impact with the ground. The aircraft systems were examined to thedegree possible, and no evidence of amalfunction was found.

1.10 Flight Path

The aircraft had been observed in straight andlevel flight at an altitude of about 500 feet aglapproximately two miles southwest of the crashsite. At that time, the aircraft was headed in anortheasterly direction; nothing unusual wasnoted about the aircraft or its flightcharacteristics. The wreckage of the aircraftwas located in a field of cereal grain about onemile from the aircraft's destination, in gentlyrolling cultivated terrain.4 There were no powerlines or other obstructions nearby.

The aircraft's flight path wasreconstructed, based on its last observedposition and on the position and orientation ofthe wreckage. The flight path required for theaircraft to arrive at the crash site from its lastobserved position is a descending turn with adiameter of one-half statute mile, commencingabout one mile northeast of its last observedposition. At the aircraft's normal cruise speed,the average bank angle required for the turnwould be about30 degrees, and the acceleration in the turnwould be about 1.2 times the force of gravity(g). This bank angle and

acceleration was easily attainable by theaccident aircraft.

1.11 Survival Aspects

The deceleration forces at impact exceeded thelimit of human tolerance. Three of the foursupporting structures of the pilot's seat failed inoverload. The fourth (left rear) seat legremained unbroken, but detached from its seat

rail. The pilot was wearing an approved flighthelmet at the time of the accident.

The aircraft was equipped with acombination lap belt and shoulder harnessassembly. The Technical Service Order (TSO)label for the restraint system indicated that itwas manufactured in 1966. The shoulderharness attachment, located behind and abovethe pilot's head, was a solid attachment on theprimary cockpit structure, and was found intact. The stitching for the two shoulder harnessstraps failed at the lap belt attachment, and theshoulder harness stitching at the left attachmenthardware failed as well.

The failure of the harness occurred inthe stitching between the fabric layers. Sincethere is no specified "life limit" for the restraintsystem, replacement is "on condition." A 50-hour inspection of the aircraft was carried out19 days before the accident. One of the itemsto be checked on the 50-hour inspection is theseat-belt and shoulder harness. Inspection ofthese items is done by visual inspection. Anyprogressive weakening of the stitching wouldprobably not be visible on external inspectionof the harness.

1.12 Medical Information

The autopsy indicated that the pilot sustainedmultiple non-survivable injuries. Toxicologytesting was conducted at the Civil AviationMedical Unit (CAMU) at the Department ofNational Health and Welfare in Toronto,Ontario, and at the RCMP Forensic Laboratoryin Regina, Saskatchewan.

Test results for the presence ofcommon drugs were negative. The pilot wasreportedly applying 2,4-D Ester, Buctril M, andLaser agricultural herbicides on the day of theaccident. Test results for the presence of theactive ingredients in these herbicides werenegative. Test results for the presence of thesolvents, in which the active ingredients weredissolved, were also negative; however, these

FACTUAL INFORMATION


solvents are volatile and they may havedissipated before the tests were carried out.

According to the information in thematerial safety data sheets (MSDS) provided bythe manufacturers, symptoms of exposure tothese herbicides include dizziness, shortness ofbreath, nausea, muscle spasms, and eyeirritation.

1.13 Inner Ear Disorder

During the evening of Sunday, June 26, threedays before the occurrence, the pilotexperienced a period of vertigo (an illusion ofmovement or disorientation). At the onset ofthe disorder, the pilot indicated that he feltdizzy, and lay down in bed. He avoideddiscussing the matter and sought only to lie still. After the period of dizziness ended, the pilotreportedly felt somewhat groggy and tired. Thepilot did not consult a doctor about thecondition.

According to medical authorities, mostnon-transitory cases of vertigo result fromdisorders of the structures of the inner ear. Labyrinthitis, the most common such inner eardisorder, is usually caused by a viral infection. Persons suffering from labyrinthitis mayexperience periods of vertigo of such severitythat they are incapacitated. Typical outwardindications of vertigo include the patient'sdesire to lie down and avoid movement, in anattempt to keep from aggravating the situation. The most acute stage of the disorder usuallylasts for several days; a complete recovery maytake from four to six weeks. Persons sufferingfrom the condition may or may not experienceother symptoms of viral infection.

