Decisions

CAT File No. O-1835-60
MoT File No. 200617

CIVIL AVIATION TRIBUNAL

BETWEEN:

Lee G. Williams, Applicant

- and -

Minister of Transport, Respondent

LEGISLATION:
Aeronautics Act, R.S.C. 1985, c. A-2, s. 7.1(1)(b)


Review Determination
Pierre J. Beauchamp


Decision: March 6, 2000

I confirm the Minister's decision to issue First Officer Williams an unsatisfactory assessment on his A-320 pilot proficiency check, dated May 19, 1999.

A Review Hearing on the above matter was held Monday, November 29, 1999 at 10:00 hours at the Federal Court of Canada, in Toronto, Ontario.

BACKGROUND

Mr. Lee G. Williams is a first officer with Canada 3000. On May 19, 1999, he submitted to his first six-month pilot proficiency check (PPC), following qualification as a first officer on the Airbus 320 (A-320).

This check ride was administered by company check pilot (CCP), Captain Christopher Ludwig, in a A-320 flight simulator owned by North West Airlines. Mr. Williams was acting as first officer and PNF[1] during the first portion of the check flight.

After completion of a number of exercises, mostly directed at the renewal of the captain's PPC, the check ride was terminated and First Officer Williams's performance was judged to be unsatisfactory.

This unsatisfactory assessment resulted in a suspension of his PPC.

Subsequent to this failure, after some brief sessions in a A-320 simulator, Mr. Williams successfully re-qualified as a first officer on the A-320 by successfully completing a new PPC ride.

Nonetheless, First Officer Williams has asked the Civil Aviation Tribunal for a review of this suspension.

EVIDENCE-The Minister

Mr. Alfred Pratt, the case presenting officer for the Minister of Transport, called Captain Christopher Ludwig as a witness for the Minister. Captain Ludwig is a Canada 3000 pilot, who on May 19, 1999, was acting as a delegate of the Minister of Transport, to conduct a PPC in a simulator, on a crew where Mr. Lee Williams acted as first officer.

Captain Ludwig utilized a document entitled, recurrent PPC script (Exhibit M-3), which outlines the sequence of events planned to assess the competency of the captain and first officer.

This script was new and had been in use since the beginning of April 1999; it was the third time that Captain Ludwig had used it. It called for a normal line flight between Toronto and Montreal airports where the captain would fly the first portion of the script with the first officer, Mr. Williams, acting as PNF.

After a normal take-off carried out by the captain, the departure was interrupted (medical emergency) and a return to the airport accomplished via a CAT III approach. In this case, control of the aircraft was turned over to First Officer Williams, who became PF as the Canada 3000 Standard Operating Procedures (SOPs) require the crew to carry out a PMA (pilot monitored approach).

This approach was successful.

The captain carried out the subsequent take-off in reduced visibility, and an engine failure was introduced shortly after the take-off. Captain Ludwig testified that he noticed that the captain had not used sufficient rudder input during the engine failure procedure.

Nonetheless the exercise was continued, the crew dealt with the emergency, the engine was recovered, and while downwind, in setting up for the subsequent approach, the first officer again became the pilot flying.

At this point, an ADR-2 (Air Data Reference) failure was introduced. Captain Ludwig testified that he was surprised because First Officer Williams kept flying and he expected, at that time, that control of the aircraft would be turned over to the captain, as an ADR-2 failure affects some of the first officer's instrumentation. However the first officer continued flying and the captain carried out the necessary ECAM[2] (Electronic Centralized Aircraft Monitoring system) actions.

In the course of carrying out the ECAM[3] action, the PNF (the captain) was called upon to turn off number 2 ADR system.

When this procedure had been carried out, Captain Ludwig, as per his script, introduced a number 3 ADR failure.

Control of the aircraft was turned over to the captain who became the pilot flying, and First Officer Williams, was called upon to carry out the necessary ECAM action for a second ADR failure (number 3).

During the course of completing this procedure, the ECAM instructions called for ADR number 3 p/b switch to be turned off, and according to Captain Ludwig, First Officer Williams misidentified the number 3 push button switch; the number 2 push button switch, which is located on the right side of the lower portion of the ADIRS CDU[4], was already off, and so, testified Captain Ludwig, Mr. Williams did not select ADR 3 off, as he was required to do.

The ride continued as per the script when this exercise was completed to a point where no additional procedures were being carried out. Captain Ludwig concluded that this part of the scenario had been completed and he cleared the faults so that the ride could continue unhampered by the previous exercise.

The next portion of the check ride called for the captain to carry out a non-precision approach (LOC 06R). After completion of the approach and during the carrying out of the missed approach, an engine was failed, accompanied by an indication of "0" oil quantity.

Captain Ludwig stated that he observed numerous errors pertaining to ECAM action in the completion of the drill, that no confirmation was requested or obtained from the captain by First Officer Williams on lifting the guard on the fire push button, that the FUEL X FEED part of the procedure was initially not carried out properly, as First Officer Williams selected the X BLEED ON instead of the FUEL X FEED.

