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Reassessment of the responses from Transport Canada to Aviation Safety Recommendation A03-06
Accident investigation issues: Quality of cockpit voice recorder recording
On 02 September 1998, Swissair Flight 111, a McDonnell Douglas MD-11 aircraft, departed John F. Kennedy Airport in New York, New York, en route to Geneva, Switzerland. Approximately one hour after take-off, the crew diverted the flight to Halifax, Nova Scotia, because of smoke in the cockpit. While the aircraft was manoeuvring in preparation for landing in Halifax, it struck the water near Peggy's Cove, Nova Scotia, fatally injuring all 229 occupants on board. The investigation revealed that the flight crew had lost control of the aircraft as a result of a fire in the aircraft's ceiling area, forward and aft of the cockpit bulkhead.
The Board concluded its investigation and released report A98H0003 on 27 March 2003.
Board Recommendation A03-06 (27 March 2003)
Frequently, the cockpit voice recorder (CVR) recording of cockpit conversations is of poor quality, particularly when the conversations are recorded through the cockpit area microphone. The voice quality on CVR recordings is dramatically improved when voices are recorded through boom microphones. However, pilots are not required to wear headsets with boom microphones at cruising altitudes. The ability to decipher internal conversations between flight crew members is an important element of effective accident investigation. Therefore, the TSB recommended that:
Regulatory authorities, in concert with the aviation industry, take measures to enhance the quality and intelligibility of CVR recordings.
Response to A03-06 (29 October 2003)
In response to Recommendation A03-06, Transport Canada (TC) provided the following comments:
- TC agrees with the intent of the recommendation.
- TC agrees that boom microphone usage will improve the quality of recordings but that the issue of pilot fatigue must be addressed.
- TC intends to start regulatory action to harmonize the altitude at which the crew must use boom microphones with that specified by the Federal Aviation Regulations (FARs) (18 000 feet above sea level).
- TC will consult with stakeholders to evaluate the technical issues to improve the quality of the CVR recordings and to assess the need for advisory material and standardization with other Civil Aviation Authorities (CAAs).
Board Assessment of the Response to A03-06 (29 October 2003)
TC's response details initiatives that should, if adopted, enhance the quality and intelligibility of CVR recordings. Consequently, the response is assessed as Satisfactory Intent.
Next TSB action
The TSB Air Branch will monitor TC's efforts to change the rule for boom microphone usage and its efforts to develop advisory material and harmonization with other CAAs on this matter.
Response to A03-06 (14 December 2005)
TC's update, dated 14 December 2005, advised that it has introduced regulations (CAR 625 Appendix C, paragraph 14(d)) that require an annual intelligibility check conducted under flight conditions to verify the proper functioning of the CVR system. The evaluation of the CVR recordings is intended to identify any corrective actions needed to bring the CVR system into compliance.
Additionally, TC's update restates its position with respect the usage of boom microphone as a measure to improve the quality of voice recordings. Current operational regulations (625.33(II)(5)) mandate the use of the boom or mask microphone only during operation of the aircraft below transition altitude (10 000 feet above means sea level). This is consistent with International Civil Aviation Organization Annex 6, Chapter 6, paragraph 6.20. While TC acknowledges that the use of boom microphones would improve the quality of voice recordings, it is felt that full-time use would lead to increased fatigue on long flights and that any regulation mandating full-time use would be virtually impossible to enforce and likely to be ignored by most pilots. It is noted that the United States FARs require the wearing of boom microphones below an altitude of 18 000 feet.
TC will not pursue Notice of Proposed Amendment action to harmonize the transition altitude from (10 000 feet above means sea level) to that of 18 000 feet.
Board Reassessment of the Response to A03-06 (23 June 2006)
TC's letter of 14 December 2005 indicates that it has introduced regulations (CAR 625 Appendix C, paragraph 14(d)) that require an annual intelligibility check conducted under flight conditions to verify the proper functioning of the CVR system. As far as the increased usage of boom microphones is concerned, TC agrees that this would enhance quality and intelligibility of recordings. However, contrary to its original response, TC now has no intention of increasing the use of boom microphones for Canadian operators. The planned action or the action taken will reduce but not substantially reduce or eliminate the deficiency.
Therefore, the assessment is assigned Satisfactory-in-Part.
Next TSB action
Further action is unwarranted as TC has stated that it has no intention of taking steps to improve the quality of voice recordings by requiring the increased usage of boom microphones in Canada. Hence, the residual risk associated with the limited use of boom microphones aspect of the A03-06 safety deficiency will remain.
Review of A03-06 Deficiency File Status (23 September 2009)
As TC has stated that plans no action to address any residual risk associated with the deficiency identified in Recommendation A03-06, the Board concludes that continued reassessment will not likely yield further results.
Therefore, the assessment remains at Satisfactory-in-Part
Next TSB action
TSB Air Branch staff will not actively monitor TC's regulatory activities to enhance the quality and intelligibility of CVR recordings as stated in Recommendation A03-06.
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