Canadian Aviation Safety Seminar 2008
Opening Remarks by
Transportation Safety Board of Canada
at the Canadian Aviation Safety Seminar 2008
April 29, 2008
Good afternoon. Thank you for the kind introduction. It is my pleasure to have the opportunity to speak to you as a Board Member of the Transportation Safety Board of Canada (TSB).
The Canadian Aviation Safety Seminar is an important forum because it brings together many aviation experts and practitioners to discuss safety issues; and places those issues in the context of safety management, personnel and systems. The TSB always appreciates the opportunity to speak to, and hear from, such a well informed group.
The objectives of CASS and the TSB are truly aligned. CASS explores emerging safety issues with a view to creating awareness, and considers strategies to eliminate hazards and manage their effects. While the TSB's mandate is to identify safety issues, through the investigation of accidents, and make recommendations for the advancement of transportation safety and the protection of the traveling public.
The second of September this year will mark the tenth anniversary of the destruction of Swissair 111 off Peggy's Cove, Nova Scotia; with the tragic loss of everyone on board - 215 passengers and 14 crew. Late last year, the Board made a conscious decision to mark this tenth year by placing the investigation and its results in the context of what has been achieved, what remains outstanding, what has happened since, and how the identified issues and safety deficiencies have subsequently developed.
I make no apology for this retrospective. If we don't acknowledge where we have been, we cannot truly grasp current and future opportunities to address emerging issues.
So, I thought what I would do today is to speak to how our investigations and recommendations affect the aviation industry - not just from a technical perspective, but more specifically from the management of safety, its processes and personnel - using the Swissair investigation as the example.
What you are going to hear is:
- a quick recap on the TSB and its procedures
- identification of the five themes or groupings into which the Swissair recommendations fall,
- some information on our recommendation process - how we follow-up and rate recommendations.
Then I want to speak specifically to:
- material flammability - thermal acoustic insulation blankets and wiring,
- in-flight fire fighting - integrated approaches and check lists, and
- flight recorders - with particular reference to the protection of recordings.
And finally, I wish to enlist your help in pursuit of further change.
One thing worth mentioning at this point is the somewhat limited ability of both the TSB and Transport Canada to instigate and affect change in an international regulatory environment.
If we at the TSB make a recommendation to "the regulatory authorities", only Transport Canada is required to respond. If a change is outside Transport Canada's purview, what can we expect? In many instances, change in Canada is reliant on prior action taken in the US and supported in Europe.
Yes, Transport Canada can play a role within international organizations to advocate change. And Yes, Transport Canada staff can liaise informally and formally with their international counterparts. But, after the initial flurry of activity that follows a major accident, priorities rapidly shift, resources are diverted, and change becomes dependent on the long, hard slog of representations, international meetings and other consultative processes.
That said, the TSB is highly appreciative of the efforts of Transport Canada to implement the Swissair (and other aviation) recommendations.
The Transportation Safety Board of Canada is an independent organization with a mandate to advance transportation safety by conducting investigations in the marine, rail, air and pipeline modes.
We inform the public about what happened, and why it happened. We identify safety deficiencies. We make recommendations to government and industry to address those deficiencies.
The TSB is not a regulator or a court; we don't make laws, nor do we find guilt or assign blame.
Approximately 1,900 aviation occurrences are reported to the TSB each year. They cover the spectrum from precautionary landings and equipment malfunctions to accidents that have resulted in significant aircraft damage, major injuries and loss of life.
When notified of an occurrence, we collect and assess available information, and then decide if a full investigation is warranted. This decision hinges on whether there is significant potential for the investigation to reduce future risks to people, property or the environment.
The TSB is guided by our legislation, internal policies, international guidelines, and various industry standards to help ensure that investigations are conducted in a systematic, thorough, and unbiased manner.
The TSB practice is not to wait until an investigation is complete, to make important safety information public. When we identify a safety deficiency, we act quickly by communicating it to those who can make transportation safer. This allows stakeholders to take timely and appropriate safety action.
The really big safety payoff occurs when everyone agrees during the course of an investigation about what needs to be done. In these situations, safety deficiencies are quickly addressed. All we need do is to document in our final report the actions already taken.
The Board uses formal recommendations to draw attention to particular safety deficiencies that involve significant risk and require prompt action. Recommendations are typically used to handle the more difficult, systemic issues.
And the Board recognizes that the most difficult part in this whole process is not ours. But rather belongs to the regulator and industry - those who have the responsibility to determine how best to mitigate the identified risks.
Swissair 111 and the five themes
Now, let's get back to the investigation of the 1998 Swissair accident to demonstrate how the Board recommendations led to change and what remains to be done.
The Swissair investigation took four and a half years to complete. It was the biggest, longest, and most complex safety investigation that the TSB has ever undertaken.
The need for coordinated national and international effort was paramount. And the efforts of the many hardworking people from various countries, industries and regulatory authorities led to a world-class investigation, culminating in a comprehensive report that has helped to change the face of aviation safety.
As part of this investigation, the TSB made a total of 23 recommendations:
- 6 were issued in 1999,
- 5 in 2000,
- 3 in 2001, and
- 9 in 2003 with the final report.
These recommendations can be grouped as follows:
- flight recorders,
- circuit breaker resetting procedures,
- the supplemental type certification process
- material flammability, and
- in-flight firefighting.
But making safety recommendations is only the initial part of advancing transportation safety. Action must then be taken to mitigate the risks - frequently a long and complex process.