Furthermore, in assessing engine parameters for a determination of whether the engine was damaged or not, First Officer Williams did not notice the ZERO oil quantity indication.

Captain Ludwig further stated that no review of the affected systems was carried out by the first officer as is required by normal ECAM discipline, and that the captain was aware of the difficulty of First Officer Williams, and was assisting him in conducting the ECAM procedures correctly.

Captain Ludwig testified that the exercise was then continued to a single engine landing. At that point he had decided that he was not satisfied, from the captain's point of view, with his handling of the engine failure, and as far as the first officer was concerned, with his handling of the ECAM procedures.

Captain Ludwig therefore decided to continue the ride with an additional exercise and decided to give the crew a straightforward ECAM difficulty to further assess procedures. In that context, the captain carried out an additional take-off, and an engine fire/failure was introduced.

During the completion of the ECAM procedures associated with this failure, Captain Ludwig observed that the first officer activated the fire push button without any confirmation by the captain and additionally, cleared the status pages out of normal sequence.

Once the aircraft had returned to a normal landing, this concluded the first planned portion of the script.

Captain Ludwig testified that at that point, as the two candidates filed out of the simulator for a break, he stayed behind and referred to the CCP Manual[5] as "I didn't feel that First Officer Williams's performance met the standards set out for a PPC."

Captain Ludwig stated that he did inform the candidates that as far as the captain was concerned he had passed the ride, but that he had assessed First Officer Williams's performance as unsatisfactory. He stated that he informed Mr. Williams of the Civil Aviation Tribunal (CAT) review process and followed with a full debriefing focussing particularly on ECAM discipline.

He testified that Mr. Williams stated that he felt that this check ride had imposed too high a workload on him and that he was tired, which would explain his hesitation and errors. Captain Ludwig indicated to him that everything that had been introduced during this ride followed the normal script and that the only additional exercise that had been required was to carry out an additional take-off with engine fire/fail, because of the events that had transpired in the earlier portion of the ride.

The remaining portion of the simulator's session was then spent in training First Officer Williams on ECAM procedures.

Finally, Captain Ludwig testified that he had known First Officer Williams prior to this ride, as Mr. Williams had been his instructor, in the military during his initial flying training in the Canadian Armed Forces at Moose Jaw, and that he had met up with him again when he was posted to CFB Trenton, where they had been co-owners of a property where Captain Ludwig resided for a while.

CAPTAIN LUDWIG—Cross-examination

During the cross-examination of Captain Ludwig by First Officer Williams, a number of points were covered:

ADR 2 Failure

The question of the "surprise" of the check pilot, during the ADR-2 failure, where the first officer did not turn over the control of the aircraft to the captain was raised; it was established that the first officer maintained full control of the aircraft, that SOPs do not require a change of control in such a situation, and that this procedure had no bearing on the evaluation of the first officer's ride, but only served the check pilot in his assessment of the captain's ability to carry out ECAM procedures.

ADR3

First Officer Williams stated in his question that this additional failure of an ADR resulted in a significant lost of instrumentation and that he required no prompting to turn over control of the aircraft to the captain, which Captain Ludwig acknowledged. Furthermore on the question of the ADR3 misidentification, Mr. Williams suggested that it would be easy to do, considering the low level of lighting during a night exercise. Captain Ludwig retorted that the sequence of switch positions 1, 3 and 2 is indicative of, and is a schematic description of the functioning of the ADR system, in that ADR 1 feeds the left side (captain's instruments), number 2 ADR normally feeds the right side (F/O's instruments), and that number 3 ADR, in the middle, is available to feed either side, and that is why they are not in numerical order 1, 2 and 3 but in the order 1, 3 and 2. First Officer Williams then suggested to Captain Ludwig that when he was stating to the captain that number 3 (which he was misidentifying) ADR was already off, he was requesting assistance, and that the captain failed to provide any assistance, although the ADIRS CDU is located on his side of the cockpit just above his head.

Further cross-examined on this question, Captain Ludwig admitted that although he did not remember exactly the sequence of events in relation to the ADR3 failure, nor the captain's statements to First Officer Williams, in the hypothetical case suggested by Mr. Williams that the captain's assistance was limited to the statement "...Just read the ECAM!" he admitted that that was not very helpful. Captain Ludwig explained the (possible) captain's behaviour by the fact that the latter may have been overloaded and relying on the PNF (First Officer Williams) to carry out his duties correctly. Pressed on this point, Captain Ludwig admitted that, in this context, he would not have been satisfied with the captain's actions. Questioned as to whether, if he had considered this part of the ride to have been critical to its successful completion, he would have stopped the ride, First Officer Williams answered that yes, in such case he would have stopped the ride... but he had not.

Engine Fire/Fail

Captain Ludwig was then questioned on the issue of not obtaining confirmation before pushing the fire push button and reiterated that what he recalled, from his notes, was that no confirmation was requested before the push button was activated; when questioned as to whether, again hypothetically, if the PNF asked the PF 5 times for something and the PF did not respond, would the PNF be expected to carry out action without confirmation? Captain Ludwig stated that he had never seen this, but that in such a hypothetical case the answer could be "yes".

