Annual Report to Parliament 2006-2007

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Transportation Safety Board Annual Report to Parliament 2006-2007

2.5 Rail Sector

2.5.1 Annual Statistics

A total of 1144 rail accidents were reported to the TSB in 2006, an 8 per cent decrease from the 2005 total of 1247 but a 5 per cent increase from the 2001-2005 average of 1091. Rail activity is estimated to be comparable to 2005 and to have increased by 4 per cent over the five-year average. The accident rate decreased to 11.9 accidents per million train-miles in 2006, compared to 13.0 in 2005 and the five-year rate of 11.9. Rail-related fatalities totalled 95 in 2006, compared to 103 in 2005 and the five-year average of 96.

Three main-track collisions occurred in 2006, compared to six in 2005 and the five-year average of six. In 2006, there were 133 main-track derailments, a decrease of 31 per cent from the 2005 total of 194 and 10 per cent from the five-year average of 148. Non-main-track derailments decreased to 480 in 2006 from 540 in 2005, but increased from the five-year average of 422.

In 2006, crossing accidents decreased to 248 from the 2005 total of 269 and from the five-year average of 260. Crossing-related fatalities numbered 28, down from 37 in 2005 and the five-year average of 35. Trespasser accidents decreased by 8 per cent to 59 in 2006 from 64 in 2005, but increased by 4 per cent over the five-year average of 57. With a total of 94 fatalities in 2006, trespasser accidents continue to account for the majority of rail fatalities.

In 2006, 181 rail accidents involved dangerous goods (this also includes crossing accidents in which the motor vehicle is carrying a dangerous good), down from 214 in 2005 and from the five-year average of 215. Three of these accidents resulted in a release of product.

In 2006, rail incidents reported to the TSB in accordance with the mandatory reporting requirements reached a 24-year low of 226, down from 243 in 2005 and the five-year average of 283. For the first time, movements exceeding limits of authority incidents (101) comprised the largest proportion of the 226 reportable incidents, surpassing dangerous goods leaker incidents (86).

Figure 7: Rail Occurrences and Fatalities

Figure 7 - Rail Occurrences and Fatalities
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One indicator of rail transportation safety in Canada is the main-track accident rate. This rate decreased from 3.1 accidents per million main-track train-miles in 2005 to 2.4 in 2006. Over the past 10 years, the downward trend approaches statistical significance.

Figure 8: Main-Track Accident Rates

Figure 8 - Main-Track Accident Rates
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2.5.2 Investigations

A total of 18 new rail investigations were started in 2006-2007 and 12 investigations were completed. The average duration of completed investigations increased to 598 days compared to 519 days the year before.

Table 5: Rail Productivity

  2002-2003 2003-2004 2004-2005 2005-2006 2006-2007
Investigations Started 18 14 14 9 18
Investigations Completed 22 15 25 9 12
Average Duration of Completed Investigations (Number of Days) 755 894 618 519 598
Recommendations 5 4 3 0 2
Safety Advisories 6 7 6 9 8
Safety Information Letters 9 11 10 8 2

Note: Results can fluctuate significantly from year to year due to a number of factors such as staff turnover, the complexity of investigations and the investigation of major occurrences.

2.5.3 Safety Actions Taken

Two rail safety recommendations were issued in 2006-2007.

The Rail Branch reassessed responses to 118 recommendations issued in previous years. With Board approval, 29 recommendations went from active to inactive status and 23 recommendations remained active. The Board's reassessments were communicated to the appropriate change agent(s) for information and action.

