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Advancing Transportation Safety One Investigation at a Time

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Presentation on theme: "Advancing Transportation Safety One Investigation at a Time"— Presentation transcript:

1 Advancing Transportation Safety One Investigation at a Time
Wendy A. Tadros, Chair Transportation Safety Board of Canada ISASI th Annual Seminar September 9, 2008 Halifax, Nova Scotia

2 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

3 Morningstar Air Express Loss of Control and Collision with Terrain October 6, 2005, Winnipeg, Manitoba

4 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: immediately exit icing conditions exceeding “light” Transport Canada adopted both ADs

5 Air Transat Flight 861 Loss of Rudder In Flight March 6, 2005, Varadero, Cuba

6 Air Transat Flight 861

7 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

8 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.

9 © Paul Paulsen, www.airliners.net
Making Flying Safer © Paul Paulsen,

10 MK Airlines Reduced Power at Takeoff and Collision with Terrain October 14, 2004, Halifax, Nova Scotia

11 MK Airlines – Occurrence Aircraft

12 MK Airlines – Collision with berm

13 MK Airlines – Not the First Time…
12 similar accidents worldwide 4 aircraft destroyed 297 lives lost Additional defenses needed to prevent these accidents.

14 MK Airlines Recommendation and Action Taken
Transport Canada working with industry to develop takeoff performance monitoring system.

15 Air France Flight 358 Runway Overrun and Fire August 2, 2005, Toronto, Ontario

16 Air France Flight 358

17 Runway Overruns A Worldwide Challenge
1 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 __________ Air Accident Investigation Commission, Interstate Aviation Committee, Russia. Accident Investigation Board, Norway National Transportation Safety Board, USA 2 ` 3

18 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

19 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

20 Air France Recommendations Runway End Safety Areas

21 Air France Recommendations Evacuations

22 Courtesy of Airport Magazine
Air France Recommendations Engineered Materials Arresting System (EMAS) Courtesy of Airport Magazine Courtesy of Stantec

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

24 Swissair Flight 111 (cont.)
Halifax International Airport Pilots declare an emergency 1024PM ADT Comm and Nav radios and other systems lost 1025 PM ADT Water impact 1031 PM ADT 1015PM ADT Pilots decided to divert to Halifax 1011PM ADT Pilots smell an abnormal odour in the cockpit

25 TSB’s Investigation – 1998 Swissair Flight 111 Accident
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26 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.

27 Swissair Investigation MPET burn test

28 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

29 In-flight fires: Action Still Required
International adoption of emergency checklist template Designated fire zones and systematic firefighting approach

30 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

31 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

32 www.tsb.gc.ca 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

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