TSB Recommendation A96-08

Survival Equipment

The current requirements for survival equipment, contained in ANO V; No. 12, the Carriage of Emergency Equipment and Radio Communication Systems in Sparsely Settled Areas Order, applied only to operations in sparsely settled areas. The new Canadian Aviation Regulations (CARs) address survival equipment for all aircraft operations. Except for certain conditions of lower risk as outlined in section 602.61 (2), which were reviewed as part of the Canadian Aviation Regulation Advisory Council (CARAC) process, section 602.61 of the new CARs requires that an aircraft flying over land must carry on board survival equipment sufficient for the survival on the ground of each person on board, given the geographical area, the season of the year and the anticipated seasonal climatic variations. This equipment must provide the means for starting a fire, providing a shelter, providing or purifying water and a means of visually signalling distress. Except for the means for starting a fire, aircraft that must carry life rafts over water must provide the same amenities.

In accordance with these regulations, the requirement for survival equipment becomes carrier‑specific in that the carrier must demonstrate to Transport Canada that its survival kit meets the intent of the Regulation. The equipment must be inspected regularly in accordance with the inspection schedule set out in the carrier’s operations manual. For flights over land, the operations manual must show how compliance with the CARs will be achieved, a list of survival equipment and information on how to use it must be on board, a survival manual appropriate for the season and climate must be available, and crew members must be trained in the operation and use of all emergency equipment. For flights over water where life rafts are carried, the rafts will be equipped with a survival kit containing the items listed in subsection 724.84(2) of the CARs.

First Aid Kits

Paragraph 2.5.2 of the Analysis section of the report states that although the first aid kit met the regulatory requirements, its contents were inadequate to deal with the types of injuries sustained in this accident.

The new CARs stipulate that the first aid kit shall meet the Aviation Occupational Safety and Health Regulations (OSH), Part X, Schedule II, for a type A or type B kit. The Aviation OSH Regulations clearly identify the specific items required as well as the quantities of each. The new CARs now identify the number of kits that must be carried, which varies with the number of passengers for which an aircraft is configured. For aeroplanes with more than 100 passenger seats, an approved emergency medical kit must be carried as well and must contain as a minimum the items listed in the CARs. This requirement is based on the accepted risk management methodology that statistically for every 100 passengers there will be a person with medical credentials sufficient to successfully handle the medical supplies such as specific medicines (Epinephrine, Nitroglycerin tablets) and equipment (syringes and needles).

In addition to the above, Transport Canada has also established an Aviation OSH Regulations Review Working Group. This Working Group will be tasked to review the adequacy of the contents of first aid kits to deal with injuries to survivors of a crash.

Emergency Locator Transmitter (ELT)

Transport Canada feels that the adoption of the TSO C126 ELT would solve many of the problems with ELTs currently in use. The use of effective ELTs is currently being discussed within the Federal Aviation Administration (FAA) Aviation Rulemaking Advisory Committee (ARAC) of which Transport Canada is a member. The Part VI Technical Committee of the CARAC has been advised of the overall ELT issue. After the ARAC has completed its activities on the subject, the TCA Regulatory Committee will consider assigning this issue to the Part VI Technical Committee to study the ARAC findings in the Canadian context.

The Board was concerned that without appropriate guidelines for the carriage of enhanced first aid kits for post-crash use, and for the granting of waivers regarding the carriage of survival equipment, and without the upgrading of ELT requirements for all commercial passenger‑carrying aircraft, accident survivors would continue to be put at risk as a result of delayed rescue, lack of preparedness for harsh climatic conditions, and/or inadequate first aid treatment. Therefore, the Board recommended that

the Department of Transport, using accepted risk management methodologies, create carrier-specific requirements for the carriage of first aid kits, survival equipment, and upgraded ELTs on all commercial aircraft.

The TC response addresses the issues of survival equipment, first aid kits and upgraded ELTs separately; the staff assessment follows this format.

