Upgrading flight data recorder and cockpit voice recorder requirements
The Department of Transport expedite legislation for upgrading the flight recorder requirements for Canadian-registered aircraft.
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Air transportation safety investigation report
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|---|---|
| Date the recommendation was issued |
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| Date of the latest response |
June 2018
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| Date of the latest assessment |
October 2017
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| Rating of the latest response |
Unsatisfactory
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| File status |
Closed
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All responses are those of the stakeholders to the TSB in written communications and are reproduced in full. The TSB corrects typographical errors in the material it reproduces without indication but uses brackets [ ] to show other changes or to show that part of the response was omitted because it was not pertinent.
Summary of the occurrence
On 29 November 1988, the air ambulance Beechcraft King Air A-100, Voyageur 796, with two flight crew members and two paramedics on board, departed Timmins for Chapleau, Ontario on an instrument flight rules (IFR) flight. There, a seriously injured person was to be boarded and flown to Sault Ste. Marie, Ontario. The aircraft proceeded from Timmins en route at 12,000 feet, and, on arrival at Chapleau, the aircraft overflew the airport at low altitude and crashed 1.5 miles southwest of the airport. The four occupants were fatally injured, and the aircraft was destroyed by the impact and post-impact fire.
The Transportation Safety Board of Canada determined that the flight crew descended below the minimum applicable IFR altitude while approaching the Chapleau non-directional beacon. It could not be determined why the crew allowed the aircraft to descend, in controlled flight, into the ground.
The Board concluded its investigation and released report A88O0491 on 12 February 1991.
Rationale for the recommendation
Although standard investigative techniques enabled the Board to determine that a serviceable aircraft descended into the trees while in controlled flight, the underlying cause(s) of this accident will likely remain obscure. This case is one of many in which a flight data recorder (FDR) or a CVR could have provided information which would point to a cause(s) and an associated safety deficiency from which preventative measures could have been identified. In the years 1988 to 1989, 14 Canadian major air occurrences were investigated. Of these, five aircraft were equipped with recorders, providing vital information in two occurrences and simplifying the investigation of the other three. Nine aircraft were not equipped, and in five of these, a recorder could have provided information to assist in confirming the cause(s) and in developing safety action. The cause(s) in four cases, including this one, will likely remain uncertain because of a lack of information.
The present Canadian regulations for flight recorders were enacted in 1969, and since then, only editorial or administrative changes have been made. In 1985, the International Civil Aviation Organization (ICAO) issued new Standards and Recommended Practices (SARPS) for flight recorders. The existing Canadian legislation met the ICAO standard, but fell short of the Recommended Practice. Canada endorsed the SARPS and formed a Flight Recorder Standards Review Group in 1986. In November 1987, the CASB produced a Statement of Requirement (SOR) which advocated improved rules for flight recorders. Subsequent to consultation with the Canadian aviation industry, Transport Canada stated their intention to issue new legislation which would correspond as closely as possible to U.S. rules issued in July 1988.
These rules, and thus the planned Canadian legislation do not meet all of the ICAO Recommendations nor those of the CASB SOR; nevertheless, they do offer a significant improvement over the existing Canadian rules. CVRs would be required in more of the smaller aircraft that are widely used by small air carriers. Also, CVRs would be required in many helicopters, and both CVRs and FDRs would be mandatory for large, passenger-carrying helicopters.
Better recorder technology, such as a solid-state digital CVR with a potential for two-hour capacity, will soon be available, and agencies such as EUROCAE (European Organization for Civil Aviation Electronics) are considering rule changes to take advantage of these new capabilities. However, as indicated above, new rules are needed in the near-term to provide information that may be necessary for safety investigations and effective corrective measures.
Therefore, despite the limitations of the proposed legislation and the prospect of better hardware to come, the TSB recommends that, in the interim,
The Department of Transport expedite legislation for upgrading the flight recorder requirements for Canadian-registered aircraft.
Transportation Safety Recommendation A91-13
Previous responses and assessments
September 1991: Transport Canada’s response to A91-13
The proposed amendments to the Flight Data Recorder (FDR) and Cockpit Voice Recorder (CVR) Orders have been formulated to correlate with the FAA FDR/CVR Final Rule issued on July 11, 1988 and which is scheduled to come into effect in the United States on October 11, 1991. One provision of the proposed CVR Order will require two pilots by certification or operating rule, such as the King Air A100 that was involved in the accident, be equipped with a CVR.
Transport Canada has accorded the highest priority to the processing of the FDR/CVR Orders and has advised the Department of Justice of the importance of expediting the promulgation of these Orders.
September 1991: Board assessment of Transport Canada’s response to A91-13
TSB staff have been advised by Transport Canada staff that a meeting between operational and legal staff within TC was scheduled in the second week of October to finalize the draft legislation. Following this, approval from the Department of Justice will be sought, and the proposed regulations will be published in Part I of the Canada Gazette.
Transport Canada recognizes the need to expedite legislation and although the process of producing it is long, it appears that progress is being made. TSB staff believe the response to be satisfactory.
November 1997: Board reassessment of the response to A91-13
Current CARs re CVR/FDR requirements were adopted despite observations by TSB (DGIO letter dated 27 Sep 95) that warned they were outdated. TSB is currently participating in a CARAC working group to develop more relevant CARs.
Therefore, the response is assessed as Satisfactory Intent.
As such, Further Action is Unwarranted on this recommendation, the safety issue is addressed by A94-04 and the status of A91-13 is now Inactive.
April 2014: Board review of A91-13 deficiency file status
The Board requested that A91-13 be reviewed to determine whether the deficiency file status was appropriate. After an initial evaluation, it was determined that the safety deficiency addressed by Recommendation A91-13 is addressed by the more recent Recommendation A99-02.