CCP Manual

With reference to the CCP Manual (Exhibit M-4), Captain Ludwig was then questioned as to which items of the ride he had evaluated as unsuccessful. Captain Ludwig referred to page 6-10, at paragraph 6.9.4, and stated that upon review of this paragraph, which deals with unsatisfactory (U) assessments, at least one item mentioned at the Flight Test Report form (Exhibit M-1) was a U, and that subparagraphs c), f) and h) could apply to a number of items, any one of which was sufficient for a U, and applicable to this ride.

In that context, Captain Ludwig admitted that on the A-320, a two-crew aircraft, CRM is very important, both pilots being required to assist in carrying out duties.

On the question of errors during the ADR2 + 3 fault, he stated that the pilot flying should expect that the PNF would be able to carry the procedures set on the ECAM and the identification of the appropriate ADR switches with minimal assistance.

With Minimal Assistance—Continual Prompting

When questioned on this issue by First Officer Williams, Captain Ludwig stated that he observed that the captain was concerned that items of ECAM procedures were not being done and felt obligated to intervene and direct the first officer as to how ECAM action should be carried out, although, when pressed on this by Mr. Williams, he could not recall anything specific, even when asked to refer to his notes: "I could not document everything said in the cockpit through the ride. I recall that 'continuous prompting,' meant exactly that."

Debriefing

First Officer Williams then questioned Captain Ludwig on what transpired during the debriefing and Captain Ludwig reiterated that, in fact, he was "rattled" as he had only failed two candidates previously in his career and felt that there were too many "s/bs"[6] for the ride to be a pass therefore the check ride had to be assessed as a failure, that as the debriefing went on, he felt that First Officer Williams became argumentative, until it was decided by both to use the leftover period of time available in the simulator, for training. This training period turned out to be actually quite short and centred on a review and practice of ECAM procedures.

X-Bleed vs. X-Feed

Questioned on the issue of the selection of the X-Bleed instead of the X-Feed in carrying out the ECAM procedure for an engine failure, Captain Ludwig was unable to recall how long the cross bleed had been selected and left selected on, and did not remember whether the selection was self-corrected before landing.

Finally, Mr. Williams questioned Captain Ludwig on their relationship when they were both stationed at CFB Trenton as military pilots. Mr. Pratt objected to this line of questioning but his objection was overruled as such questioning went to the appreciation of the credibility of the witness.

Captain Ludwig testified that their co-ownership of a piece of land had, in fact, been a good experience albeit not profitable: "I made no money, I had cheap rent, there was no malice..."

This concluded the proof of the minister.

EVIDENCE—First Officer Williams

First Officer Williams then testified on his own behalf.

He first stated that with reference to the duration of the ride inscribed at the Flight Test-Pilot Proficiency Check Report form (M-1), the flight time was written as 2 hours and 30 minutes and that was not accurate, that in fact, it was 2 hours and 46 minutes and that that was significant to him. "My submission is that it is a long time to be submitted to this...!"

First Officer Williams then went on to give his version of events and rebut the testimony given by Captain Ludwig, point by point.

ADR Failure

Mr. Williams stated that he disagreed with Captain Ludwig's statement in reference to the ADR2 failure when Captain Ludwig stated that he was surprised that First Officer Williams did not turn control of the aircraft over to the captain. First Officer Williams stated that nothing in the FCOM[7] or SOPs required that control be passed over to the other pilot in such circumstances.

ADR 3

With reference to the statement on the check pilot form (M-1) that he had misidentified ADR 3, Mr. Williams stated that this Airbus 320 was not a single pilot aircraft and referred to D-1 and the paragraph entitled "ECAM ACTIONS" that states: "1. It is essential that both pilots are aware of the present display when carrying out ECAM procedures...". It is in that context, that he felt that no assistance had been rendered to him: "I turned to the pilot and said ADR 3 is already off. I don't understand? His response was: 'Just read the ECAM.' Following that, I stated 'Clear ECAM!' and the captain responded 'Clear ECAM!'"

First Officer Williams stated that the procedure was now completed, the emergency cleared, and the ride continued.

LOC Approach

Mr. Williams stated that there had been no problems encountered.

Missed Approach and Engine Failure and Low Oil Quantity

On this issue, Mr. Williams testified that with reference to the mis-selection of X-Bleed instead of X-Feed, that this was a momentary mis-selection, immediately corrected and that ECAM action was then completed; furthermore that there was an ECAM advisory of low oil quantity of 3. He stated that he was, according to the ECAM procedure, to assess for damage. "I did that from the top of the panel, working my way down on the engine instrument display, verbalising aloud that there was 'N1' no damage, then 'EGT' nothing significant, 'N2' no indication of damage; at this point the PF interjected and stated 'Low oil quantity. Engine damage!' I then moved to that warning display and recognized him to be correct; there was low oil quantity. I agreed." Mr. Williams stated that at that point, he did continue to the engine shut down procedure and that according to the ECAM procedure the systems should be reviewed, and that this review was carried out "out of sequence", but that, notwithstanding what was written on the check ride report, that the systems were reviewed. Mr. Williams stated that there was no prompting from the captain on this procedure, except for his jumping in on the question of oil quantity.