2.5.3.1 Rail Recommendations Issued in 2006-2007
Main-Track Derailment, Canadian Pacific Railway Train, Whitby, Ontario, 14 January 2004

Report No. R04T0008
RECOMMENDATION R06-01

The Department of Transport work with the Railway Association of Canada to implement rail traffic control protocols and training that will recognize periods of high workload and make safety paramount.
RESPONSE Transport Canada (TC) agrees in principle with the recommendation and will work with the industry in the context of this recommendation and other related regulatory initiatives.
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending
Pedestrian Fatality, Canadian National Train, Brockville, Ontario, 17 February 2005

Report No. R05T0030
RECOMMENDATION R06-02

The Department of Transport assess the risk to pedestrians at all multi-track main-line crossings, make its assessment public and implement a program, in conjunction with stakeholders, to mitigate the risk of second-train pedestrian accidents.
RESPONSE TC disagrees with the recommendation, challenging the analysis and describing various initiatives taken at many locations. TC must balance a multitude of competing interests when determining how to improve rail safety.
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending
2.5.3.2 Other Rail Safety Actions

In response to Rail Safety Advisory 03/06 (TSB Occurrence R06T0022), Canadian National (CN) and Canadian Pacific Railway (CPR) accelerated the inspection and removal from service of certain wheel sets that had been identified as having a risk for developing a loose wheel condition.

In response to Rail Safety Advisory 06/06 (TSB Occurrence R06V0136), CN took action with a "blitz" campaign to test locomotive check valves, and defective valves were replaced. Additionally, the mandatory replacement frequency for these valves was increased.

In response to two other Rail Safety Advisories (07/06 and 08/06) concerning TSB Occurrence R06V0183, Transport Canada (TC) issued two Notices under Section 31 of the Railway Safety Act to the White Pass & Yukon Route railway on 12 separate operational/equipment issues requiring explanations on how the issues would be resolved.

In response to a Rail Safety Information letter (02/06), CPR took action to ensure that emergency response communications protocols between the Ontario Provincial Police and the company were enhanced and that training procedures were developed and communicated.

In response to Rail Safety Information letter 03/06 (TSB Occurrence R05C0082), TC indicated that future audits will have more emphasis on locomotive side bearing clearance and bolster bowl liner condition.

In response to Rail Safety Information letter 04/06 (TSB Occurrence R05C0082), TC indicated that future inspections and audits will have more emphasis on the inspection of locomotive truck bolster stops.

2.6 Air Sector

2.6.1 Annual Statistics

Canadian-registered aircraft, other than ultralights, were involved in 262 reported accidents in 2006, a 2 per cent increase from the 2005 total of 258 but a 5 per cent decrease from the 2001-2005 average of 275. The estimate of flying activity for 2006 is 4 161 000 hours, yielding an accident rate of 6.2 accidents per 100 000 flying hours, unchanged from the 2005 rate but down from the five-year rate of 7.1. Canadian-registered aircraft, other than ultralights, were involved in 31 fatal occurrences with 52 fatalities in 2006, comparable to the 34 fatal occurrences with 51 fatalities in 2005 and the five-year average of 31 fatal occurrences with 52 fatalities. A total of 15 fatal occurrences involved commercial aircraft (6 aeroplanes and 9 helicopters), and 12 of the remaining 16 fatal occurrences involved privately operated aeroplanes.

The number of accidents involving ultralights decreased to 27 in 2006 from 31 in 2005, and the number of fatal accidents decreased substantially to 1 in 2006 from 5 in 2005.

The number of foreign-registered aircraft accidents in Canada decreased to 14 in 2006 from 18 in 2005. Fatal accidents decreased to 2 in 2006 from 6 in 2005.

In 2006, a total of 823 incidents were reported to the TSB in accordance with the mandatory reporting requirements. This is comparable to the 2005 total of 822 and a 4 per cent decrease from the 2001-2005 average of 857.

Figure 9: Air Occurrences and Fatalities

Figure 9 - Air Occurrences and Fatalities

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One indicator of air transportation safety in Canada is the accident rate for Canadian-registered aircraft. In 2006, this rate has remained unchanged from the 2005 rate of 6.2 accidents per 100 000 hours, but remained below the five-year average of 7.1. The trend line also shows a downward direction over the past 10 years.

Figure 10: Canadian-Registered Aircraft Accident Rates

Figure 10 - Canadian-Registered Aircraft Accident Rates

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2.6.2 Investigations

A total of 41 air investigations were started in 2006-2007 and 36 investigations were completed. This represents a decrease in the number of investigations completed compared to the previous year (53). The average duration of completed investigations has increased to 516 days, compared to 404 days the year before. This is attributable to concentrated efforts to complete older investigations.

