Presentation to Air Transport Association of Canada 2013

Air Transport Association of Canada Annual General Meeting 2013

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Joe Hincke
Member, Transportation Safety Board of Canada
Montreal, Quebec, 17 November 2013

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Slide 1: Title Page

Good morning. It's a pleasure to be here.

Slide 2: Outline

Today I'll be focusing on 703s and 406s: air taxis and flight-training units.

This presentation will address a number of key areas, including:

  • the TSB Watchlist, and the issue of CFITs
  • lightweight flight data recorders
  • post-impact fires
  • safety management systems
  • floatplane safety.

Click any image to enlarge.

Slide 3: About the TSB

The TSB is an independent government agency. Our mandate is to advance safety by conducting independent investigations into four federally regulated modes of transportation: marine, pipeline, rail, and air.

To that end, we conduct independent investigations, identify safety deficiencies, identify causes and contributing factors, make recommendations, and make our reports public.

It is also important to note that it is not the function of the TSB to assign fault or determine civil or criminal liability.

Slide 4: Where are the most accidents happening?

With respect to commercial aviation, the vast majority of accidents happen in those sectors covered by the Canadian Aviation Regulations (CARs) subparts 702, 703, and 704. In other words, those aircraft engaged in commercial aerial work, as air taxis, and commuter operations.

Here are two key statistics:

702s, 703s, and 704s account for 94% of commercial aviation accidents in Canada—and 95% of all commercial aviation fatalities. That's why the TSB is very focused on this area.

(Note that this includes floatplanes, as we'll see later.)

Slide 5: Transportation Safety Board of Canada Watchlist

The Watchlist identifies the transportation safety issues that pose the greatest risk to Canadians. In each case, the TSB has found that actions taken to date are inadequate, and that industry and regulators need to take additional concrete measures to eliminate the risks.

The first Watchlist was released in 2010. An updated version released in 2012 featured some new issues, as well as old issues where there had been insufficient progress. This includes the issues of Safety Management Systems and CFIT: controlled flight into terrain.

Slide 6: Watchlist issue: Controlled Flight Into Terrain (CFIT)

CFITs occur when an airworthy aircraft under the control of the pilot is inadvertently flown into the ground, water, or an obstacle. This type of accident often happens when visibility is low, at night, or during poor weather—conditions that reduce a pilot's situational awareness and make it difficult to tell whether the aircraft is too close to the ground.

The risk is even greater for small aircraft, which venture further into remote wilderness or into mountainous terrain, but are not required to have the same ground proximity warning equipment as large airliners.

This image is from a recent TSB investigation report (A11W0151) involving a Cessna 208B Caravan, operated by Air Tindi Ltd., in the Northwest Territories. You can see the flight path, the first point of impact, and the result.

Slide 7: CFIT statistics

Over the last 10 years, CFITs have accounted for just 4% of accidents, but 19% of all fatalities.

Between 2003 and 2012, there were 114 accidents of this type in Canada, resulting in 120 fatalities.

Slide 8: CFIT recommendations

Following the 2009 crash of a Beech A100 just 3 nautical miles short of Chicoutimi/Saint–Honoré Airport in Quebec,Footnote 1 the TSB made two recommendations.

One called for TC to require that the design and depiction of the non-precision approach charts incorporate the optimum path to be flown. (A12-01)

The other called for TC to require the use of the stabilized constant descent angle approach technique in the conduct of non-precision approaches by Canadian operators. (A12-02).

Current status for each of those recommendations (“satisfactory intent”) is shown in red.

Slide 9: CFIT: Solutions

TC has introduced regulatory amendments that will require TAWS (terrain awareness warning systems) for commercial aeroplanes with six or more passenger seats, and in turbine-powered private aeroplanes. However, until this equipment is installed, the residual risk to Canadians will remain.