1.14 Organizational and ManagementInformation

The pilot was the registered owner of theaccident aircraft and the owner of theagricultural application company whichoperated the aircraft. The aircraft's permanentbase was Stettler, Alberta, but the aircraft wasoperated during part of the application season

from several private airstrips in the Marengo,Saskatchewan, area.

The pilot was the only full-timeemployee of the company; other people wereengaged from time to time to assist in itsoperation. Most of the chemical applied by thepilot was supplied by the farmer who ownedthe field being treated. On the morning of theaccident, an assistant helped mix theagricultural chemical, load the chemical into theaircraft, and mark the field where the chemicalwas being applied.

In addition to aerial chemicalapplication, the pilot performed a number ofother duties in the operation of his business. These duties included:

a. receiving orders for spraying andchecking fields for obstructions andsensitive surrounding crops;

b. arranging for the purchase of somechemicals and arranging their mixingfor application;

c. arranging for refuelling, andmaintenance and repair of the aircraft;

d. maintaining a chemical log, andbusiness records required for hisbusiness.

The pilot carried out these dutiesbetween flights, or on those days when weatheror other factors precluded flight.

1.15 Pilot's Work Schedule

The pilot began the 1994 aerial applicationseason in late April. From June 7 until June 29(the day of the accident), he flew every dayexcept June 11, 14, and 15. He departed on thefirst flight on the morning of the accident atabout 0500. The pilot's flight times for theperiod before the accident, reconstructed frombilling records and the aircraft log-book,indicate that he flew 26 hours in the last 7 days,63 hours in the last 14 days, and 90 hours in thelast 30 days.

FACTUAL INFORMATION


The pilot went to sleep at 2330 thenight before the accident, and awoke at 0430. He had maintained a similar schedule forseveral days before the accident, although hispractice was to sleep during the day if he wasworking early in the morning and late in theevening. He was described as being tired onthe morning of the accident. The applicationflights were conducted in the early morning andin the late evening. The pilot would typicallywork past sunset, approximately 2100.

1.16 Fatigue

Because of the subjective nature of fatigue, it isusually most difficult to determine with anycertainty whether a particular person was at anytime in a state of fatigue. Each individual variesin his or her ability to maintain mental stabilityand control under conditions which aregenerally regarded as conducive to fatigue, suchas inadequate sleep or rest, poor health,excessive working hours, business pressures,etc. Some or all of these factors, often linkedto a person's general health and the nature ofhis or her work, may lead to a state of fatiguewhich could adversely affect that person'smotivation, concentration, and ability toexercise sound judgement in making decisions.

Transport Canada regulations limitdaily "on duty" time to 15 hours. The sameregulations also limit flying times to 120 hoursfor any 30-day period, and provide that a pilotshould be scheduled for one day off duty inevery seven days.

1.17 Safety Precautions

Application of agricultural chemicals must beconducted when winds are light to avoid havingspray drift onto adjoining crops or residentialareas. Winds are generally light during the earlymorning and late evening. Application flightsare conducted at low altitude, and requirefrequent turns and numerous take-offs andlandings.

The manufacturers of the agriculturalchemicals applied by the pilot on the day of theaccident recommend (in their MSDS) thatpersons using the products avoid physicalcontact with them, and wear approvedrespirators. The pilot was not wearing arespirator at the time of the accident, nor was ithis practice to wear one when applyingherbicides such as the ones used on the day ofthe accident. Witnesses reported that the pilotwore a respirator when applying pesticides orfungicides.

Witnesses reported that the generalpractice of agricultural application pilots is towear respirators only when applying pesticideor fungicide.

Witnesses described the pilot's flyingstyle as cautious and safety-conscious andreported that the pilot maintained his aircraftconscientiously, made relatively wide turnswhile spraying, and avoided aerobaticmanoeuvres.