Table 6: Air Productivity

  2002-2003 2003-2004 2004-2005 2005-2006 2006-2007
Investigations Started 56 47 44 50 41
Investigations Completed 70 40 67 53 36
Average Duration of Completed Investigations (Number of Days) 494 485 524 404 516
Recommendations 17 0 4 6 4
Safety Advisories 13 9 9 7 16
Safety Information Letters 6 8 6 5 12

Note: Results can fluctuate significantly from year to year due to a number of factors such as staff turnover, the complexity of investigations and the investigation of major occurrences.

2.6.3 Safety Actions Taken

Four air safety recommendations were issued in 2006-2007. One response was assessed as Satisfactory Intent, and initial assessments are pending for the other three.

The Air Branch reassessed responses to 35 recommendations issued in previous years. With Board approval, 7 recommendations went from active to inactive status. At the end of fiscal year 2006-2007, there were 37 active recommendations. The Board's reassessments were communicated to the appropriate change agent(s) for information and action.

2.6.3.1 Air Recommendations Issued in 2006-2007
Reduced Power at Take-off and Collision with Terrain, MK Airlines Limited, Boeing 747-422SF, Halifax International Airport, Nova Scotia, 14 October 2004

Report No. A04H0004
RECOMMENDATION A06-07

The Department of Transport, in conjunction with the International Civil Aviation Organization, the Federal Aviation Administration, the European Aviation Safety Agency, and other regulatory organizations, establish a requirement for transport category aircraft to be equipped with a take-off performance monitoring system that would provide flight crews with an accurate and timely indication of inadequate take-off performance.
RESPONSE Transport Canada (TC) agrees that, if a take-off performance monitoring system (TPMS) could be designed to function as intended, it could provide a significant safety benefit. However, TC believes that, in order for civil aviation authorities to establish a requirement for aircraft to be equipped with a TPMS, an acceptable system would have to exist. TC is not aware of any certified system that is available at this time to meet this recommendation.

TC states that it is conceivable that such a system could be designed with current technology. However, a significant effort would be required by private industry and researchers to establish appropriate design criteria, to perform detailed design and system development, and then to conduct significant testing to ensure high reliability before acceptance. In addition, design criteria and standards would also require harmonization with other civil aviation authorities.

TC's letter also states that, at this time, TC cannot establish a requirement for aircraft to be equipped with a TPMS but will revisit this issue when a certifiable product is developed.
BOARD ASSESSMENT OF RESPONSE In its response, TC states that it cannot establish a requirement for a TPMS because it does not know of any certified system available to the industry. However, TC notes TSB's suggestion that research into TPMS technology would be beneficial and consequently has formed a cross-disciplinary project team to look into this subject. TC describes what work has already been accomplished by the project team and outlines details of its action plan, which includes establishing what remains to be done before a certifiable TPMS could be made available, consulting with industry to gauge their interest in a TPMS solution, and working with industry to bring about a certifiable system. Additionally, TC invites TSB's participation in its preliminary research project team.
BOARD ASSESSMENT RATING Satisfactory Intent
Post-Impact Fires Resulting from Small-Aircraft Accidents, Safety Issues Investigation

Report No. SII A05-01
RECOMMENDATION A06-08

Transport Canada, together with the Federal Aviation Administration and other foreign regulators, revise the cost-benefit analysis for Notice of Proposed Rule Making 85-7A using Canadian post-impact fire statistics and current value of statistical life rates, and with consideration to the newest advances in post-impact fire prevention technology.
RESPONSE Under review
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending
RECOMMENDATION A06-09

To reduce the number of post-impact fires in impact-survivable accidents involving new production aeroplanes weighing less than 5700 kg, Transport Canada, the Federal Aviation Administration, and other foreign regulators include in new aeroplane type design standards:

