Annual Report to Parliament 2007-2008

Table of Contents | 2 | 3

Transportation Safety Board Annual Report to Parliament 2007-2008

2.5 Rail Sector

2.5.1 Annual Statistics

A total of 1331 rail accidents were reported to the TSB in 2007, a 3 per  cent decrease from the 2006 total of 1378 and a 4 per  cent decrease from the 2002-2006 average of 1391. Estimated rail activity decreased by 3 per cent from 2006, but is comparable to the five-year average. The accident rate decreased to 14.3 accidents per million train-miles in 2007, compared to 14.4 in 2006 and the five-year rate of 15.2. Rail-related fatalities totalled 86 in 2007, compared to the 2006 total and five-year average of 95.

Eight main-track collisions occurred in 2007, compared to three in 2006 and the five-year average of six. In 2007, there were 161 main-track derailments, an increase of 14 per  cent from the 2006 total of 141 and of 3 per cent from the five-year average of 156. Non main-track derailments decreased to 639 in 2007 from 704 in 2006 and from the five-year average of 707.

In 2007, crossing accidents decreased to 218 from the 2006 total of 248 and from the five-year average of 254. Crossing-related fatalities numbered 27, down from 28 in 2006 and from the five-year average of 33. Trespasser accidents increased by 8 per cent to 99 in 2007 from 92 in 2006, and increased by 21 per cent over the five-year average of 82. With a total of 57 fatalities in 2007, trespasser accidents continued to account for the majority of rail fatalities.

In 2007, 192 rail accidents involved dangerous goods (this also includes crossing accidents in which the motor vehicle is carrying a dangerous good), up from 183 in 2006 but down from the five-year average of 210. Five of these accidents resulted in a release of product.

In 2007, rail incidents reported to the TSB in accordance with the mandatory reporting requirements totalled 233, up from 221 in 2006 but down from the five-year average of 265. Movements exceeding limits of authority incidents (113) comprised the largest proportion of the 233 reportable incidents. The second largest proportion was dangerous goods leaker incidents (90).

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 increased from 2.6 accidents per million main-track train-miles in 2006 to 3.2 in 2007.5

Figure 8: Main-Track Accident Rates

Figure 8 - Main-Track Accident Rates
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2.5.2 Investigations

A total of 11 new rail investigations were started in 2007-2008 and 14 investigations were completed. The average duration of completed investigations increased to 697 days compared to 598 days the year before. This increase is attributable to concentrated efforts to complete older investigations.

Table 4: Rail Productivity

  2003-2004 2004-2005 2005-2006 2006-2007 2007-2008
Investigations Started 14 14 9 18 11
Investigations Completed 15 25 9 12 14
Average Duration of Completed Investigations (Number of Days) 894 618 519 598 697
Recommendations 4 3 0 2 4
Safety Advisories 7 6 9 8 16
Safety Information Letters 11 10 8 2 13
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

Four rail safety recommendations were issued in 2007-2008.

The Rail Branch reassessed responses to 120 recommendations issued since 1991. With Board approval, 4 recommendations went from active to inactive status and 21 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 2007-2008

Derailment, Canadian National Freight Train,
Wabamun, Alberta, 03 August 2005

Report No. R05E0059
RECOMMENDATION R07-01

The Department of Transport establish minimum standards for the quality and strength of maintenance rails.
RESPONSE Transport Canada has included this as a project to be undertaken in order to establish standards and has also included it for consideration in modernizing the Railway Track Safety Rules.
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending
RECOMMENDATION R07-02

The Department of Transport establish standards requiring that rails approaching their fatigue limit be replaced.
RESPONSE Transport Canada has included this as a project to be undertaken in order to establish standards and has also included it for consideration in modernizing the Railway Track Safety Rules.
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending

Main-Track Derailment, Canadian National Freight Train,
Saint-Henri-de-Lévis, Quebec, 17 August 2004

Report No. R04Q0040
RECOMMENDATION R07-03

The Department of Transport and the railway industry conduct in-depth studies on the behaviour of saturated organic materials under cyclic loading.
RESPONSE Awaiting response
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending
RECOMMENDATION R07-04