Second Fire/Fail Exercise

On that sequence of events, his version was that when carrying out the ECAM action for the Fire/Fail phase of the procedure, he went through the Fire Drill on the ECAM, that one of the last items there, is to push the Fire Switch push button. He stated that appropriate confirmation was obtained at items "Trust lever: ... closed, Fuel control switch: ... off"; on the next step, "Fire P/B", "it was illuminated, it was # 2, there was no response from the captain, he was quite busy..." First Officer Williams stated that he clearly stated again "confirm Engine Fire push button #2". Again there was no response. Mr. Williams then stated that at that point he pushed the push button because he thought he should, and that immediately after he had pushed the button, the captain said: "# 2 confirmed". "I realised he was back with me but overloaded at the time".

ECAM System Review

On that issue First Officer Williams admitted that he was not following the ECAM Clear procedure[8] correctly and that he was using the Page button function instead of the Clear button pressing procedure. He stated that this misconception on his part was cleared up both during debriefing and in the following short simulator training session with Captain Ludwig.

Demeanour

Finally First Officer Williams testified on the question of his demeanour and then indicated that his attitude change during the debriefing arose out of the way Captain Ludwig had indicated that he had failed his check ride: "You passed, you failed!" From his point of view, he was professional, open and accepting of the points raised, not argumentative. He testified that he changed demeanour after the retraining portion of the simulator ride where his training had consisted mainly of a review of the use of the Clear button function of the ECAM.

It was only after this retraining period, when Captain Ludwig suggested to him, because of their past relationship, to tell him what he really thought of the ride "off the record", that he became argumentative. First Officer Williams stated that he felt that the information he had received on the question of the appeal procedure from Captain Ludwig was wrong, and that he was the one who had volunteered the information on the appeal to this Tribunal. He stated that at that stage, he was quite concerned as this was the first check ride in 22 years of professional flying of which 12 years had been spent as a check pilot, where he had experienced a failure. Furthermore, he felt that at that stage he had to step in and indicate to the check pilot "what to do". First Officer Williams stated that having been Captain Ludwig's instructor in the "Air Force", co-owner of a property with him, he wondered whether Captain Ludwig held a grudge against him.

On that statement First Officer Williams ended his direct testimony.

CROSS-EXAMINATION—First Officer Williams

Under cross-examination by Mr. Pratt, First Officer Williams reiterated that he was not convinced of Captain Ludwig's "unobjective demeanour".

Questioned by Mr. Pratt as to whether his reaction to the assessment had been a question of ego and whether he was "prepared" going into the ride, Mr. Williams retorted that he was aware that there had been a number of failures recently on this equipment and that he had prepared himself for the ride, and thought he was ready for it; in fact during the following eleven days before his next check ride, there was one more training session in the simulator, but he had done no further studying as he had really prepared himself well prior to the May 19 ride. On his past experience, he testified that he had been a first officer on the Boeing 757 for five and a half years prior to his coming on the Airbus 320 and had flown Tutors, Hercules and Boeing 707 aircraft in the military. Furthermore in his eight years as instructor on Hercules and Boeing 707 aircraft in the military, he had never allowed a ride to go on for more than 2 hours and 45 minutes without a break.

Mr. Pratt then cross-examined First Officer Williams on specific points of the ride:

ADR 3

When questioned by Mr. Pratt as to "who's job is it to turn it off?" and whether he had in fact turned ADR 3 off, First Officer Williams stated that he had required assistance from the captain and having not received it, # 3 ADR stayed on. "No doubt it wasn't turned off, but it had no significance on the rest of events because it was faulted..."

X-Feed and X-Bleed and Oil Quantity

Questioned on these two issues by Mr. Pratt, First Officer Williams reiterated that the selection of the cross bleed had been a momentary selection which had then been immediately corrected by himself without prompting; as to the oil quantity and as to the question of whether, if the oil quantity was shown to be below minimum, whether the engine should have been restarted, First Officer Williams stated that this was a question of airmanship: "If you had a fire in #1 maybe starting #2 with low oil quantity would be OK." Questioned as to whether if he had noticed a low oil quantity, he could have restarted the engine, his answer was "no";

Systems Review

On this issue, First Officer Williams in answering the questions of Mr. Pratt admitted that there were two different versions of the events, as they related to whether he was able to carry out a proper ECAM action and system review during the first engine failure or whether he needed prompting.

Finally, First Officer Williams agreed with the statement put to him by Mr. Pratt that his handling of the engine fire was the crux of the failure:

Q. "You think that the engine fire is the crux?"
A. "Yes."
Q. " I agree!"

Mr. Williams also agreed with Mr. Pratt that he "surely needed training". He felt that because of a lack of training on SOPs, he was quite happy to receive the information that he got from Captain Ludwig.

