Advancing Transportation Safety One Investigation at a Time Wendy A. Tadros, Chair Transportation Safety Board of Canada ISASI 2008 39 th Annual Seminar.

Advancing Transportation Safety

One Investigation at a Time

Wendy A. Tadros, Chair

Transportation Safety Board of Canada

ISASI 2008 39th Annual Seminar

September 9, 2008

Halifax, Nova Scotia

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Presentation Outline

• Look back at 5 major Canadian investigations– Morningstar Air Express, C-208, Winnipeg, Manitoba

– Air Transat Flight 861, A310, Varadero, Cuba

– MK Airlines, B747, Halifax, Nova Scotia

– Air France Flight 358, A340, Toronto, Ontario

– Swissair Flight 111, MD-11, Peggy’s Cove, Nova Scotia

• Successes• Areas for improvement

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Morningstar Air ExpressLoss of Control and Collision with Terrain

October 6, 2005, Winnipeg, Manitoba

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Morningstar Air Express

Recommendations:Cessna 208 pilots:

– do not take off into anything more than “light” icing conditions

– maintain 120 kts minimum speed in icing conditions

Action Taken:FAA Airworthiness Directives (ADs)• Cessna 208 pilots must:

– maintain 120 kts minimum speed in icing conditions – immediately exit icing conditions exceeding “light”

Transport Canada adopted both ADs

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Air Transat Flight 861Loss of Rudder In Flight

March 6, 2005, Varadero, Cuba

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0701:53ZFDR Anomaly(Loss-of-rudder)

Fort Laudersdale

Miami

0702:58Z Reports of a problem

0710:30ZRequest for landing Fort Lauderdale

0717:19ZCleared to 5000 feet

0728:16ZRequest for vectors for Miami

0737:27ZRequest forreturn to

Varadero

A05F0047

0645ZDeparts Varadero

0819:00ZLands at Varadero

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Air Transat Flight 861

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Air Transat Flight 861 Findings

Rudder made of composite material

Airbus issued All Operators Telex to inspect rudders.

•Similar rudder assemblies were found on 408 A300, A310, A330 and A340 aircraft

•Disbonds, hinge damage, fluid ingress

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Air Transat Flight 861

Recommendation:

That industry develop and implement an inspection program that allows early and consistent detection of damage to aircraft with this type of rudder assembly.

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Making Flying Safer

© Paul Paulsen, www.airliners.net

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MK AirlinesReduced Power at Takeoff and Collision with Terrain

October 14, 2004, Halifax, Nova Scotia

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MK Airlines – Occurrence Aircraft

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MK Airlines – Collision with berm

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MK Airlines – Not the First Time…

• 12 similar accidents worldwide – 4 aircraft destroyed– 297 lives lost

• Additional defenses needed to prevent these accidents.

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MK Airlines Recommendation and Action Taken

Transport Canada working with industry to develop takeoff performance monitoring system.

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Air France Flight 358Runway Overrun and Fire

August 2, 2005, Toronto, Ontario

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Air France Flight 358

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• November 9, 2007 – Quito, Ecuador• September 6, 2007 – Phuket, Thailand• July 17, 2007 – Sao Paulo, Brazil• March 7, 2007 – Java, Indonesia• October 10, 2006 – Stord, Norway• July 9, 2006 – Irkutsk, Siberia• April 16, 2006 – Guyaramerin, Bolivia• December 10, 2005 – Port Harcourt, Nigeria• December 8, 2005 – Chicago, USA• October 31, 2005 – Maiema, Congo__________

1. Air Accident Investigation Commission, Interstate Aviation Committee, Russia.

2. Accident Investigation Board, Norway

3. National Transportation Safety Board, USA

Runway OverrunsA Worldwide Challenge

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Air France Flight 358 Seven Recommendations

• Five focus on crews, and the need for mandatory standards, training and procedures

• Two are aimed at reducing the risk of injury following an accident

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Air France Recommendations Severe weather landings

• Standards limiting landings in severe weather

• Improved training for pilot decision-making in worsening weather

• Requirement to always calculate runway distance at destination

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Air France Recommendations Runway End Safety Areas

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Air France RecommendationsEvacuations

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Air France Recommendations Engineered Materials Arresting System (EMAS)

Courtesy of Stantec

Courtesy of Airport Magazine

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Swissair Flight 111In-Flight Fire Leading to Collision with WaterSeptember 2, 1998, near Peggy’s Cove, NS

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Swissair Flight 111 (cont.)

Pilots smell an abnormal odour in the cockpit1011PM ADT

Pilots decided to divert to Halifax1015PM ADT

Pilots declare an emergency 1024PM ADT

Comm and Nav radios and other systems lost

1025 PM ADT

Halifax International

Airport

1031 PM ADT

Water impact

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TSB’s Investigation – 1998 Swissair Flight 111 Accident

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Swissair Flight 111 Recommendations

23 recommendations in regards to:– on-board recorders;– circuit breaker resetting procedures;– supplemental type certification process;– material flammability; and– in-flight firefighting.

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Swissair InvestigationMPET burn test

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In-flight fires: Action Taken

• Crews diverting to land immediately at first hint of fire

• IATA/Flight Safety Foundation emergency checklist template

• Improved checklists and procedures being adopted by some manufacturers

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In-flight fires: Action Still Required

• International adoption of emergency checklist template

• Designated fire zones and systematic firefighting approach

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Data Recorders

• The FAA published its final rule on:– CVR two-hour recording capacity and

independent power supply providing 10 more minutes of recording by 2012

– power redundancy in that any single electrical failure must not result in disabling both the CVR and the FDR (flight data recorder)

• Canadian harmonization with FAA rule

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Swissair Flight 111: Image Recorder Proposal

• Improve quality of data available to accident investigators by installing image recorders

• Canadian law protects data recordings for accident investigation use only and protects their confidentiality

• If image recorders installed similar protection of data to Canada’s must be extended internationally

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Conclusion

• Air investigations international in scope– Need for continued co-operation among

manufacturers, regulators, operators and investigative agencies worldwide

• Major aviation investigation reports posted on TSB website in Air section. – Consider adopting TSB recommendations when

similar deficiencies are found during your investigations

www.tsb.gc.ca

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