Presentation to ATAC
Kathy Fox
Board Member
Transportation Safety Board
Vancouver, BC
13 November, 2012
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Outline
• Watchlist 2012: What is it? What’s new?
• Watchlist Air Issues
• Related TSB Investigations
• Role of Governance/Oversight
• Q&A
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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 2012
Landing 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
Runway overrun, Cargojet Boeing 727, Moncton, NB
TSB Investigation report A10A0032
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More Common Than You Might Think
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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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Stopping Distance After an Overrun
(FAA 1975-1987 study)
Source: ATSB, Runway excursions, Part 2: Minimising the likelihood
and consequences of runway excursions. An Australian perspective, (2009).
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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 overruns
do 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
© Australian Transport Safety Bureau
Reproduced with permission
Beech 1900, following runway collision with Beech A90 King Air,
Quincy Municipal Airport, IL, USA.
© Scroggins Aviation, reproduced with permission
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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
Cessna 206, collision with hilltop near Shawinigan, QC
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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
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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)
Profile view with 3° descent path and ICAO Annex 4 recommendations.
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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 accidents
Number of ALAs by Operation Type
Air Taxis
Commuters
Airlines
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Air SMS
Aéropro, Quebec City, 2010 (A10Q0098)
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Aéropro (A10Q0098)
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Aéropro: Findings as to Risk
• “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 …”
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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
Safety Regulators
• Do we have realistic
expectations on the
extent to which
regulators can
influence day to day
safety?
• Regulatory Oversight
Policy versus
Regulatory Oversight
Effectiveness
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Regulatory Oversight
“The gap between what is legal and what
is safe already is large, and it will get
bigger. … 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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