  • Wider use of technology
    • TAWS
    • Also: some currently available GPS systems will provide pilots with the vertical component of an approach
  • Improved non-precision approach procedures
    • e.g., stabilized constant descent angle

Hopefully, these kind of solutions will lead to a reduction in CFITs.

Slide 10: Lightweight flight data recorders

Now I'd like to switch topics and address another issue: lightweight flight data recorders.

In a number of investigations into aviation accidents that involved commercial operators using small aircraft, the TSB could not conclusively determine WHY an occurrence happened.

Having reliable data would help lead investigators to findings. It would also help remove doubts about what happened. Current data sources that are helpful include GoPro cameras and GPS units. However, these are not always available—or reliable.

This need for data was highlighted in the latest investigation report: an accident in 2011 involving a Black Sheep Aviation and Cattle Co. Ltd. Turbine-powered de Havilland DHC-3 Single Otter. It spurred TSB Recommendation A13–01.

Slide 11: Flight data recorders: recommendation

The Black Sheep accident was not the first time the TSB could not conclusively determine WHY an occurrence happened. In fact, we have discussed the issue of data recorders in the past. But this investigation served as a launching point for a Board recommendation calling for the installation of lightweight flight recorder systems by commercial operators using small aircraft.

Our recommendation? That TC work with industry to remove obstacles and develop recommended practices for the implementation of flight data monitoring and the installation of lightweight flight recording systems for commercial operators not required to carry these systems.

2013 status: “Satisfactory intent” (shown in red).

Slide 12: Flight data recorders: Case study – Black Sheep (A11W0048)

31 March 2011
Mayo, Yukon, 38 nm NE
Black Sheep Aviation & Cattle Co. Ltd. turbine powered de Havilland DHC-3 Otter

  • Leaves Mayo on a day VFR flight to the Rackla Airstrip, Yukon.
  • Approximately 19 minutes later a 406 MHz emergency locator transmitter (ELT) alert was received by the Canadian Mission Control Centre.
  • JRCC-Victoria was notified and a commercial helicopter was dispatched to find the aircraft.
  • Wreckage was located on a hillside 38 nautical miles northeast of Mayo.
  • Departed controlled flight;  broke up due to high speed.
  • The pilot—the sole occupant—was fatally injured.
  • Findings as to risk: If cockpit or data recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded.

Slide 13: Flight data monitoring

Flight data monitoring (FDM) is a proactive learning tool that operators can carry out. FDM ties in well with Safety Management Systems because it allows you to identify risks and potential safety issues before an accident happens.

Here are some of the advantages FDM offers to operators.

  • It can be used for flight sampling and review
  • You can track and evaluate flight operations trends
  • You can identify risk precursors
  • You can facilitate corrective actions in a range of operational areas
  • It helps to develop SOPs and training plans
  • It helps operators notice deviations from SOP
  • It can offer clear evidence of events that can eliminate doubt or conflicting reports about what happened (for crew, operators, manufacturers, Next-of-kin, survivors, etc.)
  • Factual evidence helps reduce litigation costs.

Slide 14: With more data, everybody wins

Flight data monitoring will give operators the tools to look carefully at individual flights (and ultimately at the operation of their fleets) over time, so they can figure out what needs to be fixed to prevent an accident.  FDM provides an opportunity for Canada's operators using small aircraft to really reduce the number of accidents.

The TSB believes that the information recorded on lightweight flight recording systems will also be useful in occurrence investigations. This will help investigators better understand the events that led up to the occurrence, and hopefully reduce the number of accidents.

Ultimately, operators could reduce costs, offer better training, and increase efficiency by installing and using them.

In the event of an accident, these recorders provide clear evidence of the event.

Eliminating doubt helps reduce:

  • Investigation time
  • Litigation costs
  • Anxiety of crew, survivors, next-of-kin

Now let's look at another issue currently on the TSB's radar.

Slide 15: Post-impact fires (PIF)

This issue has been a concern for a number of years. In 2005, we conducted a safety issues investigation (SIIA0501) to look into what was happening, why it was happening, and what could be done to reduce the number of post-impact fires.