The Department of Transport extend the safety provisions of the construction standards applicable to 286 000-pound cars to all new non-pressurized tank cars carrying dangerous goods.
RESPONSE Awaiting response
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending

2.5.3.2 

Assessment of Responses to 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 agrees in principle with the intent of this recommendation and will work with the industry to examine periods of high rail traffic controller workload activity in the context of this recommendation and other regulatory initiatives.
BOARD ASSESSMENT OF RESPONSE On 23 August 2007, Transport Canada indicated that a qualified outside consultant was hired to conduct a study to examine rail traffic controller workload. On 31 October 2007, Transport Canada indicated that, upon recent review and discussion with the TSB of the specific requirements of the recommendation, it has determined that a comprehensive study is not warranted.
BOARD ASSESSMENT RATING Unsatisfactory

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 Transport Canada disagrees with the recommendation and feels that it would not be safety productive to comply.
BOARD ASSESSMENT OF RESPONSE Transport Canada has prioritized some high-risk crossings, and improvements are being made as resources permit. Transport Canada is drafting a Pedestrian Crossing Standard.
BOARD ASSESSMENT RATING Satisfactory Intent

2.5.3.3 Other Rail Safety Actions

The United States Federal Railroad Administration and the North American railway industry signed a memorandum of cooperation in April 2007 to develop a better understanding of the factors contributing to high-pressure tank car safety and to enhance the effectiveness of railway-specific hazardous material bulk packaging under the project "Next Generation Tank Car" (TSB investigation report R04Q0040).

Canadian National (CN) issued instructions to keep heavy cars on the head end whenever possible based on the possibility that destination marshalling may increase the risk of undesirable track-train dynamics (TSB investigation report R05C0116). It also instituted a complete restriction on the handling of certain maintenance-of-way equipment in trains after a derailment involving that equipment (TSB occurrence R07T0110), and issued a bulletin directing operators of remotely controlled trains to visually verify that the movement is responding in the required direction (TSB investigation report R07W0042).

Canadian Pacific Railway (CPR) revised its General Operating Instructions to prescribe certain improvements to marshalling of locomotives without coupler alignment control (TSB investigation report R05C0082). It also conducted a system-wide review to verify the safe condition of all derails, including correct size and proper securement of derails (TSB Rail Safety Information letters 13/07 and 16/07), and issued internal instructions to track maintenance forces that modifications to car equipment must first be approved by the car engineering group (TSB occurrence R07H0015).

CSX Transportation Inc. reduced the permissible speed to 10 mph on several portions of its Montréal Subdivision, and performed track rehabilitation from the United States border to Beauharnois, Quebec (TSB investigation report R07D0030).

VIA Rail Canada Inc. (VIA) and Goderich-Exeter Railway (GEXR) issued instructions for the use of cellular telephones in Occupancy Control System territory over the Guelph Subdivision (TSB investigation report R06H0013).

Transport Canada (TC) issued a Notice to CN concerning its rail inspection records as required by the Railway Track Safety Rules. CN subsequently incorporated data used for the verification check into the railway's rail flaw testing databases with the capability to be uploaded on a daily basis. TC also issued Notices and Orders to CN concerning train operations on the Squamish Subdivision in British Columbia relating to safety deficiencies in train operations on the former BC Rail line (TSB investigation report R05V0141).

TC issued a Notice to CN requiring that employees who operate trains be adequately instructed and trained in the procedures to be followed for the safe and proper operation of the equipment, and to be familiar with the territory (TSB Rail Safety Advisory 12/07).

TC also noted deficiencies in the Railway Freight and Passenger Train Brake Rules and, in consultation with an industry working group, is considering proposed amendments to address the inadequacies. TC is researching the issues of train length and train handling to develop safety guidelines or standards (TSB investigation report R05C0116).

TC reviewed work records of randomly selected VIA locomotive engineers within the Pacific Region to verify compliance with Rule 5.1.2 of the Work/Rest Rules for Railway Operating Employees (TSB Rail Safety Information letter 07/07).

It also reviewed the loading and unloading facilities of shipments of copper concentrate in open gondola cars arriving at the Vancouver Wharf, British Columbia (TSB Rail Safety Information letter 06/07).

Furthermore, TC reviewed the securement of rail cars being stored on siding tracks that had track gradient and frequent exposure to high winds on the Montmagny Subdivision (TSB Rail Safety Information letter 02/08).

