Assessment of Response to Aviation Safety Recommendation A00-11
Proper Maintenance of Aircraft Journey Log Books
On 18 July 1998, at about 0850 Eastern Daylight Time, a flight instructor and a student took off on a local training flight from Runway 25 at Montréal/Les Cèdres Aerodrome, Quebec. The student pilot was practicing spins and recoveries. The student initiated a spin to the left, his sixth of the day, at an altitude of 3600 feet above sea level. The first 5 spins were to the right. The aircraft entered the spin normally. After 1.5 turns, the flight instructor asked the student to recover. The student applied pressure on the right rudder pedal, as taught by the flight instructor, and the rotation did not stop. The flight instructor took over the controls and applied pressure on the right rudder pedal to stop the rotation, but the rotation did not stop. The aircraft, by then, was established in a stabilized spin, rotating to the left, and continuing its descent. The flight instructor applied full power for a moment, then full flaps, to no avail. Throughout the recovery attempt, the flight instructor continued in his efforts to avoid the crash. The aircraft struck the surface of Lac Saint-François. The student pilot sustained serious injuries but managed to evacuate the sinking aircraft through the right, rear window. He then tried to pull out the unconscious flight instructor, but without success. A fisherman close to the scene rescued the student and transported him ashore where emergency vehicles were standing by. The flight instructor did not evacuate the aircraft and died in the accident.
The Board concluded its investigation and authorized the release of report A98Q0114 on 06 July 2000.
Board Recommendation A00-11 (14 July 2000)
The required logbook entries regarding the maintenance performed on the rudder system were not made, and it was evident that the operator, in general, did not maintain the aircraft journey logbooks in accordance with the Canadian Aviation Regulations (CARs). Therefore, the Board recommends that:
The Department of Transport take steps to ensure that operators and maintenance personnel are aware, in the interests of safety, of the importance of proper maintenance of aircraft journey logbooks and are aware of their responsibilities in this regard.A00-11
Transport Canada's Response to A00-11 (10 October 2000)
In its response, Transport Canada (TC) indicated that CAR 605.94 requires that defects be entered in the aircraft journey log as soon as practicable after the defect is discovered, but, at the latest, before the next flight. However, there is evidence that the practice of not using the aircraft journey log to document all aircraft defects is not an isolated condition in the flight training community. TC will identify causes for this practice and develop a co-ordinated effort to redress the situation.
TC will also develop an article for publication in its Aviation Safety Maintainer newsletter. The article will use the facts of the accident to illustrate the importance of correctly documenting aircraft defects and maintenance action. TC intends to place emphasis on maintenance documentation during field inspections, audits and visits to commercial operators.
TC has already addressed the necessity of, and relevant regulation concerning, correct maintenance record keeping at recent flight instructor refresher courses. This will be a recurrent instructional item at refresher courses. Regional flight training inspectors communicate regularly with flight training units in their area. There will be further emphasis placed on this issue through audits and inspections of these training organizations. A guidance note on this issue has been drafted and will be posted to the TC flight training web site.
Board Assessment of Transport Canada's Response to A00-11 (21 March 2001)
In its reply, TC indicated that it concurs with Recommendation A00-11. TC will try to identify causes for this
"malpractice" and develop a coordinated effort to redress the situation. TC published an article in Issue 4/2000 of their Aviation Safety Maintainer newsletter and will place emphasis on maintenance documentation during field inspections, audits, and visits to commercial operators and training organizations. Correct maintenance record keeping was part of a recent flight instructor refresher course, and it will become a recurrent subject on this course. A guidance note will be posted on TC's flight training web site.
In summary, TC has acknowledged the existence of this safety deficiency and is taking positive action to enhance the effectiveness of its regulatory program and industry awareness of this problem area, thereby, substantially reducing the risk of recurrence of this safety deficiency.
Consequently, this response is considered Fully Satisfactory.
Next TSB action
This deficiency file is assigned an Inactive status.
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