In closing, Mr. Pratt asked First Officer Williams:

Q. "You think this ride should have been a pass?"
A. "I believe the crux was the mishandling of the Engine Fire/Failure. He said to me: 'When you pushed that button, you did yourself in'."

THE LAW

Paragraph 7.1(1)(b) of the Aeronautics Act:

7.1 (1) Where the Minister decides

[...]

(b) to suspend or cancel a Canadian aviation document on the grounds that the holder of the document is incompetent or the holder or any aircraft, airport or other facility in respect of which the document was issued ceases to have the qualifications necessary for the issuance of the document or to meet or comply with the conditions subject to which the document was issued, or

[...]

the Minister shall, by personal service or by registered mail sent to the holder or to the owner or operator of the aircraft, airport or facility, as the case may be, at the latest known address of the holder, owner or operator, notify the holder, owner or operator of the Minister's decision.

ARGUMENT

For the Minister

Mr. Pratt's argumentation was succinct and to the point.

He argued that on May 19, 1999, CCP Captain Ludwig was placed in an awkward position, in that, in three instances he observed unsatisfactory performance of procedures that required debriefing: ADR 2 and 3 malfunction, low oil quantity associated with an engine failure, the lifting of the guard on the engine fire push button switch without confirmation, as well as the mis-selection of the cross bleed instead of the cross feed during the carrying out of the ECAM procedures following the engine failure, and finally the lack of a systems review following ECAM action, as per the SOPs.

Mr. Pratt argued that although there are diverging views as to what happened and the amount of prompting done by the captain with regards to the ECAM procedures, Mr. Pratt submitted that the check pilot, in any event, did hear such prompting.

With regards to the second Engine Fire/Fail exercise, Mr. Pratt also noted that First Officer Williams admitted in his testimony that he had, in fact, pushed the Engine Fire pushbutton switch prior to obtaining confirmation by the captain.

Mr. Pratt argued that the CCP had noted these errors, that the first officer required continual prompting by the captain and that these failings, as noted at the Flight Test Report (M-1), were sufficient to justify the unsatisfactory assessment.

For the Applicant

First Officer Williams's argument methodically reviewed each item of debriefing mentioned at the Flight Test Report form.

With reference to ADR 2 and 3 failure, he argued that his handling of this situation was not a fail point and submitted that this was the case since the check ride was not stopped at that time, but continued on.

With reference to the low oil quantity question, he argued that there were differing versions of the events between his interpretation and that of Captain Ludwig's, but that on one point there was no dispute: if low oil quantity is exhibited, associated with an engine failure, the engine is deemed to be damaged and so he would not recommend starting it. He argued that the dispute centred on the question as to whether he had recognized the low oil quantity situation as indicative of engine damage. He submitted that, as an experienced pilot, he would have recognized this at such point, but that, in the particulars of this case, it was just that the captain had jumped in with his appreciation of the situation first.

On the question of the lifting of the guard during the carrying out of the Engine Fail emergency procedures, he argued that this was not a critical item and therefore should not have been a debriefing point; the pressing of the button without confirmation would be an unsatisfactory procedure [sic!]; but if that had been the case, Captain Ludwig would not have permitted the ride to continue further.

On the question of the mishandling of the cross bleed and cross-feed, he submitted that this was a momentary mis-selection and that it was corrected immediately.

On the question of CLEARING of ECAM pages, he argued that the procedure he followed may not have been elegant, but the same result was obtained albeit not in the same order. He submitted that therefore this was a question of polish (he had only been on the aircraft for five months) and not a failure. Again this was the case as evidenced by the fact that the ride was allowed to continue.

The crux of the case occurred at the end of the first portion of the ride when the check pilot was not satisfied with the performance of both the captain and the first officer. He had therefore elected to carry out one additional exercise. Mr. Williams argued that, at this point, the check pilot may have been stressed out and tired due to the heavy workload imposed on him during this ride, to say nothing about the events that had transpired to that point, which he submits may be the reason why Captain Ludwig may have overlooked or not heard Mr. Williams's efforts to get the captain's concurrence before pushing the fire push button switch during the second Fire/Fail exercise.

Mr. Williams argued that to obtain confirmation before the pushing of the fire push button switch is so basic that he would not have made such an error. Either he asked for confirmation and then the check pilot did not hear it, which is a situation he cannot understand because he argued that, when in the simulator, because of the requirements of good cockpit management (CRM) he speaks clearly, or he did not, but he remembered stating clearly, twice: "engine fire switch 2". He argued that he acted that way because the PF (the captain) was "swamped" and there was no possibility of error. As he got no response from him, and because no mistake was possible (because the fire push button switch which he was about to push was illuminated red), he activated the switch. "I got the response after I pushed the Fire pb." He admits that pushing the push button without confirmation is something out of the norm but because of the circumstances, his action was justified.

DISCUSSION

The issue to be decided is whether, on May 19, 1999, First Officer Williams failed to meet the standard required to maintain the validity of his PPC on the A320. The Minister must prove, on a balance of probability, that he did not meet that standard.