It is therefore appropriate to follow the progress on the flight data recording (FDR) safety issue through Recommendation A99-02.
Therefore, the assessment remains as Satisfactory Intent.
November 2014: European Aviation Safety Agency's response to Recommendation A91-13
The European Aviation Safety Agency (EASA) has provided a closing reply to this safety recommendation on 18 December 2012. As foreseen in this reply, this safety recommendation was considered within the framework of rulemaking tasks RMT.0400 and RMT.0401, "Amendment of requirements for flight recorders and underwater locating devices", which were launched on 26 September 2012.
The results of these considerations were published in a Notice of Proposed Amendment (NPA 2013-26) in December 2013. The resulting EASA Opinion (Opinion 01/2014) was then published in May 2014.
This Opinion includes the proposal to require that, by 01 January 2019, all aeroplanes which are required to carry a cockpit voice recorder (CVR) shall be fitted with a CVR which has a minimum recording duration of 2 hours.
The Opinion was submitted to the European legislator (European Commission, European Parliament and Council), which is currently assessing it.
March 2015: Transport Canada's response to Recommendation A91-13
Transport Canada (TC) agrees with the intent of the recommendation. It is anticipated that proposed regulations that address this recommendation will be pre-published in the Canada Gazette Part I in spring 2016.
TC indicated that delays are sometimes inevitable when higher-priority tasks take up resources in the regulatory program. The defined criteria for assigning priority to regulatory initiatives are presented in the following table.
| Priority 1 | Speech from the Throne, Budget, Other High Level Government Commitment, initiatives related to the Red Tape reduction and Canada-U.S. Regulatory Cooperation Council |
| Priority 2 | Ministerial priority, Urgency, Transportation Safety Board Watchlist Initiatives |
| Priority 3 | High Strategic Outcome Priority, International/Federal-Provincial Obligations, Time Pressure, other TSB initiatives |
| Priority 4 | Efficiency, Parliamentary, Stakeholder Priorities |
| Priority 5 | Miscellaneous Amendments |
Note that the TSB Watchlist initiatives and other TSB initiatives are assigned Priority 2 and 3 respectively. These high ratings were assigned because the Department takes TSB safety action very seriously. Occasionally, however, even important regulatory initiatives are shifted due to higher-priority issues. The Board should be aware, however, that once Civil Aviation commits to regulatory action, timing may change, but the Department will proceed with the initiative until is completed.
March 2015: TSB reassessment of the response to Recommendation A91-13
In the Board's last reassessment, the response to this recommendation was linked to Transport Canada's response to A99-02. Transport Canada's response restates its support for the intent of Recommendation A99-02. Additionally, it advises that the proposed regulations contained in NPA 2011-010 are further delayed and will not be pre-published in the Canada Gazette Part I until the first quarter of 2016. This further delay will undoubtedly push the implementation date of the proposed regulatory change well beyond the current target of 01 January 2016. In the meantime, the Canadian Aviation Regulations (CARs) will continue to lack harmonization with both the Federal Air Regulations (FAR) requirement and the ICAO standard for 2-hour CVR.
The European Aviation Safety Agency (EASA) reviewed their actions to date in response to Recommendation A91-13. The latest version of EASA rulemaking tasks RMT.0400 and RMT.0401 would indicate that implementation is now scheduled for 01 January 2019.
Despite implementation delays, Transport Canada is proposing regulatory changes that, when fully implemented, will substantially reduce or eliminate the safety deficiency identified in Recommendation A99-02, which in turn will do the same for A91-13. While Transport Canada's proposed measures are reasonable, the protracted delays are not.
Therefore, the assessment of the response to Recommendation A91-13 is changed to Unsatisfactory.
November 2015: Transport Canada's response to Recommendation A91-13
(Includes recommendations A94-04, A99-02, and A99-03.)
Transport Canada agrees with the intent of the recommendation. It is anticipated that the proposed regulations that address this recommendation will be pre-published in the Canada Gazette, Part I in 2016.
March 2016: TSB reassessment of Transport Canada's response to Recommendation A91-13
The Board has linked the mitigation of the risks associated with Recommendation A91-13 to its assessment of Recommendation A99-02. Transport Canada's latest update repeats the statement that its proposed regulations to address the risks identified in Recommendation A99-02 are to be pre-published in the Canada Gazette, Part I in 2016.
While Transport Canada's proposed regulatory changes are reasonable, the protracted delays are not.
Therefore, the assessment of the response to Recommendation A91-13 remains as Unsatisfactory.
January 2017: Transport Canada's response to Recommendation A91-13
It is anticipated that the proposed regulations that address the CVR (2-hr recording capacity) component of this recommendation will be pre-published in the Canada Gazette, Part I, in summer 2017.
March 2017: TSB reassessment of Transport Canada's response to Recommendation A91-13
TC's latest update indicates that its proposed regulatory amendments, designed to mitigate the risks associated with the CVR component of Recommendation A91-13, is anticipated to be pre-published in the Canada Gazette, Part I, in summer 2017. Since 2011, this milestone has been revised three times, extending the anticipated pre-publishing in the Canada Gazette, Part I, from 2012 to 2017.
Progress toward mitigation of the risks associated with this recommendation has been slow. Such extended delays have prompted the TSB to add an item to its key safety issues Watchlist that calls for both TC and the Government of Canada to move towards an improved and accelerated process for taking action on TSB recommendations.
While TC's proposed regulatory changes are reasonable, the protracted delays are not.
Therefore, the response to Recommendation A91-13 is assessed as Unsatisfactory.