Advancing Transportation Safety

One Investigation at a Time

Wendy A. Tadros, Chair
Transportation Safety Board of Canada
ISASI 2008 39th Annual Seminar
September 9, 2008
Halifax, Nova Scotia

Presentation Outline
Look back at 5 major Canadian investigations

Morningstar Air Express, C-208, Winnipeg, Manitoba

Air Transat Flight 861, A310, Varadero, Cuba
MK Airlines, B747, Halifax, Nova Scotia
Air France Flight 358, A340, Toronto, Ontario
Swissair Flight 111, MD-11, Peggys Cove, Nova Scotia

Successes
Areas for improvement
2

Morningstar Air Express

Loss of Control and Collision with Terrain
October 6, 2005, Winnipeg, Manitoba

Morningstar Air Express

Recommendations:
Cessna 208 pilots:
do not take off into anything more than light icing
conditions
maintain 120 kts minimum speed in icing conditions

Action Taken:
FAA Airworthiness Directives (ADs)
Cessna 208 pilots must:
maintain 120 kts minimum speed in icing conditions
immediately exit icing conditions exceeding light
Transport Canada adopted both ADs
4

Air Transat Flight 861

Loss of Rudder In Flight
March 6, 2005, Varadero, Cuba
A05F0047

0717:19Z
Cleared to
5000 feet

0710:30Z
Request for
landing Fort
Lauderdale

0702:58Z
Reports of a
problem

Fort Laudersdale
Miami

0728:16Z
Request for
vectors
for Miami

0737:27Z
Request for
return to
Varadero

0701:53Z
FDR Anomaly
(Loss-ofrudder)
0645Z
Departs
Varadero

0819:00Z
Lands at
Varadero
3

Air Transat Flight 861

Air Transat Flight 861 Findings

Rudder made of composite material
Airbus issued All Operators Telex to
inspect rudders.
Similar rudder assemblies were
found on 408 A300, A310, A330 and
A340 aircraft
Disbonds, hinge damage, fluid
ingress

Air Transat Flight 861

Recommendation:
That industry develop and implement an
inspection program that allows early and
consistent detection of damage to aircraft with
this type of rudder assembly.

Making Flying Safer

Paul Paulsen, www.airliners.net

MK Airlines
Reduced Power at Takeoff and Collision with Terrain
October 14, 2004, Halifax, Nova Scotia

10

MK Airlines Occurrence Aircraft

11

MK Airlines Collision with berm

12

MK Airlines Not the First Time

12 similar accidents worldwide

4 aircraft destroyed
297 lives lost
Additional defenses needed to prevent these
accidents.

13

MK Airlines
Recommendation and Action Taken
Transport Canada working with industry to
develop takeoff performance monitoring
system.

14

Air France Flight 358

Runway Overrun and Fire
August 2, 2005, Toronto, Ontario

15

Air France Flight 358

16

Runway Overruns
A Worldwide Challenge
1

November 9, 2007 Quito, Ecuador

September 6, 2007 Phuket, Thailand
July 17, 2007 Sao Paulo, Brazil
March 7, 2007 Java, Indonesia
October 10, 2006 Stord, Norway
July 9, 2006 Irkutsk, Siberia
`
April 16, 2006 Guyaramerin, Bolivia
December 10, 2005 Port Harcourt, Nigeria
December 8, 2005 Chicago, USA
October 31, 2005 Maiema, Congo

__________
1. Air Accident Investigation Commission, Interstate Aviation
Committee, Russia.
2. Accident Investigation Board, Norway
3. National Transportation Safety Board, USA

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Air France Flight 358

Seven Recommendations
Five focus on crews, and the need for mandatory
standards, training and procedures
Two are aimed at reducing the risk of injury
following an accident

18

Air France Recommendations

Severe weather landings
Standards limiting landings in severe weather
Improved training for pilot decision-making in
worsening weather
Requirement to always calculate runway distance at
destination

19

Air France Recommendations

Runway End Safety Areas

20

Air France Recommendations

Evacuations

21

Air France Recommendations

Engineered Materials Arresting System (EMAS)

Courtesy of Airport Magazine

Courtesy of Stantec

22

Swissair Flight 111

In-Flight Fire Leading to Collision with Water
September 2, 1998, near Peggys Cove, NS

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Swissair Flight 111 (cont.)

Pilots declare an emergency

Comm and Nav radios
and other systems lost

Halifax
International
Airport
1024PM ADT
1025 PM
ADT

Water impact

1031 PM

ADT

1015PM ADT Pilots decided to divert to Halifax

1011PM ADT

Pilots smell an abnormal odour in the cockpit

24

TSBs Investigation
1998 Swissair Flight 111 Accident

25

Swissair Flight 111 Recommendations

23 recommendations in regards to:
on-board recorders;
circuit breaker resetting procedures;
supplemental type certification process;
material flammability; and
in-flight firefighting.

26

Swissair Investigation
MPET burn test

27

In-flight fires: Action Taken

Crews diverting to land immediately at first hint of

fire
IATA/Flight Safety Foundation emergency checklist
template
Improved checklists and procedures being adopted
by some manufacturers

28

In-flight fires: Action Still Required

International adoption of emergency checklist

template
Designated fire zones and systematic firefighting
approach

29

Data Recorders
The FAA published its final rule on:
CVR two-hour recording capacity and
independent power supply providing 10 more
minutes of recording by 2012
power redundancy in that any single electrical
failure must not result in disabling both the CVR
and the FDR (flight data recorder)
Canadian harmonization with FAA rule

30

Swissair Flight 111:

Image Recorder Proposal
Improve quality of data available to accident
investigators by installing image recorders
Canadian law protects data recordings for accident
investigation use only and protects their
confidentiality
If image recorders installed similar protection of
data to Canadas must be extended internationally

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Conclusion
Air investigations international in scope
Need for continued co-operation among
manufacturers, regulators, operators and
investigative agencies worldwide

Major aviation investigation reports posted

on TSB website in Air section.
Consider adopting TSB recommendations when
similar deficiencies are found during your
investigations

www.tsb.gc.ca
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