2.6 Air Sector

2.6.1 Annual Statistics

Canadian-registered aircraft, other than ultralights, were involved in 284 reported accidents in 2007, an 8 per cent increase from the 2006 total of 262 and a 6 per cent increase from the 2002-2006 average of 268. The estimate of flying activity for 2007 is 4 373 000 hours, yielding an accident rate of 6.5 accidents per 100 000 flying hours, up from the 2006 rate of 6.3 but down from the five-year rate of 6.7. Canadian-registered aircraft, other than ultralights, were involved in 33 fatal occurrences with 49 fatalities in 2007, comparable to the 31 fatal occurrences with 52 fatalities in 2006 and the five-year average of 30 fatal occurrences with 50 fatalities. A total of 12 fatal occurrences involved commercial aircraft (7 aeroplanes and 5 helicopters), and 14 of the remaining 21 fatal occurrences involved privately operated aeroplanes.

The number of accidents involving ultralights increased to 30 in 2007 from 28 in 2006, and the number of fatal accidents increased to 5 in 2007 from 1 in 2006.

The number of foreign-registered aircraft accidents in Canada decreased to 10 in 2007 from 14 in 2006. There were no fatal accidents in 2007, down from 2 in 2006.

In 2007, a total of 874 incidents were reported to the TSB in accordance with the mandatory reporting requirements. This represents a 6 per cent increase from the 2006 total of 825 and a 3 per cent increase from the 2002-2006 average of 851.

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 2007, this rate increased to 6.5 accidents per 100 000 hours from the 2006 rate of 6.3, but remained below the five-year average of 6.7. The trend line shows a significant downward trend 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 49 air investigations were started in 2007-2008 and 47 investigations were completed. This represents an increase in the number of investigations completed compared to the previous year (36). The average duration of completed investigations has decreased to 493 days, compared to 516 days the year before.

Table 5: Air Productivity

  2003-2004 2004-2005 2005-2006 2006-2007 2007-2008
Investigations Started 47 44 50 41 49
Investigations Completed 40 67 53 36 47
Average Duration of Completed Investigations (Number of Days) 485 524 404 516 493
Recommendations 0 4 6 4 11
Safety Advisories 9 9 7 16 13
Safety Information Letters 8 6 5 12 9
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

Eleven air safety recommendations were issued in 2007-2008. Of that number, seven responses have been received to date and are being assessed by the staff.

The Air Branch reassessed responses to 39 recommendations issued in previous years. With Board approval, 5 recommendations went from active to inactive status. At the end of fiscal year 2007-2008, there were 43 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 2007-2008

Runway Overrun and Fire, Air France, Airbus A340-313,
Toronto/Lester B. Pearson International Airport, Ontario, 02  August 2005

Report No. A05H0002
RECOMMENDATION A07-01

The Department of Transport establish clear standards limiting approaches and landings in convective weather for all air transport operators at Canadian airports.
RESPONSE Transport Canada's response was received and is being assessed.
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending
RECOMMENDATION A07-02

France's Direction Générale de l'Aviation Civile and other civil aviation authorities establish clear standards limiting approaches and landings in convective weather.
RESPONSE The Direction Générale de l'Aviation Civile's response was received and is being assessed.
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending
RECOMMENDATION A07-03

The Department of Transport mandate training for all pilots involved in Canadian air transport operations to better enable them to make landing decisions in deteriorating weather.
RESPONSE Transport Canada's response was received and is being assessed.
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending
RECOMMENDATION A07-04

France's Direction Générale de l'Aviation Civile and other civil aviation authorities mandate training for air transport pilots to better enable them to make landing decisions in deteriorating weather.
RESPONSE The Direction Générale de l'Aviation Civile's response was received and is being assessed.
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending
RECOMMENDATION A07-05

The Department of Transport and other civil aviation authorities require crews to establish the margin of error between landing distance available and landing distance required before conducting an approach into deteriorating weather.
RESPONSE Transport Canada's response was received and is being assessed.
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending
RECOMMENDATION A07-06

