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remain within the confines of the runway.
5. The first officer was unfamiliar with procedures for operating at uncontrolled
aerodromes and in the use of ARCAL lighting and, as a result, the captain conducted
both PF and PNF duties, which increased his workload.
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Findings as to Risk
1. The captain made the appropriate radio calls while manoeuvring the aircraft on the
taxiways and prior to proceeding onto the runway; however, these transmissions
were not made on the ATF of 124.7 MHz.The flight crew did not adhere to
uncontrolled aerodrome procedures and as a consequence were not aware of any
communiques directed to them on the ATF.
2. Skyservice does not include operations at uncontrolled aerodromes in either initial or
recurrent ground training for flight crews.
Safety Action
As a result of this occurrence, Skyservice Airlines identified 10 safety actions that were
implemented in 2003. They are as follows:
1. Operations at uncontrolled airports in Canada to be addressed during company
indoctrination training for all Skyservice pilots.
2. Use of ARCAL airfield lighting systems to be addressed during company
indoctrination training for all Skyservice pilots.
3. Winter operations training now includes a discussion of the illusion effects created by
drifting snow during ground operations.
4. Operations at uncontrolled airports and/or where ARCAL lighting is in use to be
addressed in the Briefing and Airport Notes manual. Such information could be
addressed in a summary section with a list of applicable airfields included.
5. Special airspace and ATC procedures unique to Windsor Airport and the surrounding
airspace to be addressed in the Briefing and Airport Notes manual.
6. The role of the PNF as a monitoring pilot during all flight phases will be emphasized
in ground and simulator training and during line training and checking. Special
emphasis of monitoring of taxiing path and ground speed during ground operations
to be included.
7. Low visibility taxiing and ground operations in conditions involving surface
contamination will be addressed in simulator training.
8. Develop a set of “best practices” techniques which serve as an enhancement to SOP’s.
Best practices include methods for maintaining an appropriate level of flight discipline
during dynamic phases of flight.
9. Pilots involved in any reportable accident or incident where damage is incurred or
suspected must not operate as flight crew until a thorough assessment of the
accident/incident has been made by the VP flight operations in accordance with
FOM DIV 111, 17.10.3.
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10. Any movement of aircraft following an excursion from a paved surface will be
conducted only under the guidance of Skyservice maintenance, who will ensure that
the aircraft manufacturer’s guidelines are followed.
This report concludes the Transportation Safety Board’s investigation into this occurrence. Consequently,
the Board authorized the release of this report on 25 February 2004.
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Appendix A - Windsor Aerodrome Chart
AVIATION INVESTIGATION REPORT
A03P0259
NAVIGATIONAL ERROR – PREMATURE DESCENT
AIR CANADA
AIRBUS A319–114 C–FYKW
VERNON, BRITISH COLUMBIA
23 AUGUST 2003
The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of
advancing transportation safety. It is not the function of the Board to assign fault or determine
civil or criminal liability.
Aviation Investigation Report
Navigational Error – Premature Descent
Air Canada
Airbus A319–114 C–FYKW
Vernon, British Columbia
23 August 2003
Report Number A03P0259
Summary
An Air Canada Airbus A319 (serial number 0695, registration C–FYKW), operating as ACA183,
was on a scheduled flight from Toronto, Ontario, to Kelowna, British Columbia. Before
departure from Toronto, the crew was informed by the Notice to Airmen (NOTAM) that,
because of extensive forest fires in the area, only the non-directional [radio] beacon (NDB)
B approach would be available at Kelowna. When the flight was in the vicinity of the Enderby
VOR (very high-frequency omni-directional beacon), the crew was advised by the Vancouver
Area Control Centre (ACC) that the NDB B approach was no longer available. The only
approach available to the Kelowna Airport was a visual approach.
The crew commenced a descent into Kelowna and advised the Vancouver ACC controller that
they had the Kelowna Airport in sight. The controller cleared ACA183 to the Kelowna Airport
for a visual approach – Runway 15 was active – and handed off the aircraft to the Kelowna
　
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