Survival Equipment

The Board was concerned that, as with the previous Air Navigation Orders (ANOs), the new CARs would allow exemptions (waivers) to the survival equipment requirements, and that broad interpretations of the waivers would result in some air carriers being ill-equipped to provide for post-occurrence survival. Exact wording from the CARs was used as an example to illustrate an anomaly in TC’s reasoning for the granting of waivers; yet, TC did not comment on the validity of this example, nor the “waiver” issue at all. Therefore, without an indication to the contrary, some air carriers having a higher risk of exposing accident survivors to harsh conditions and delayed rescue may still receive exemptions from outfitting their aircraft with critical survival equipment. As such, this part of the reply is assessed as Unsatisfactory.

First Aid Kits

The reply indicates that, in addition to the CARs stipulating that aircraft first aid kits must meet the Aviation Occupational Safety and Health (OSH) Regulations, TC has tasked the Aviation (OSH) Review Working Group to look at the adequacy of the contents of first aid kits to deal with injuries to survivors of a crash. Informal follow-up by TSB staff has determined that the Working Group review has been completed and some recommendations for improvements to the kits have been proposed. There was no information available as to what will be implemented and when. Since the first aid kits may be made more suitable for use in aircraft accidents, this part of the reply is assessed as Satisfactory Intent; however, there is as yet no commitment to correct the safety deficiency identified by the Board.

Emergency Locator Transmitters (ELTs)

TC indicates that the adoption of the (new) TSO C126 ELT would solve many of the problems with the ELTs currently in use. Considerable information is provided on the numerous stages of review that are either underway or will have to be done before the TSO is implemented. However, the reply does not provide any insight regarding approval or implementation dates for the better ELTs (even though the newer generation of ELTs (TSO C126) have been on trial since 1991). As stated in the preamble to the recommendation, the “success” record of the ELTs presently in service has been less than adequate. Therefore, considering that the shortcomings with the existing ELTs will apparently continue for the foreseeable future, this section of the reply is assessed as Unsatisfactory.

Conclusion

The substantiation for Recommendation A96-08 was not only based on the specific circumstances arising from the accident at Big Trout Lake, but also on the history of previously identified shortcomings with post-accident survivability and the apparent inaction over the years by both the aviation industry and Transport Canada to effectively address the problems. The deficiencies that were evident in the Big Trout Lake accident are representative of those that have existed for some time. In view of this reply to the latest Board recommendation, these deficiencies will continue for some time to put accident survivors at risk. Therefore, TC’s response to Recommendation 96-08 is assessed overall as Unsatisfactory.

Staff comment

Around 1990, TC adopted a “consultative” approach towards industry for the development of new safety regulations. While industry acceptance of any new regulations is required for effective implementation, the current situation is marked by a “wait and see attitude” by TC. Important safety issues are deferred through the consultative process to various working groups populated by industry representatives. Safety initiatives are often stymied by vested interests; industry sometimes drives the agenda to the lowest common denominator, de facto setting its own rules and standards. At best, progress in effecting significant change is slow; at worst, TC has abdicated its regulatory authority to industry.

In this instance, longstanding systemic risks to the survival of fare paying passengers in the remote regions of Canada persist. In spite of TC’s reasoned reply, apparently commercial considerations continue to supersede safety consideration. The chronology of events pertaining to such a publicly sensitive issue would not stand up well to the rigorous scrutiny of a public inquiry.

Therefore, the response to Recommendation A96-08 is assessed as Unsatisfactory.

The deficiencies that were evident in this accident have existed for some time. In view of current regulatory environment, these deficiencies will continue to put accident survivors at risk.

Therefore the assessment remains as Unsatisfactory.

The Board requested that Recommendation A96-08 be reviewed to determine if the deficiency file status was appropriate. After an initial evaluation, it was determined that the safety deficiency addressed by Recommendation A96-08 still needed to be reassessed.

A request for further information was sent to Transport Canada and a reassessment will be conducted upon receipt of Transport Canada’s response.

Therefore, the assessment remains as Unsatisfactory.

Consequently, the status of Recommendation A96-08 is changed to Active.