advancing transportation safety one investigation at a time wendy a. tadros, chair transportation...
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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
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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, Peggy’s Cove, Nova Scotia
• Successes• Areas for improvement
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Morningstar Air ExpressLoss of Control and Collision with Terrain
October 6, 2005, Winnipeg, Manitoba
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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
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Air Transat Flight 861Loss of Rudder In Flight
March 6, 2005, Varadero, Cuba
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0701:53ZFDR Anomaly(Loss-of-rudder)
Fort Laudersdale
Miami
0702:58Z Reports of a problem
0710:30ZRequest for landing Fort Lauderdale
0717:19ZCleared to 5000 feet
0728:16ZRequest for vectors for Miami
0737:27ZRequest forreturn to
Varadero
A05F0047
0645ZDeparts Varadero
0819:00ZLands at Varadero
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Air Transat Flight 861
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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
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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.
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Making Flying Safer
© Paul Paulsen, www.airliners.net
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MK AirlinesReduced Power at Takeoff and Collision with Terrain
October 14, 2004, Halifax, Nova Scotia
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MK Airlines – Occurrence Aircraft
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MK Airlines – Collision with berm
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MK Airlines – Not the First Time…
• 12 similar accidents worldwide – 4 aircraft destroyed– 297 lives lost
• Additional defenses needed to prevent these accidents.
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MK Airlines Recommendation and Action Taken
Transport Canada working with industry to develop takeoff performance monitoring system.
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Air France Flight 358Runway Overrun and Fire
August 2, 2005, Toronto, Ontario
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Air France Flight 358
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• 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
Runway OverrunsA Worldwide Challenge
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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
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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
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Air France Recommendations Runway End Safety Areas
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Air France RecommendationsEvacuations
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Air France Recommendations Engineered Materials Arresting System (EMAS)
Courtesy of Stantec
Courtesy of Airport Magazine
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Swissair Flight 111In-Flight Fire Leading to Collision with WaterSeptember 2, 1998, near Peggy’s Cove, NS
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Swissair Flight 111 (cont.)
Pilots smell an abnormal odour in the cockpit1011PM ADT
Pilots decided to divert to Halifax1015PM ADT
Pilots declare an emergency 1024PM ADT
Comm and Nav radios and other systems lost
1025 PM ADT
Halifax International
Airport
1031 PM ADT
Water impact
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TSB’s Investigation – 1998 Swissair Flight 111 Accident
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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.
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Swissair InvestigationMPET burn test
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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
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In-flight fires: Action Still Required
• International adoption of emergency checklist template
• Designated fire zones and systematic firefighting approach
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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
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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 Canada’s 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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