ANALYSIS


2.0 Analysis

2.1 Flight Path

A reconstruction of the aircraft's flight pathshows that a descending 30-degree banked turnwith an average acceleration of 1.2 g would berequired to follow the calculated flight path. Since this flight path was well within theperformance capabilities of the aircraft and isconsistent with the aircraft wreckage, it is themost likely accident scenario. The aircraft wasobserved in normal flight shortly before theaccident, no defects were found with theaircraft's engine and flight controls, and theweather was not a factor. It is likely, therefore,that the pilot lost situational awareness andallowed the aircraft to descend to the ground asa result of some degree of incapacitation.

2.2 Medical Factors

The symptoms experienced by the pilot on26 June 1994, three days before the accident,are consistent with those of an inner eardisorder. The pilot may have suffered fromthis disorder without other indications ofillness, because the disorder can be presentwithout other outward indications. Becauserecovery from the disorder may take from fourto six weeks, the vertigo that occurred on26 June may have recurred at the time of theaccident, although this cannot be proven. If aperiod of vertigo similar to the one of 26 Juneoccurred in flight, the pilot could have becomeincapacitated as a result.

Although tests did not reveal thepresence of agricultural chemicals or solvents,their presence cannot be ruled out becauseagricultural chemical solvents are volatile. Ifsuch solvents were present, they may haveadversely affected the pilot's performance. Thepilot's precautions against contact or ingestionof the agricultural chemicals being used wereconsistent with those observed by other pilotsin the industry. However, the pilot'sprecautions were not as extensive as thoserecommended by the chemical manufacturers.

2.3 Fatigue

The pilot's flying schedule shows that, althoughhe began the 1994 application season in lateApril, the busiest part of the season started inJune. Because agricultural application requireslow winds to limit drifting of the spray, mostflights took place early in the morning or in theevening.

In addition to his flying duties, the pilothad the responsibility of operating his business. The time spent planning and carrying outbusiness-related duties increased the pilot'sworkload and reduced the amount of timeavailable during the day for sleep.

Although the pilot did not exceed the30-day maximum flying time, he sometimesexceeded the 15-hour daily "on duty" time. Because the pilot sometimes napped during theday, he experienced a disturbance in his sleeppatterns. Though it cannot be proven, it ispossible that fatigue contributed to the pilot'sloss of situational awareness.

2.4 Survival Aspects

The impact with the ground was not survivablebecause of the high deceleration forces. In animpact at lower speed, however, the failure ofthe pilot's shoulder harness would have been afactor affecting the chances of survival. Theharness is checked at regular maintenanceintervals by visual inspection, but, because theharness stitching between fabric layers is notvisible, a visual inspection of the harness atmaintenance intervals would probably notreveal any weakening of such stitching.

ANALYSIS


CONCLUSIONS


3.0 Conclusions

3.1 Findings

1. The pilot was certified and qualified forthe flight in accordance with existingregulations.

2. The aircraft's technical records indicatethat, except for the control cables, theaircraft was certified and maintained inaccordance with existing regulations.

3. The engine was producing power at thetime of impact with the ground.

4. No evidence of a failure or malfunctionin any of the aircraft's systems wasfound.

5. The aircraft struck the ground in adescending turn at a speed in thenormal cruise speed range.

6. The pilot experienced symptoms ofdizziness and vertigo three days beforethe accident. The cause of thesesymptoms could not be determined;however, they were most likely theresult of an inner ear disorder.

7. The pilot's flying and non-flying dutiesresulted in long hours of work. As aresult, he may have been sufferingfrom fatigue.

8. Toxicological testing did not reveal thepresence of agricultural chemicals orsolvents; however, because of thevolatility of the solvents, their presencecannot be ruled out.

3.2 Causes

The exact cause of the accident could not bedetermined. While en route to his destination,the pilot most likely became incapacitated to

such a degree that he allowed the aircraft toenter a descending turn and strike the ground. The pilot's incapacitation may have been causedby an inner ear disorder. Possible contributingfactors were fatigue resulting from the pilot'swork schedule, and the effects of agriculturalchemicals.

SAFETY ACTION


4.0 Safety Action

The Board has no aviation safetyrecommendations to issue at this time.

This report concludes the Transportation Safety Board'sinvestigation into this occurrence. Consequently, the Board,consisting of Chairperson John W. Stants, and membersZita Brunet and Hugh MacNeil, authorized the release ofthis report on 21 April 1995.