- methods to reduce the risk of hot items becoming ignition sources;
- technology designed to inert the battery and electrical systems at impact to eliminate high-temperature electrical arcing as a potential ignition source;
- requirements for 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;
- requirements for fuel system crashworthiness;
- requirements for fuel tanks to be located as far as possible from the occupied areas of the aircraft and for fuel lines to be routed outside the occupied areas of the aircraft to increase the distance between the occupants and the fuel; and
- improved standards for exits, restraint systems, and seats to enhance survivability and opportunities for occupant escape.
RESPONSE Under review
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending

RECOMMENDATION A06-10

To reduce the number of post-impact fires in impact-survivable accidents involving existing production aircraft weighing less than 5700 kg, Transport Canada, the Federal Aviation Administration, 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.
RESPONSE Under review
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending

2.6.3.2  Assessment of Responses to Air Recommendations Issued in 2005-2006
Cessna 208 Operation into Icing Conditions, Morningstar Air Express Inc., Winnipeg, Manitoba, 06 October 2005

Report No. A05C0187
RECOMMENDATION A06-01

The Department of Transport take action to restrict the dispatch of Canadian Cessna 208, 208A, and 208B aircraft into forecast icing meteorological conditions exceeding "light," and prohibit the continued operation in these conditions, until the airworthiness of the aircraft to operate in such conditions is demonstrated.
RESPONSE To address the subject of Cessna 208 operation into icing conditions, the Federal Aviation Administration (FAA) issued Airworthiness Directive (AD) 2006-06-06 on 10 March 2006. This mandatory corrective action allows dispatch into forecast icing meteorological conditions exceeding "light," but requires pilots to exit moderate or more severe icing conditions if such conditions are encountered in flight. Cues are provided to enable pilots to determine when they must depart the icing conditions. The AD discusses the actions necessary to remove the restrictions imposed for flight in icing conditions. The FAA AD became effective 24 March 2006.

On 24 January 2006, Transport Canada (TC) issued Service Difficulty Alert 2006-01. Service Difficulty Alert 2006-01R1 was released on 01 February 2006 and the latest revision 2006-01R2 was released on 24 March 2006.

TC also reviewed FAA AD 2006-06-06. The Department supports the FAA's determination that these actions are necessary for safe operation. FAA AD 2006 06-06 has been accepted and is mandatory in Canada.
BOARD ASSESSMENT OF RESPONSE TC has essentially adopted the response from the FAA, who issued AD 2006-06-06. Action taken by the FAA will reduce, but not substantially reduce or eliminate, the deficiency raised in Board Recommendation A06-01. The response from TC does not address the issue of restricting the dispatch of the Cessna 208 into icing conditions forecast to exceed "light."
BOARD ASSESSMENT RATING Satisfactory in Part

RECOMMENDATION A06-02

The Department of Transport require that Canadian Cessna 208 operators maintain a minimum operating airspeed of 120 knots during icing conditions and exit icing conditions as soon as performance degradations prevent the aircraft from maintaining 120 knots.
RESPONSE To address the subject of Cessna 208 operation into icing conditions, the FAA issued AD 2006-06-06 on 10 March 2006. FAA AD 2006-06-06 was issued to implement the content of this recommendation. This mandatory corrective action specifies the minimum speed in icing conditions of 120 knots indicated airspeed (KIAS) in the flaps UP condition, and requires that the pilot depart icing conditions if 120 KIAS cannot be maintained in level flight.

On 24 January 2006, TC issued Service Difficulty Alert 2006-01. Service Difficulty Alert 2006-01R1 was released on 01 February 2006 and the latest revision 2006-01R2 was released on 24 March 2006.

TC also reviewed FAA AD 2006-06-06. The Department supported the FAA's determination that these actions are necessary for safe operation. FAA AD 2006-06-06 has been accepted and is mandatory in Canada.