We found that, for smaller aircraft (maximum certified take-off weight of 5700 kg or less), post-impact fires contribute significantly to injuries and fatalities in accidents that are otherwise potentially survivable.

(A “potentially survivable” accident is one in which the impact forces are within the limits of occupant tolerance, the aircraft structure preserves the required survival space, and the occupant restraint is adequate.)

We looked at 128 accidents where PIF contributed to serious injuries or fatalities, and where the aircraft occupants were in close proximity to fire or smoke for some time following the impact. We learned that there is a significant risk of PIF in small-aircraft accidents.

Slide 16: TSB Recommendation A06-10

TC, the FAA, and other foreign regulators conduct risk assessments to determine the feasibility of retrofitting aircraft with the following: selected technology to eliminate hot items as a potential ignition source; technology designed to inert the battery and electrical systems at impact to eliminate high-temperature electrical arcing as a potential ignition source; protective or sacrificial insulating materials in locations that are vulnerable to friction heating and sparking during accidents to eliminate friction sparking as a potential ignition source; and selected fuel system crashworthiness components that retain fuel.”

2013 status: Unsatisfactory

It's important to note that the technology and design concepts to reduce the incidence of PIF already exist; moreover, these concepts have been demonstrated to be effective in helicopter, race car, and automotive applications.

In 1994, the US Federal Aviation Regulations (FARs) were amended to introduce comprehensive fuel system crash resistance certification standards for normal and transport category helicopters, to minimize the hazard of fuel fires to occupants following otherwise survivable impacts.

However, there is currently no requirement to incorporate these countermeasures into new or existing small aircraft certified before November 1994.

Slide 17: PIF risk factors for small aircraft

Occupants of small aircraft are at a greater risk of PIF because of:

  • the high volatility of aviation fuel;
  • the close proximity of fuel to occupants;
  • the limited escape time;
  • the limited energy-absorption characteristics of small-aircraft airframes in crash conditions;
  • the high propensity for immobilizing injuries; and
  • the inability of airport firefighters and emergency response personnel to suppress PIFs in sufficient time to prevent fire-related injuries and fatalities.

Slide 18: PIF case study: Northern Thunderbird Air (A11P0149)

In October 2011, a Beechcraft King Air 100, operated by Northern Thunderbird Air, departed Vancouver International Airport for Kelowna, BC. Onboard were 7 passengers and 2 pilots. About 15 minutes after take-off, the flight diverted back to Vancouver because of an oil leak. No emergency was declared.

Shortly thereafter, when the aircraft was about 300 feet above ground level and about 0.5 statute miles from the runway, it suddenly banked left and pitched nose-down. The aircraft collided with the ground and caught fire before coming to rest on a roadway just outside of the airport fence.

Upon impact, fuel spilled from the broken aircraft and ignited from friction heat, and possibly from arcing electrical wiring.

Passersby helped to evacuate six passengers; fire and rescue personnel rescued the remaining passenger and the pilots. The aircraft was destroyed, and all of the passengers were seriously injured. Both pilots eventually succumbed to their injuries in hospital.

Slide 19: Key Findings (A11P0149)

  • During routine aircraft maintenance, it is likely the left engine oil reservoir cap was left unsecured.
  • There was no complete pre-flight inspection of the aircraft, resulting in the unsecured engine oil reservoir cap not being detected and the left engine venting significant oil during operation.
  • A non-mandatory modification designed to limit oil loss when the engine oil cap is left unsecure had not been made to the engines.
  • On final approach, the aircraft slowed to below VREF speed. When power was applied, likely only to the right engine, the drag from the left engine at idle would have created an asymmetric condition. With the aircraft speed below that required to maintain directional control in this condition it yawed and rolled left, and pitched down.

