Transcript Slide 1

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
Presentation Outline
• Look back at 5 major Canadian investigations
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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 Express
Loss 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 861
Loss of Rudder In Flight
March 6, 2005, Varadero, Cuba
A05F0047
0717:19Z
Cleared to
5000 feet
0710:30Z
Request for
landing Fort
Lauderdale
0702:58Z
Reports of a
problem
Fort Laudersdale
Miami
0728:16Z
Request for
vectors
for Miami
0737:27Z
Request for
return to
Varadero
0701:53Z
FDR Anomaly
(Loss-ofrudder)
0645Z
Departs
Varadero
0819:00Z
Lands 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 9
MK Airlines
Reduced 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 358
Runway Overrun and Fire
August 2, 2005, Toronto, Ontario
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Air France Flight 358
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Runway Overruns
A Worldwide Challenge
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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
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April 16, 2006 – Guyaramerin, Bolivia
December 10, 2005 – Port Harcourt, Nigeria
December 8, 2005 – Chicago, USA
October 31, 2005 – Maiema, Congo
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1. Air Accident Investigation Commission, Interstate Aviation
Committee, Russia.
2. Accident Investigation Board, Norway
3. National Transportation Safety Board, USA
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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 Recommendations
Evacuations
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Air France Recommendations
Engineered Materials Arresting System (EMAS)
Courtesy of Airport Magazine
Courtesy of Stantec
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Swissair Flight 111
In-Flight Fire Leading to Collision with Water
September 2, 1998, near Peggy’s Cove, NS
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Swissair Flight 111 (cont.)
Halifax
International
Airport
Pilots declare an emergency
Comm and Nav radios
and other systems lost
1024PM ADT
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
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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 Investigation
MPET 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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