TC agreed with Recommendation A06-02. TC reviewed FAA AD 2006-06-06, accepted the AD, and it is now mandatory in Canada.
BOARD ASSESSMENT OF RESPONSE In its response, TC adopted the action of the FAA, who issued AD 2006-06-06. Action taken by the FAA will substantially reduce or eliminate the deficiency raised in Board Recommendation A06-02.
BOARD ASSESSMENT RATING Fully Satisfactory

RECOMMENDATION A06-03

The Federal Aviation Administration take action to revise the certification of Cessna 208, 208A, and 208B aircraft to prohibit flight into forecast or in actual icing meteorological conditions exceeding "light," until the airworthiness of the aircraft to operate in such conditions is demonstrated.
RESPONSE On 27 September 2006, the Board received a letter dated 18 September 2006 in which the FAA responded to Recommendation A06-03. The response stated that the FAA agreed with the intent of the recommendation, and has taken action by issuing AD 2006-06-06, which limits the operation of Cessna 208 and 208B in icing conditions. The response also indicated that the FAA assessed its response as fully meeting the intent of this TSB recommendation.
BOARD ASSESSMENT OF RESPONSE FAA AD 2006-06-06 will require that pilots exit moderate or more severe icing conditions, when such conditions are encountered. In addition, AD 2006-06-06 provides a definition of icing conditions of moderate or greater intensity as they apply to the Cessna 208 and 208B type, identifies several cues to enable pilots to determine when they must depart such icing conditions, and provides guidance on how to exit icing conditions exceeding "light." Notwithstanding, the results of the FAA flight tests and review of accident data have not demonstrated that a Cessna 208 or 208B can successfully exit from such icing conditions. Effectively, the action taken by the FAA still allows the dispatch of aircraft into forecast icing conditions exceeding "light." The FAA action taken will reduce, but will not substantially reduce or eliminate, the deficiency raised in Board Recommendation A06-03.
BOARD ASSESSMENT RATING Satisfactory in Part

RECOMMENDATION A06-04

The Federal Aviation Administration require that Cessna 208 operators maintain a minimum operating airspeed of 120 knots during icing conditions and exit icing conditions as soon as performance degradations prevent the aircraft from maintaining 120 knots.
RESPONSE Although the FAA has not yet provided the TSB with a direct response regarding its actions taken in response to TSB Recommendation A06-04, the FAA letter dated 13 March 2006, in response to National Transportation Safety Board Recommendation A-06-01, is pertinent to the risks identified in TSB Recommendation A06-04. To address the subject of Cessna 208 operation into icing conditions, the FAA issued AD 2006-06-06 on 10 March 2006. FAA AD 2006-06-06 was issued to implement the content of this recommendation. This mandatory corrective action specifies the minimum speed in icing conditions of 120 KIAS in the flaps UP condition, and requires that the pilot depart icing conditions if 120 KIAS cannot be maintained in level flight.

On 19 May 2006, the FAA advised the TSB that Recommendation A06-04 had been forwarded to the Wichita Aircraft Certification Office for review and evaluation. The FAA Office of Accident Investigation is waiting for a reply from the Wichita Aircraft Certification Office.
BOARD ASSESSMENT OF RESPONSE FAA AD 2006-06-06 effectively mandates that 120 KIAS be the minimum Cessna 208 speed for flight in icing conditions as recommended in TSB Recommendation A06-04. The action taken by the FAA will substantially reduce or eliminate the deficiency raised in Board Recommendation A06-04.
BOARD ASSESSMENT RATING Fully Satisfactory
Rudder Separation in Flight, Air Transat, Airbus 310-308, Varadero, Cuba, 06 March 2005

Occurrence No. A05F0047
RECOMMENDATION A06-05

The Department of Transport, in coordination with other involved regulatory authorities and industry, urgently develop and implement an inspection program that will allow early and consistent detection of damage to the rudder assembly of aircraft equipped with part number A55471500 series rudders.
RESPONSE In its 14 June 2006 letter, TC provided the following comments:

- TC concurs with the TSB suggestion that the current A310-300 inspection program may not be adequate to provide timely detection of defects to the rudder assembly. This may be caused by either inappropriate inspection intervals or inadequate inspection techniques.
- At the time of this occurrence, composite materials in general were, from a maintenance perspective, believed to have a no-damage growth design philosophy. It was also believed that, from a fatigue point of view, more frequent inspections of composite materials would not prove to be more effective. In addition, these concepts were an industry-accepted philosophy during the development of maintenance programs using the Maintenance Review Board (MRB) process.
- As a result of this occurrence, and the additional findings based on the Airbus All Operators Telex, TC now believes that there is potential for damage growth. Following this determination, the Department inspected additional Canadian-registered A310-300 series aircraft in order to evaluate the effectiveness of the current Airbus maintenance program.