Slide 20: Board Concern: Post-impact fires

This accident investigation revealed evidence of live battery powered circuits after the aircraft came to a stop, and fire in areas like the cockpit where electrical wiring is concentrated. Both pilots died from burn-related injuries.

More needs to be done to reduce the risks associated with post-crash fires.

The Board is concerned that if no action is taken by Transport Canada to address the recommendations made in the 2006 TSB Safety Study, ignition sources will remain and the risk of post-crash fire will persist.

Clearly, then, the Northern Thunderbird accident was about the dangers of post-impact fires. But it was also about handling of the aircraft in low speed conditions when operating with asymmetric thrust. Knowledge regarding the drag created from an engine at idle versus one that was feathered may have resulted in different choices during the approach. That kind of knowledge can be addressed via training.

And training is a perfect segue to my next topic: safety management systems.

Slide 21: Safety Management Systems (SMS)

Implemented properly, SMS allows aviation companies on their own to identify hazards, manage risks, and develop and follow effective safety processes. Canada's large commercial carriers have been required to have an SMS since 2005. However, this is not the case for smaller operators.

Yet many recent TSB investigations have highlighted instances where an SMS (or an improved SMS) would have helped.

With respect to Northern Thunderbird Air, the company has now changed its operating procedures so that, for Beechcraft King Air 100s, 130 knots shall be maintained until the aircraft is:

  • In final landing configuration;
  • Is on final approach slope to the runway;
  • The airport visual reference is obtained; and
  • The PF verbalizes “target VREF”.

The image on screen shows the oil streaks visible on the plane's left engine.

It also implies a question: would a more robust SMS process have identified the potential hazard of not modifying the cap? Or the risks of an incomplete pre-flight inspection?

That's not to say that SMS is a panacea. It can't catch everything. But SMS is about vigilance, and reviewing your procedures, so that when you do find trouble indicators, they can be addressed, before there is an accident.

There are many other examples of TSB investigations involving SMS. Let's look at another.

Slide 22: SMS case study: Harrison Lake (A11P0106)

In July 2011, a Cessna 152 departed Boundary Bay, B.C., for a mountain training flight. On board were a flight instructor and student pilot. Approximately 90 minutes later, the aircraft collided with terrain at 2750 feet above sea level, about 10 nautical miles west of Harrison Lake, in daylight conditions. The aircraft was destroyed by impact forces, and occupants of the aircraft were fatally injured. There was no fire.

The investigation concluded that it was “likely that the aircraft stalled aerodynamically, while attempting a turn, at an altitude from which the pilots could not recover before impacting terrain.”

Slide 23: Stalling during a turn: risk factors

This image shows the degree of risk associated with various tight turns at different speeds for small training aircraft.

As you can see, slower speeds allow for a tighter turn. So does a higher angle of bank.

But too much bank—or too slow a speed—and …

Slide 24: Positioning during a turn

These two images show poor positioning and good positioning, respectively, when executing a turn in a valley.

Slide 25: Findings as to Risk (A11P0106)

The TSB's report into the Harrison Lake accident identified a number of risks.

  • “Without proper training in mountain flying techniques, pilots and passengers are exposed to increased risk of collision with terrain due to the complex nature of mountain flying.”
  • “If pilots are not taught how to recognize, and recover from, high angle of bank stalls, there is an increased risk of collision with terrain if one is encountered.”
  • “If a flight school's standards and procedures are not incorporated into company manuals, flight instructors may deviate from the company-approved methods of instruction.”
  • “Without flight tracking or some system of post flight monitoring, there is a risk that management will not be aware of deviations from a school's standards which expose the flight to hazards.”
  • “If cockpit and data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.”