The Department of Transport require all Code 4 runways to have a 300 m runway end safety area (RESA) or a means of stopping aircraft that provides an equivalent level of safety.
RESPONSE Transport Canada's response was received and is being assessed.
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending
RECOMMENDATION A07-07

The Department of Transport require that passenger safety briefings include clear direction to leave all carry-on baggage behind during an evacuation.
RESPONSE Transport Canada's response was received and is being assessed.
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending
Engine Power Loss - Forced Landing, Sonicblue Airways, Cessna 208B (Caravan),Port Alberni, British Columbia, 21 January 2006

Report No. A06P0010
RECOMMENDATION A07-08

The Department of Transport take into account all propulsion system failures when assessing the safety of single-engine commercial operations.
RESPONSE Awaiting response
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending
Hydraulic Flight Control Malfunction, Vancouver Island Helicopters, Eurocopter AS 350 B2 (Helicopter), Kamarang, Guyana, 06 February 2005

Report No. A05F0025
RECOMMENDATION A07-09

The European Aviation Safety Agency, in coordination with other involved regulatory authorities and industry, ensure that the AS 350 helicopter hydraulic cut-off (HYD CUT OFF) switch is capable of handling the inductive electrical load of the circuit.
RESPONSE Awaiting response
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending
Hard Landing - Fuel Leak and Fire, Sundance Balloons International, FireFly 12B Hot Air Balloon, Winnipeg, Manitoba, 11 August 2007

Report No. A07C0151
RECOMMENDATION A08-01

The Department of Transport ensure that passenger-carrying commercial balloon operations provide a level of safety equivalent to that established for other aircraft of equal passenger-carrying capacity.
RESPONSE Awaiting response
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending
RECOMMENDATION A08-02

The Department of Transport ensure that balloons carrying fare-paying passengers have an emergency fuel shut-off.
RESPONSE Awaiting response
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 2006-2007


Post-Impact Fires Resulting from Small-Aircraft Accidents,
Safety Issues Investigation

Report No. A05C0187
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 In its 20 November 2006 response, Transport Canada (TC) did not make reference to the deficiency described in Recommendation A06-08.

In its response dated 29 January 2007, TC states that it does not select the value of statistical life (VSL) but merely uses a VSL established by Treasury Board Secretariat (TBS) for use in its regulatory-related cost-benefit analysis. TC has contacted TBS to discuss Recommendation A06-08, and TBS staff has expressed interest in reviewing the VSL. TC states that it is interested in participating in a TBS - led interdepartmental review of the VSL. TC's response suggests that the TSB may wish to participate in such a review of VSL rates and calculation methodology.

Additionally, TC states that, because the VSL is not solely an aviation issue, it would be inappropriate to approach the Federal Aviation Administration (FAA) regarding changes to the VSL. TC advises that the FAA is aware of TSB's report SII A05-01 and that TC is in regular contact with the FAA and will relay any information regarding FAA's intentions to the TSB.
BOARD ASSESSMENT OF RESPONSE As TC's response dated 20 November 2006 contained no action or proposed action that would reduce or eliminate the risks associated with this deficiency, TSB staff sought an update of TC's position to Recommendation A06-08.

TC's updated response does not indicate TC's position with respect to the core of Recommendation A06-08; that the cost-benefit analysis used in FAA's Notice of Proposed Rule Making 85-7A be revised in accordance with suggested criteria. Instead, it focuses on the issues related to a single criterion: the current VSL rates. Additionally, there is no mention of revising the cost-benefit analysis in light of the benefits of the Canadian post-impact fire statistics or in consideration of the newest advances in post-impact fire-prevention technology.

As far as working with foreign regulators, TC indicates that it will not take any extraordinary measures in its dealings with the FAA to advance the merits of Recommendation A06-08 and makes no mention of contacting other foreign regulators. Essentially, TC's action plan is limited to working with TBS to review the VSL.
BOARD ASSESSMENT RATING Satisfactory in Part
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 TC's response dated 20 November 2006 makes a general statement that many amendments to Airworthiness Manual (AWM) 523/FAR 23 regulations have been adopted and may address certain elements of Recommendation A06-09. Furthermore, it states that many of the aircraft identified in the TSB report were certified to earlier design standards and would not have benefited from subsequent regulatory changes. Additionally, TC's response expresses support for the intent of this recommendation but concludes by declaring that TC is not in a position to commit the necessary resources at this time.