To that end, the Minister submitted the testimony of CCP Captain Ludwig who administered the ride that day, as well as his Flight Test Report form, which indicated the events that had been adjudged as failing to meet such standard.

First, with regards to the standard to be achieved and maintained, reference can be made to the approved CCP Manual.[9]

Airplane Checklist and Alerting System

...Candidates must demonstrate a satisfactory knowledge of airplane checklist and alerting systems appropriate to the airplane type. Effective use of the checklist and/or ECAM/EICAS can be confirmed by each crew member's adherence to company SOPs, and by their demonstration of knowledge, ability and discipline during normal and abnormal procedures. (The emphasis is ours.)

Each pilot shall demonstrate procedures of sufficient complexity and detail to confirm adequate knowledge, ability and discipline to effectively use the checklist or ECAM/EICAS system as appropriate to the airplane type.

Some common errors that may affect the assessment of this sequence are:

[...]

c) failure to review the airplane status;

[...]

e) inadequate knowledge of airplane systems to allow proper completion of procedures;

f) inadequate knowledge of QRH and/or ECAM/EICAS procedures or content

[...]

6.9.4 Unsatisfactory (U)

If a sequence cannot be rated Satisfactory or Satisfactory with Briefing according to the preceding guidelines, it shall be rated Unsatisfactory.

A sequence shall also be rated Unsatisfactory if:

[...]

c) multiple errors are made in the completion of any one exercise;

[...]

e) the aim of the exercise is complete but there is a major deviation from standard procedures or practices or the safety of the airplane was jeopardized;

f) the candidate required continual prompting or help from the other crew member to complete a task;

[...]

h) the candidate demonstrates unsatisfactory knowledge of airplane systems, equipment, or procedures.

It is in that context, that this Member must review the proof brought forward by the Minister, as well as the rebuttal evidence of the Applicant.

Looking at the s/b or fail items mentioned at the check report one by one, I am satisfied that Mr. Williams mishandled the ADR double failure. The evidence on this point is clear, and Mr. Williams admitted to it.

With regards to the ECAM procedures, Mr. Williams also acknowledged inadequate knowledge of the proper sequence to be followed in clearing the pages following a system failure displayed on the ECAM.

The evidence relating to the noted mishandling of the X-Bleed vs. X-Feed pushbutton switch and whether Mr. Williams failed to assess the engine as damaged in his review of parameters following the first engine failure is unclear.

Captain Ludwig's recollection was that the oil indication was flashing and indicating "0" oil quantity, whereas Mr. Williams's testimony was to the effect that the oil quantity showed 3. In any event the appropriate procedures were carried out, and the engine shut down after the captain's intervention during Mr. Williams's review of parameters, and Mr. Williams's concurrence that this was indicative of engine damage.

There is no doubt that during the first engine failure, the check pilot identified a number of hesitations and deviations: Mr. Williams admits to mis-selecting the X-Feed switch (albeit momentarily, from his point of view). He admits that his review of systems required by proper ECAM procedures was faulty, and that he did not follow normal ECAM clearing procedure.

On the question of the first engine failure and the assessment of whether engine damage had occurred or not, his testimony was clear that "0" or low oil quantity associated with engine failure was indicative of engine damage and therefore not conducive to an engine re-light but to a shut down procedure.

The evidence is inconclusive as to whether at the time of the ride, the captain jumped in before he got to that part of his evaluation of the situation, or whether, as claimed by the check pilot, he had not assessed the engine as damaged. In any event, it is clear from the evidence, that no attempt or re-light was conducted, and the engine was shut down.

But in any event, these aforementioned errors and omissions in the handling of PNF duties during a Go-Around (G/A) followed by engine failure (which can be deemed to be a critical situation), would have certainly brought any check pilot to pay close attention to his subsequent performance as PNF, particularly in the contexts that he had already demonstrated a lack of knowledge of, at least, the ADIRS system, its panel and appropriate pb switch selection, as required by ECAM procedure following a double ADR (2 and 3) failure.

Now whether his lifting of the guard of the Engine Fire pushbutton switch without confirmation, is an error or contravention of Canada 3000 SOPs, is not clear from the evidence.

Captain Ludwig seemed to think so, and noted it in his assessment. At least one of the carriers with which this Member is very familiar, requires such confirmation from the pilot flying, but it is not clear from the documentary evidence submitted at trial, whether such is the situation at Canada 3000.

The only corroborative evidence on this question is Exhibit D-1, Canada 3000 A320/A330 SOP, dealing with "B. ECAM ACTIONS" which only states the following:

  1. It is essential that both pilots are aware of the present display when carrying out ECAM procedures... The following table illustrates the crew coordination and cross check procedure:

and under the heading:

ECAM PROCEDURES

WARNING DISPLAY

PILOT FLYING

PILOT NOT FLYING

HYD B RSVR OVHT

BLUE ELEC PUMP....OFF

READ FAILURE

"ECAM ACTIONS, I HAVE ATC"

- READ FAILURE

   

- "READ FAILURE"

- "READ ACTION" (full line)

- PERFORM ECAM ACTION or CONFIRM (THRUST LEVER, ENG MASTER, FIRE P/B) BEFORE PERFORMING ECAM ACTION      

(We have underlined)

So it appears that, at least from this documentary evidence, that there is no such requirement at Canada 3000.