APPENDICES


Appendix A - Map of Area Showing Last Observed Flight Path

APPENDICES


Appendix B - List of Supporting Reports

The following TSB Engineering Branch Laboratory Reports were completed:

LP 109/94 - Cables Examination; and

LP 110/94 - Instrument Analysis.

These reports are available upon request from the Transportation Safety Board of Canada.

APPENDICES


Appendix C - Glossary

agl above ground levelasl above sea levelCAMU Civil Aviation Medical UnitCPL Commercial Pilot LicenceCST central standard timefpm feet per minuteg G load factorhr hour(s)lb pound(s)mph miles per hourMSDS material safety data sheetsnm nautical milesRCMP Royal Canadian Mounted PoliceTSB Transportation Safety Board of CanadaTSO Technical Service OrderUTC Coordinated Universal TimeVFR visual flight rules' minute(s)'' second(s)° degree(s)°M degrees of the magnetic compass°T degrees true

TSB OFFICES

HEAD OFFICE

HULL, QUEBEC*Place du Centre4th Floor200 Promenade du PortageHull, QuebecK1A 1K8Phone (819) 994-3741Facsimile (819) 997-2239

ENGINEERINGEngineering Laboratory1901 Research RoadGloucester, OntarioK1A 1K8Phone (613) 998-823024 Hours (613) 998-3425Facsimile (613) 998-5572

*Services available in both officiallanguages

REGIONAL OFFICES

ST. JOHN'S, NEWFOUNDLANDMarineCentre Baine Johnston10 Place Fort William1st FloorSt. John's, NewfoundlandA1C 1K4Phone (709) 772-4008Facsimile (709) 772-5806

GREATER HALIFAX, NOVA SCOTIA*MarineMetropolitain Place11th Floor99 Wyse RoadDartmouth, Nova ScotiaB3A 4S5Phone (902) 426-234824 Hours (902) 426-8043Facsimile (902) 426-5143

MONCTON, NEW BRUNSWICKPipeline, Rail and Air310 Baig BoulevardMoncton, New BrunswickE1E 1C8Phone (506) 851-714124 Hours (506) 851-7381Facsimile (506) 851-7467

GREATER MONTREAL, QUEBEC*Pipeline, Rail and Air185 Dorval AvenueSuite 403Dorval, QuebecH9S 5J9Phone (514) 633-324624 Hours (514) 633-3246Facsimile (514) 633-2944

GREATER QUÉBEC, QUEBEC*Marine, Pipeline and Rail1091 Chemin St. LouisRoom 100Sillery, QuebecG1S 1E2Phone (418) 648-357624 Hours (418) 648-3576Facsimile (418) 648-3656

GREATER TORONTO, ONTARIOMarine, Pipeline, Rail and Air23 East Wilmot StreetRichmond Hill, OntarioL4B 1A3Phone (905) 771-767624 Hours (905)771-7676Facsimile (905) 771-7709

PETROLIA, ONTARIOPipeline and Rail4495 Petrolia StreetP.O. Box 1599Petrolia, OntarioN0N 1R0Phone (519) 882-3703Facsimile (519) 882-3705

WINNIPEG, MANITOBAPipeline, Rail and Air335 - 550 Century StreetWinnipeg, ManitobaR3H 0Y1Phone (204) 983-599124 Hours (204)983-5548Facsimile (204) 983-8026

EDMONTON, ALBERTAPipeline, Rail and Air17803 - 106 A AvenueEdmonton, AlbertaT5S 1V8Phone (403) 495-386524 Hours (403)495-3999Facsimile (403) 495-2079

CALGARY, ALBERTAPipeline and RailSam Livingstone Building510 - 12th Avenue SWRoom 210, P.O. Box 222Calgary, AlbertaT2R 0X5Phone (403) 299-391124 Hours (403)299-3912Facsimile (403) 299-3913

GREATER VANCOUVER, BRITISHCOLUMBIAMarine, Pipeline, Rail and Air4 - 3071 Number Five RoadRichmond, British ColumbiaV6X 2T4Phone (604) 666-582624 Hours (604)666-5826Facsimile (604) 666-7230

aviation occurrence report collision with terrain cessna 188 … · 2019. 4. 1. · cessna 188...

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