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 Challenge1
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 Accident25

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