Although it is axiomatic to state that in the carrying out of any emergency procedure during flight, no irreversible action will be accomplished without a positive cross check and approval by both pilots, and that the pilot in charge of carrying out the action must wait for agreement and confirmation from the other pilot before acting, it can be argued in this case, since no mention of it is made in the SOPs produced at trial, that the lifting of the guard on the fire push button is not irreversible action, although the pushing of the fire push button is. At least in the case of the first engine failure introduced during the ride and noted at the item (6-B) of the test report, it appears that the pb was not activated without confirmation.

However it is clear from the evidence and Mr. Williams's own testimony that that was not the case in his handling of the second engine problem noted at item (6-C).

TWO-CREW MEMBER PHILOSOPHY

The A320 as operated by Canada 3000 is certified for operation by a minimum crew of two pilots, consisting of a pilot flying and a pilot non flying (PF and PNF).

During normal flight operations, accepted two-crew member philosophy generally dictates, that one pilot flies the aircraft, while the other is tasked with carrying out the communications, performing the normal checks and checklists. It is therefore essential for safety that a strict cross check be done between both pilots.

This two-crew member philosophy more specifically implies good crew communications, crew coordination, cross check and crew discipline.

Good crew coordination requires strict adherence to normal, abnormal and emergency procedures. Any deviation from these procedures should be avoided. If a deviation is required due to a special circumstance, it should be announced in advance.

Good cross check between pilots implies that any action, selection or setting leading to a modification of the present aircraft status must be clearly announced, enabling the other pilot to check that there is not a mistake. Each pilot must know the intentions of the other in order to detect a possible undesired deviation.

Finally, good crew discipline requires that procedures and task sharing as defined in standard operating procedures (SOPs) be strictly adhered to.

In applying these principles to abnormal and emergency situations, it is generally accepted that if strict discipline is not applied, important items can easily be missed because of the stress generated by the unusual occurrence (e.g.: activation on an engine fire warning during take-off shortly after V1, engine failure during a G/A procedure etc.).

As a consequence, it is deemed to be of the utmost importance not to rush, to properly identify the failure and to correctly carry out the appropriate ECAM action. In that context, both pilots will accomplish no irreversible action without a positive cross check and approval.

There can be no doubt that the pushing (activation) of the Fire pb switch is such irreversible action. It causes the aural warning cancellation, arms the fire extinguishers (SQUIBs), commands fuel low pressure valve closure, hydraulic fire, engine bleed and pack flow control valves closure and deactivates the associated engine driven electrical generator.[10]

On the other hand, the mis-selection of the X-Bleed or X-Feed, the failure to turn #3 ADR push button switch off, are, per se, minor deviations from procedures which would normally not bring about the failure of a ride. However, these errors and omissions, often indicative of a lack of understanding or knowledge of aircraft systems and/or procedures particular to the A320, coupled with the omissions and errors noted above (lack of understanding of proper sequencing of ECAM, and system review) and particularly in the light of the, shall we say, impatient activation of the Engine Fire push button switch mentioned at item 6-C, were enough to convince that CCP, that First Officer Williams was not performing to the required standard and cause the CCP to apply an unsatisfactory assessment to the portion of Mr. Williams's check ride where he had mostly only carried out PNF duties.

In that context, this member reluctantly concurs with this evaluation.

There is no doubt, as heard from all the participants' testimony and statements, that First Officer Williams is a very experienced and competent pilot who, along with his check pilot, was put in a difficult position. Of all the check rides that a new pilot will be submitted to during his time on a new aircraft, it is generally accepted that the first check ride (six-month PPC) after initially qualifying on a new aircraft is probably the most difficult.

It is obvious from all the testimony heard that there was a breakdown in CRM procedures during the course of this flight test and this Member is not in a position to assess why, as no evidence was specifically heard on this point. The fact is that for a number of reasons this resulted in First Officer Williams failing to perform to the level that was expected of him, and that he had demonstrated in the past, and that he was quickly able to recapture subsequent to this ride, with minimal training.

But the fact remains that it is not possible, given the evidence, to overrule the check pilot's assessment in these circumstances, and to recommend that the Minister re-examine this assessment.

The check pilot was in the best position to evaluate the ride as a whole. He alone was present to observe the interaction between the crew members and evaluate each pilot's performance.

Although one can argue about his interpretation of each minor deviation that was raised in the check pilot report form, and First Officer Williams certainly does that quite effectively, there however remains no doubt that when all these discrepancies (which Mr. Williams qualifies as minor) are coupled with the breakdown in communication and crew discipline that occurred in the handling of the fire push button switch on the last exercise, there is sufficient evidence to justify the unfortunate unsatisfactory assessment, which must stand.

I therefore confirm the Minister's decision on the evidence given.

DETERMINATION

I confirm the Minister's decision to issue First Officer Williams an unsatisfactory assessment on his A-320 pilot proficiency check, dated May 19, 1999.