The following corrective actions are currently being taken by TC:

- TC will send a letter to Airbus Industries and the Direction Gnrale de l'Aviation Civile (DGAC) of France detailing the results of our additional inspection on a Canadian-registered A310-300 series aircraft.
- TC will recommend that a detailed inspection of the drainage path of the rudder for blockage be added to the current inspection program to ensure that there is adequate drainage.
- TC will request that Airbus Industries review the current inspection program for the vertical stabilizer and rudder assembly for the A300/A310 aircraft series.
- Because a tap test, a scheduled inspection of the rudder required at the time of the occurrence, is potentially not effective in determining smaller areas of delamination or disbond of composite materials, TC is currently working with the National Research Council of Canada to identify suitable inspection techniques that will detect failures in composite materials.
- To better identify failures in composite material, TC will coordinate with the International MRB Policy Board to review the logic used in developing maintenance programs.
BOARD ASSESSMENT OF RESPONSE In its 14 June 2006 response, TC stated that it is currently working with the National Research Council of Canada to identify suitable inspection techniques that will detect failures in composite materials. TC will recommend that a detailed inspection of the drainage path of the rudder for blockage be added to the current inspection program to ensure that there is adequate drainage. TC will also request that Airbus Industries review the current inspection program for the vertical stabilizer and rudder assembly for the A300/A310 aircraft series, and will work with the International MRB Policy Board to review the logic used in developing maintenance programs.
BOARD ASSESSMENT RATING Satisfactory Intent
RECOMMENDATION A06-06

The European Aviation Safety Agency, in coordination with other involved regulatory authorities and industry, urgently develop and implement an inspection program that will allow early and consistent detection of damage to the rudder assembly of aircraft equipped with part number A55471500 series rudders.
RESPONSE In its response, the European Aviation Safety Agency (EASA) stated that it agreed with the Board recommendation and that AD 2006-0066 issued on 24 March 2006 requiring a mandatory one-time inspection satisfactorily addressed the Board recommendation.

On 21 December 2006, following a TSB conference call with the EASA, the latter stated that all elements that may have potentially caused the damage growth were still being investigated. Furthermore, the EASA stated that, within the continued airworthiness process and in cooperation with Airbus Industries, it continues its efforts to determine the most appropriate corrective actions. Subsequently, the EASA will consider mandating those actions, including amending the maintenance program to require repetitive inspections.
BOARD ASSESSMENT OF RESPONSE Although the EASA agreed with the Board recommendation, AD 2006-0066 referenced in its 22 November 2006 response does not provide for a repetitive inspection cycle that will allow early and consistent detection of damage, as is implied in the core of Recommendation A06-06. Nevertheless, the TSB assessed that the EASA is well positioned to take a leadership role within the industry in advocating for the development and integration of an inspection program dealing with composite materials. On that basis, the 20 December 2006 conference call was initiated.

The 17 January 2007 response reflects EASA's commitment to continue to develop corrective actions that may include amending the maintenance program to require repetitive checks.
BOARD ASSESSMENT RATING Satisfactory Intent
2.6.3.3 Other Air Safety Actions

As a result of Recommendation A04-02 from investigation A04H0001, Transport Canada (TC) re-evaluated the standard weights for passengers and carry-on baggage and adjusted them for all aircraft to reflect current realities. The Federal Aviation Administration (FAA) issued Airworthiness Directive (AD) 2005-07-01, for the Cessna 208 and 208B aircraft. This AD was issued as a result of several accidents and incidents involving Cessna 208 and 208B operating in icing conditions, including this occurrence. The purpose of the AD was to ensure that pilots have enough information to prevent loss of control of the aircraft while in flight during icing conditions.