TC's updated response dated 29 January 2007 declares that TC still holds the fundamental position outlined in the Minister's response. It restates that there have been many amendments to AWM 523/FAR 23 regulations and that current standards are more stringent than those that prevailed during the time when the aircraft cited in report SII A05-01 were built. The response goes on to explain that elements of Recommendation A06-09 will be taken into consideration as the regulator performs due diligence on any proposed regulatory change. The remainder of the response explains the certification process and how proposed modifications to an aircraft or component are evaluated against the standards in force at the time of certification.
BOARD ASSESSMENT OF RESPONSE TC's 20 November 2006 response implies but does not state which amendments to AWM 523/FAR 23 have addressed elements of Recommendation A06-09. Additionally, the response does not provide any insight into TC's assessment of the merits of amending new aeroplane type design standards as suggested in Recommendation A06-09. Furthermore, it is not clear why TC's response focuses on existing certificated aircraft rather than addressing the need to reduce the number of post-impact fires in impact-survivable accidents by amending new aeroplane type design standards as Recommendation A06-09 suggests.

The updated response dated 29 January 2007 is a clarification of TC's position as originally stated in the Minister's response dated 20 November 2006. As in the original response, a general reference is made to AWM 523/FAR 23 amendments but no specifics are provided as to whether or not these amendments address the deficiencies to the aeroplane type design standards as identified in Recommendation A06-09. Additionally, although TC indicates that it will consider the "safety concerns" identified in Recommendation A06-09, as the standards evolve, no definitive action plan to cause a review of the aeroplane type design standards is provided. In summary, the status quo is maintained because TC states that it still holds the fundamental position outlined in the Minister's response dated 20 November 2006.
BOARD ASSESSMENT RATING Unsatisfactory
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 TC's response dated 20 November 2006 states that it is not aware of any aviation industry initiatives to retrofit production aircraft in the manner suggested in Recommendation A06-10. Furthermore, TC states that, until such technology is available, viable and required, it cannot conduct a risk assessment or mandate a retrofit to production aircraft. It concludes by stating that a study would be required to clearly identify the benefit of such an undertaking. The final paragraph of the response states that the Department is not in a position to commit the necessary resources at this time.

In its second response dated 29 January 2007, TC states that it would be inappropriate for TC to mandate changes to current production aircraft as suggested in Recommendation A06-10. TC indicates that it will review design proposals from industry in light of TSB's recommendations to assure that such modifications meet the highest standards possible.
BOARD ASSESSMENT OF RESPONSE TC's initial response dated 20 November 2006 states that TC cannot conduct a risk assessment to determine the feasibility of retrofitting aircraft, as suggested in Recommendation  A06-10, because a study must first be undertaken to establish that pertinent technologies are available, viable and required. No action plan to conduct such a study is provided in TC's response.

TC's follow-up response dated 29 January 2007 states that mandating changes to current production aircraft as suggested in Recommendation A06-10 would be inappropriate. This statement is incongruous as Recommendation A06-10 makes no mention of mandating changes but rather suggests that risk assessments be conducted. In lieu of any TC initiative to conduct risk assessments, TC would react to technology proposals from industry to ensure that such modifications meet the highest standards.
BOARD ASSESSMENT RATING Unsatisfactory

2.6.3.3 Other Air Safety Actions

As a result of A05A0161 in which a commercial airliner experienced wing tip scrape during a low-visibility approach, aviation regulations have been amended to prohibit commercial aeroplane operators from beginning an approach when visibility is so poor that a successful approach to a landing is unlikely. Termed "Approach Ban," the amended regulations establish, for all runways where visibility is reported, the minimum visibility for the crew to begin an approach.

Following a loss of separation investigation (A05C0153) near Hall Beach, Nunavut, Transport Canada (TC) issued an amendment to Section RAC 12.7.1.3 of the Aeronautical Information Manual requiring that pilots use published latitude and longitude coordinates when making position reports when compulsory reporting points have not been named. As well, on 27 June 2006, the Edmonton Area Control Centre issued a directive to the North High and Shield specialties that included a requirement that the controller activating the northern airspace display system (NADS) flight plan verify the fix field against the flight plan route to ensure an accurate setup. Since the occurrence, direct controller-pilot communications have been enhanced in the North High and Shield specialties with the establishment of 12 new communications frequencies, and the upgrade of two frequencies to long-range frequencies.