Pierre J. Beauchamp
Member
Civil Aviation Tribunal


[1] PNF designates a "pilot not flying", which, in a multi crew aircraft, is the pilot, part of the crew, who does not manipulate the flight controls; his/her function is to support the PF (pilot flying) in the execution of the tasks and functions required of a two-pilot crew (such as required on the A-320), to fly the aircraft safely.

[2] The Electric Centralized Aircraft Monitoring (ECAM) system, amongst other functions, detects failures and provides the pilots with applicable courses of action to be carried out, as well as information on the status of the aircraft after completion of the procedures. This information is provided on two cathode ray tubes or DUs (display units) located in the middle of the centre instrument panel, the Engine / Warning display and the System display. As soon as a failure is detected by the Flight Warning Computer, and provided there is no flight phase inhibition, the Electronic Warning Display (left portion of the upper DU or ECAM) displays the title of the failure and actions to be taken. Action lines are automatically cleared when corresponding actions have been taken. The "STATUS" page appears automatically on the lower DU once the crew has cleared all the pages corresponding to the current failure, and the operational summary of the aircraft status is displayed. The scrolling through the lines of the display is controlled by CLR (Clear pushbutton) actions. See AIRBUS A-320 Flight Crew Operating Manual INDICATING/RECORDING SYSTEMS - ECAM Description pp. 1.31.10, 1.31.15 p.1, 1.31.20 p. 4, 1.31.25 pp. 1-2. See also: Roger C. Hall v. Minister of Transport CAT File No. O-1813-60, Mr. Allister Ogilvie, at p. 3 for a general review of ECAM warnings and functions.

[3] The ECAM action for a number 2 ADR failure calls for Air Data switching, that is the selection of the air data selector to be moved from the NORM position to the F/O 3 position thereby replacing ADR number 2 which has failed, by number 3, to power the first officer's air data reference system. The ECAM procedure also calls for the ADR-2 pb switch, located on the ADIRS CDU located on the overhead panel, to be turned off. See A-320 FCOM op.cit. Note 2, ABNORMAL AND EMERGENCY - NAVIGATION, p. 3.02.34 pp. 1-3, and p. 1.34.10 pp.1 to 7.

[4] The ADIRS CDU (Air Data and Inertial Reference System Control Data Unit), contains in it's lower portion 3 ADR pushbutton (p/b) switches which illuminate amber, accompanied by ECAM message information, if a fault is detected in the air data reference part of the ADIRS system. The OFF position of these switches disconnects the air data output. The three switches ADR1, ADR2, ADR3, are not aligned sequentially but are aligned in the sequence ADR1, ADR3 and ADR2. See note 3.

[5] Company Check Pilot Manual: Mr. Pratt submitted pages 6-9, 6-19 and 6-21 as Minister's Exhibit 4 a), b) and c), which consist of exerpts of the approved CCP Manual (6th edition, revision1 June 1998).

[6] s/b or SB: satisfactory with briefing. See M-4 a) p. 6-9

"Satisfactory with Briefing (SB)

A sequence shall be rated satisfactory with briefing when:

a) airplane handling and knowledge are safe but of a lower standard than would be expected and any deficiency can be corrected during debriefing;

b) the candidate had a brief excursion from published tolerances but initiated corrective action;

c) a sequence deviates from standard procedures or practices but does not create a more hazardous situation and is repeated satisfactorily or clarified by the candidate during debriefing;

d) there is a deviation from standard procedures or practices which the candidate acknowledged without prompting, that does not create a more hazardous condition and from which the candidate can recover unassisted; or e) the candidate experienced some difficulty or required slight prompting from the other crew member to satisfactorily accomplish a task.

Although not required, provided it is not listed as a fail item, a procedure or sequence that would normally rate an 'SB', may be repeated at the discretion of the check pilot. Check pilots shall refrain from teaching or briefing the candidate on the correct completion of the exercise."

[7] FCOM: Airbus A-320 Flight Crew Operating Manual.

[8] In case of a failure detected by the ECAM:

  • The E /WD (upper ECAM) presents the WARNING/CAUTION messages
  • The Master Caution or Master Warning lights illuminate (except for level 1 caution)
  • An audio sound is triggered (except for level 1 caution)
  • The SD (lower ECAM) presents the affected system page
  • The CLEAR pb illuminates on the ECAM control panel

In addition a local warning light directly controlled by the affected system can illuminate.

After completion of the procedure, the crew must depress the CLR pb until return to the normal configuration, i.e.:

  • MEMO messages on E/WD
  • System page related to the present flight phase
  • CLR light extinguished on the ECAM control panel

See: A 320 FCOM op. cit. note 2, INDICATING / RECORDING SYSTEMS, ECAM SEQUENCE, p. 1.31.25 p 1 and Roger C. Hall v. Minister of Transport, id. note 2.

[9] M-4 b) page 6-20.

M-4 a) page 6-10 art. 6.9.4.

[10] See, for more on this: A320 FCOM, op. cit. note 2 p. 1.26.20 p. 3.