Following the receipt of TSB Safety Advisory A040058, generated by TSB investigation A04H0004, TC advised that it was developing and would soon dispatch a Commercial and Business Aviation Advisory letter concerning the need for accurate aircraft load control. As well, as a result of TSB Safety Advisory A040059 on erroneous runway slope information, TC sent an Aerodrome Safety Urgent Bulletin to airports and registered aerodromes reminding them of the need to verify published data.

During a TSB risk of collision investigation (A04Q0089), NAV CANADA undertook a major rewrite of the basic visual flight rules air traffic control training course delivered at its training facility and implemented the new curriculum. Emergency procedures are taught in instructor-led classroom activities that include the associated phraseology. Non compliance situations by a pilot are taught in the classroom, and are practised in a number of exercises in the dynamic 360-degree airport simulator throughout the course.

During the progress of a TSB investigation into a risk of collision incident at Vancouver International Airport, British Columbia (A04P0397), the Vancouver International Airport tower manager issued an Operations Bulletin to remind controllers to adhere to the Air Traffic Control Manual of Operations (ATC MANOPS) direction to state the name of the intersection or taxiway when issuing taxi to position instructions or take-off clearances from an intersection. NAV CANADA proposed an amendment to Section RAC 4.2.8 of the Aeronautical Information Manual (AIM), which would recommend that pilots include their location with the runway number when requesting take-off clearance.

Pursuant to Safety Advisory A050012 (A05Q0024), TC indicated that it would examine the possibility of adding information on the level of runway certification to the Canada Flight Supplement, which would provide more information and details to pilots regarding any change to the certification status of a given runway.

Following occurrence investigation A05O0112 and the subsequent audit by TC, Rapid Aircraft Repair Inc. hired a Director of Quality Assurance and designated this person as the person responsible for maintenance. The company amended its Quality Assurance Program to ensure closer scrutiny in all aspects of maintenance than was previously possible; implemented a process for regular discussions on process control; implemented the process of a full-control travel check before disassembly; implemented additional training on human factors, improving the reporting of potential problems; and began implementing a safety management system.

Following the commencement of an investigation concerning an inadvertent stick shaker at high altitude (A05W0109), Bombardier Aerospace issued a message to all operators of the CRJ705/900 variants of the CL-65 emphasizing that flight operations should not be conducted below minimum drag speed as defined in the General Speed Section of the Flight Planning Cruise Control Manual for the aircraft type. Air Canada Jazz introduced a nine-module "High Altitude and High Speed Training" program for all CRJ705 pilots. TC published Commercial and Business Aviation Advisory Circular 0247 providing guidance and recommendations to operators for stall recovery training and checking, with the goal of ensuring that flight crews recognize early indications of an approach to a stall and apply the appropriate recovery actions to prevent an aeroplane from entering a stall or upset.

Following a power loss and collision with terrain investigation (A05O0125), the aircraft kit manufacturer posted aircraft information to the technical website used by international owners describing the dangers of using a particular stick grip to actuate trim and flaps.

As a result of TSB investigation A05O0147 (collision with water), the TSB determined that the pilot was able to manoeuvre into the right seat after the aircraft became inverted, but was unable to exit the aircraft. TC undertook a risk assessment, "Egress from Submerged Floatplanes," to identify the risks related to egress from submerged seaplanes and to identify the most effective means of mitigating those risks.

Following the investigation into a helicopter in-flight break-up (A05P0269), Columbia Helicopters Incorporated advised all Boeing 107 helicopter crews of the recurrent procedures to check the operation and serviceability of the speed trim actuator switches. Boeing Aerospace Support-Philadelphia issued Service Bulletin 107-67-1001, requesting that all operators of Model 107 helicopters (BV and KV) and 107 derivatives inspect and functionally test the longitudinal cyclic trim actuator limit switches. Boeing recommended that this test be accomplished before the next flight and before each subsequent flight until further notice.