Based on the initial information uncovered during TSB investigation A05F0047 concerning the loss of the rudder on an Airbus A310, on 17 March 2005, Airbus issued an All Operators Telex for the inspection of all aircraft equipped with part number A55471500 series rudders. This one-time visual and tap-test inspection involved 222 Airbus A310s, 146 Airbus A300-600s, 6 Airbus A330s, and 34 Airbus A340s, for a total of 408 aircraft. In addition, a more detailed inspection of rudder side panels on over 20 aircraft was conducted using the elasticity laminate checker (ELCH) test method.

On 08 September 2006, following the investigation (A05P0298) into a fatal crash involving an engine failure on a Mitsubishi MU-2B, TC issued Service Difficulty Advisory (SDA) AV- 2006-07 regarding Mitsubishi MU-2B cracked combustor plenums (Honeywell TPE-331-6-252M engines). The SDA recommended compliance with the manufacturer's (Honeywell) service bulletin (SB) TPE-331-72-2023 to change the combustion chamber from a 3102613-1 (multi-casting boss plenum) to a 3102613-2 (single-casting boss plenum). TC also recommended that maintenance personnel be extra attentive to boss welds when inspecting TPE-331 series engines for plenum cracks.

Following an investigation (A06W0104) into the loss of control and collision with terrain of a Bell 206B helicopter, the Alberta Forest Protection Branch advised that a list of remedial actions had been implemented to monitor passenger and equipment loads to prevent overloading of helicopters. A process to provide pilots with accurate firefighter crew and gear weights may help to ensure that helicopters involved in firefighting activities in Alberta are flown within prescribed weight and balance limits. As well, aviation audits were conducted at three of the four major Mountain Pine Beetle controls within Alberta, and the issue of providing accurate weights was reviewed and stressed at a training course for Type 1 and Type 1F initial attack leaders.

Pursuant to Aviation Safety Advisory A07W0099-D1-A1, TC indicated that the content of the advisory would be printed in TC's Aviation Safety Letter, Issue 2/2008, to inform industry of the significance of load shifting on aircraft performance and the need to effectively secure cargo in order to reduce the risk of in-flight load shift.

On 21 November 2006, a Bombardier CL-600-2B19 aircraft experienced a low fuel emergency as a result of a missed approach at the destination airport and then had to fly to a diversion airport with flaps fully extended as a result of flap failure. Following the receipt of Aviation Safety Advisory A06Q0188-D2-A1 and a related Board concern from the TSB, TC contacted Bombardier. Bombardier committed to draft an All Operators Message (AOM) to alert all operators of the incident and of the possible impact of flap system failure on fuel management. Following the same occurrence, TC and Bombardier Aerospace initiated a review of the existing Certification Maintenance Requirements (CMRs) for the CRJ flap system to identify short- and long-term actions to improve CRJ flap system reliability.

Aviation Safety Advisory A06P0010-D1-A1 apprised TC of a safety deficiency involving pilot training in the handling of engine failures during single-engine instrument flight rules (SEIFR) flight. In response, TC advised that TC's Civil Aviation Standards Branch would prepare and issue a paper with the recommendation that air operators review their company training programs to ensure that SEIFR pilots receive practical training on engine failure procedures in instrument meteorological conditions (IMC) specific to the air operation and geographic location.

On 06 February 2007, the TSB issued occurrence bulletin (OB) A06P0190-1 to TC providing a factual description of the failure mode of the Bell 206B pylon support spindle. On 27 February 2007, TC issued Airworthiness Directive (AD) CF-2007-02, which mandated removal of all Bell 206B pylon support spindles that had been repaired by Cadorath Aerospace Inc. and mandated that maintenance records be annotated accordingly. On 09 March 2007, Bell Helicopter Textron Inc. (BHTI) issued Operational Safety Notice (OSN) 206-99-35 Revision B. This document is a revision of the previous version (Revision A) and reinforces BHTI's opposition to dimensional restoration repairs of Bell 206B pylon support spindles.

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