Slide 26: Safety Action Taken (A11P0106)

Following the occurrence, Pacific Flying Club implemented numerous actions. Here are some of them:

  • Mountain flying instruction was suspended pending a review and analysis using SMS principles.
  • The creation of a formal, regimented Mountain Flying Training Syllabus, and training for all instructors that includes defined procedures for canyon turns, minimum altitudes, mandatory routing, and standard operating procedures.
  • Modifications to the Mountain Flying Program, including a ground school prior to flight, prescribed new routing and the use of flight training devices to enhance pilot awareness of hazards.
  • Mandatory mountain flying awareness written test to ensure students have comprehension of the principles taught prior to flight.
  • Portable GPS to be carried on all flights outside Lower Mainland to allow for increased oversight by both senior management and instructional staff.

I'd now like to talk about a different subject: floatplane safety.

Slide 27: Case study: Lillabelle Lake (A12O0071)

On May 25, 2012, a de Havilland Beaver floatplane, operated by Cochrane Air Service, crashed into Lillabelle Lake in northern Ontario. There were three people on board. And while the initial impact was survivable, only one made it out of the wreckage.

The other two, trapped upside down in the submerged floatplane, drowned.

Floatplanes operate all over Canada. Whether they are used as air taxis to ferry wilderness travellers in and out of remote lakes, or to get commuters to work every morning, they are an indispensable part of Canada's transportation network.

How valuable? In just one region—the Vancouver Harbour, there are about 33 000 floatplane movements a year, carrying about 300 000 passengers.

These flights are normally safe, but occasionally there are situations where strong winds and bad weather can challenge even the best of pilots and aircraft.

Slide 28: TSB floatplane recommendations (2013)

After the accident at Lillabelle Lake, the TSB made two recommendations. First, for all commercial floatplane crews to take underwater egress training. And second, for small commercial floatplanes to have shoulder harnesses for all passengers.

Slide 29: Previous TSB floatplane recommendations

But this wasn't the first time we'd investigated a floatplane accident. Nor was it the first time we'd issued recommendations aimed at improving floatplane safety.

Following a 2009 crash of a de Havilland Beaver in Lyall Harbour, BC, we also made a pair recommendations. First, for doors and windows that come off easily after a crash, to better permit rapid egress. And second, that all passengers wear personal flotation devices.

Slide 30: TC action on floatplane safety

The accidents at Lyall Harbour and Lillabelle Lake fit into a larger pattern. The statistics we have point to a single, sobering fact: roughly 70 percent of the fatalities involving aircraft that crash and are submerged in water … are from drowning. 70 percent! Not from the crash. Not from the impact. But because people are unable to get out. Or if they do, because they're too exhausted or injured to stay afloat.

Transport Canada has already made it mandatory for commercial pilots to have shoulder harnesses. The same goes for passengers in new floatplanes. But not passengers who fly in older aircraft. And that's a loophole that needs to be closed.

More recently, TC has also committed to making flotation devices mandatory for all passengers. And on exits there has been lots of study, and more is planned. TC has urged voluntary compliance, but no decisions have yet been made to require that windows and doors come off easily after a crash.

Slide 31: Conclusions

Here's what we'd like to see:

  • To reduce CFITs, we'd like to see improved non-precision approach procedures, and a wider use of technology.
  • Lightweight flight data recorders are relatively cheap to install, and they can help our investigations by providing reliable data.
  • Flight data monitoring offers companies an opportunity to spot trends or troublesome patterns and take action before an accident occurs. This is something that many companies have begun doing.
  • More needs to be done to reduce post-impact fires (TSB Recommendation A06-10)
  • SMS can be tremendously helpful.
  • Floatplane safety: TC has taken some action, but you can do more. You can be proactive. Don't wait for TC to tell you what's safe. In fact, many companies are already taking independent, proactive action, rather than waiting for mandatory regulations from TC. They are installing pop-out windows and doors, and making it mandatory for all passengers and flight crew to wear PFDs. Some have even made it mandatory for pilots to take egress training.

Slide 32: Questions?

Slide 33: Canada wordmark


Footnote 1

TSB Investigation Report A09Q0203 (Exact Air)

Return to footnote 1 referrer