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Presentation to ATAC

Kathy FoxBoard Member

Transportation Safety Board

Vancouver, BC13 November, 2012

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• Watchlist 2012: What is it? What’s new?

• Watchlist Air Issues

• Related TSB Investigations

• Role of Governance/Oversight

• Q & A

Outline

Watchlist: What is it?

• 9 issues of greatest risk to Canada’s transportation system

• A call to action for regulators and industry

• 14 of 41 recommendations “Fully Satisfactory” since 2010

• Progress on SMS and data recorders

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Watchlist 2012Landing Accidents and Runway Overruns

Air Safety Management Systems

Risk of Collisions on Runways

Collisions with Land and Water

Marine Safety Management Systems

Loss of Life on Fishing Vessels

Passenger Trains Colliding with Vehicles

On-Board Video and Voice Recorders

Following Signal Indications

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Landing Accidents and Runway Overruns

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Runway overrun, Cargojet Boeing 727, Moncton, NB

TSB Investigation report A10A0032

More Common Than You Might Think

• June 16, 2010. Embraer 145 (Ottawa) • November 30, 2010. Boeing 737 (Montreal) • March 12, 2011. Bombardier BD100 (Iqaluit) • July 16, 2011. Boeing 727 (St. John’s) • September 4, 2011. EMB-145 (Ottawa) • January 9, 2012. Boeing 737 (Ft. Nelson) • January 15, 2012. Pilatus PC-12/45 (Timmins) • August 14, 2012. Ilyushin 76 (St. John’s)

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Source: ATSB, Runway excursions, Part 2: Minimising the likelihood and consequences of runway excursions. An Australian perspective, (2009).

Stopping Distance After an Overrun(FAA 1975-1987 study)

A Complex Problem

• Runway length is not the only factor

• Numerous lines of defence are needed to:

o Prevent overruns from happening

o Prevent injury or loss of life when overrunsdo happen

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TSB Recommendations• Approach/landing standards:

Establish clear standards limiting approaches and landings in convective weather for all air transport operators at Canadian airports. (A07-01) (Air France) (SiP)

• Pilot training:Mandate training for all pilots involved in Canadian air transport operations to better enable them to make landing decisions in deteriorating weather. (A07-03) (Air France) (SI)

• Procedures:Require crews to establish the margin of error between landing distance available and landing distance required before conducting an approach into deteriorating weather. (A07-05) (Air France) (SI)

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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.

Recommendation A07-06

TSB Investigation Report A05H0002

Current assessment: SiP

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Risk of Collisions on Runways

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© Australian Transport Safety BureauReproduced with permission

Beech 1900, following runway collision with Beech A90 King Air, Quincy Municipal Airport, IL, USA.© Scroggins Aviation, reproduced with permission

TSB Findings

• “Both crew members … were unfamiliar with the (airport) and did not correctly perceive their position on the field.” (A07O0305)

• “The co-pilot did not assist in monitoring [as] he was carrying out checks while … PIC taxied the aircraft.” (A07O0305)

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More TSB Findings

• “Believing [the runway under his] control, the … controller cleared the … vehicles onto that runway, leading to a conflict with the departing WestJet.” (A08H0002)

• The aircraft and vehicle “were operating on different frequencies, [and unaware] of the other's presence on the runway” (A09W0026)

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TSB Safety Concerns

• “Two heads up”

• “ASDE/RIMCAS at Pearson International”

• “Direct warnings to flight crews”

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Collisions with Land and Water

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Cessna 206, collision with hilltop near Shawinigan, QC

TAWS

• 2012: CARs amended to introduce requirements for the installation of Terrain Awareness Warning Systems equipped with an “Enhanced Altitude Accuracy” function in private turbine-powered aircraft configured with six or more passenger seats and in commercial aircraft configured with six or more passenger seats.

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Exact Air

3 nautical miles before Runway 12

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Descent Techniques

C-GPBA

Step down Descent

Exact Air Recommendations

That TC “require that the design and depiction of the non-precision approach charts incorporate the optimum path to be flown.” (A12-01)

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Profile view with 3° descent path and ICAO Annex 4 recommendations.

Exact Air Recommendations (continued)

That TC “require the use of the stabilized constant descent angle approach technique in the conduct of non-precision approaches by Canadian operators.” (A12-02)

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Exact Air – Safety Concern

“The Board is concerned that, despite past efforts, recognized mitigation

strategies to reduce ALAs found in the FSF recommendations, are not being

implemented into commercial operations.”

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CFITs in Canada

• From 2000-2009:– 129 CFIT occurrences– 128 fatalities– 5 percent of accidents, but nearly 25 percent of

fatalities

• Air Taxis– 26 occurrences– 42 fatalities– 7 percent of accidents, 35 percent of fatalities

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Approach and Landing Accidents

Number of ALAs by Operation Type

Nu

mb

er

of

ac

cid

en

ts

Air Taxis

CommutersAirlines

Air SMS

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Aéropro, Quebec City, 2010 (A10Q0098)

Aéropro (A10Q0098)

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Aéropro: Findings as to Risk

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• “Maintenance procedures and operating practices did not permit the determination of whether the engines could produce maximum power [in an] emergency”

• “ … a lack of rigour in documenting maintenance work …”

• “…not recording all defects in the aircraft … log poses a safety risk [possibly depriving crew] of information that may be critical …”

Aéropro: Causes and Contributing Factors

• “The poor safety culture at Aéropro contributed to the acceptance of unsafe practices.”

• “The significant measures taken by TC did not have the expected results to ensure compliance with the regulations, and consequently unsafe practices persisted.”

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Who Holds Decision-Makers to Account?

Board of Directors / owner

Shareholders / financial backers

Customers

Insurance companies

Regulators

All of the above

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The Role of Oversight in Safety Management

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Regulatory Oversight

“The gap between what is legal and whatis safe already is large, and it will getbigger. … Is this regulatory approach

sustainable? Is it fair to airlines that do everything right? Is it fair to an

unknowing public?”

-William Voss, Flight Safety Foundation

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For Further Information …

www.TSB.gc.ca

Twitter.com / TSBcanada

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