Our recommendations invariably call for change. For example, they may lead to changes in equipment, or how it is used, in crew training, and certification. The method of implementation may be amendments to regulations, or changes to standards or organizational processes. These changes (and their development) can place significant demands on you - the operator, the manufacturer, the regulator.
If the identified safety deficiency is sufficiently major and systemic, it must be expressed in a succinct and readily understandable recommendation. That recommendation must be sufficiently powerful to stand apart from its development framework (both the report and its lead-in).
We try not to be prescriptive in our recommendations. Because we recognize that it is you, and people like you, who must work out how best to eliminate, or significantly reduce, that safety deficiency.
The Swissair recommendations were no exception.
As of April 2008, of the 23 recommendations:
- 5 have been rated as fully satisfactory,
- 7 satisfactory intent,
- 9 satisfactory in part, and
- 2 unsatisfactory.
Follow-up on recommendations
A short deviation into how we handle follow-up to our recommendations is probably in order.
We are vitally interested in determining whether our recommendations are effective, therefore we track the action taken in response.
The Canadian Transportation Accident Investigation and Safety Board Act (CTAISB) requires that the Minister must advise the Board in writing of any action taken or proposed to be taken in response, within 90 days of the date of issue of the recommendations.
Of course, that is of limited use if the target of the recommendation isn't a Minister in the federal government - but, say, a transportation company or a foreign government.
Responses to Board recommendations are assessed based on the extent to which the action completed or planned will mitigate the underlying safety deficiency. Acceptance or understanding of deficiencies is not a criterion in the assessment rating.
Four categories are used to assess responses: fully satisfactory, satisfactory intent, satisfactory in part and unsatisfactory.
We publish our recommendations on our website. And, subsequently, we add the formal response, and our assessment of that response.
For every response that has been assessed as being less than fully satisfactory, the TSB attempts to follow-up with the respondent to:
- track the progress of actions being taken to mitigate the defined risks,
- encourage better buy-in, and
- explore further options that could mitigate the residual risks.
Our approach is similar in some respects to that of the NTSB. But what you will not see is an equivalent to the NTSB's closed - unacceptable action.
Our view is that the only justification for placing a recommendation in the inactive file is that the safety deficiency has been dealt with, and the residual risk either eliminated or significantly reduced.
For the purposes of today's presentation, I would like to highlight the Swissair recommendations in three specific safety areas: material flammability, in-flight firefighting, and on-board recordings.
During the Swissair investigation, the TSB issued eight recommendations associated with flammability.
For the most part, the regulatory agencies:
- readily concurred with the thrust of the recommendations,
- acknowledged that significant deficiencies existed and that
- action was required to mitigate the risk of in-flight fires on board aircraft.
In response to TSB's recommendation (A99-07) to reduce or eliminate the use of metalized polyethylene terephthalate-covered installation in aircraft, the regulators of France, the United States and Canada issued airworthiness directives mandating the removal of this type of insulation, almost immediately.
The video that you are viewing is of a burn test carried out on metalized polyethylene terephthalate (MPET) carried out as part of the Swissair investigation - a material that had passed the mandated flammability test.
The TSB issued two recommendations on flammability tests:
- A99-08 asking regulatory authorities to validate materials using more vigorous flammability test criteria, and
- A03-02 asking for the development of a test regime that would effectively identify insulation materials that could sustain or propagate a fire.
Transport Canada actively worked with the FAA and helped establish new flammability test criteria (the Radiant Panel Test), as well as regulations, standards, and guidance, all of which are now used to better validate thermal acoustic insulation materials.
For two other recommendations,
- Transport Canada worked closely with the FAA to develop and promulgate new flammability standards for material used in the manufacture of aeronautical products (A01-02), and
- both agencies have promulgated guidance material in order to establish a more accurate and consistent interpretation of flammability test standards (A03-03).
So, what is outstanding with regards to flammability recommendations?
Notwithstanding these successes, we believe that additional work is required.
For example, although airworthiness directives were developed to mandate the removal of PET-covered insulation from aircraft in service, substantive action has not been taken to comprehensively review the remaining types of insulation currently in use (A99-08).Instead, regulators are relying on in-service performance to be the catalyst for further safety action.
In other words, a material has to fail before action is taken.
Giving credit where credit is due, this type of in-service testing did result in the detection of the flammability risk associated with the AN-26 insulation material. This material subsequently failed the Radian Panel Test and was removed from service. But is that approach really good enough?
Another example: During the development of the Radiant Panel Test, a number of thermal acoustic insulation materials failed the test. The Board subsequently recommended a review to quantify and mitigate the risks associated with all the types of materials that failed these tests (A03-01). To date, no positive action has been taken by regulators to address this deficiency.
Transport Canada has been involved in a number of international initiatives related to the safety of wiring in aging aircraft. But action has not yet been taken to address our recommendation to establish a test regime that evaluates aircraft electrical wire failure characteristics under realistic operating conditions (A01-03). Testing a single wire does not necessarily predict what will happen when that wire is bundled and carries an electrical load.
In recommendation A01-04, the Board recommended that certification standards be established for all aircraft systems that could exacerbate a fire in progress. There were construction standards in place for electrical, vacuum, oxygen and other systems. But additional action has not been initiated to evaluate how these systems and their components could exacerbate an existing fire. In other words, certifying individual systems is not enough. It is the potential interplay between the systems that creates the additional risk.
Over all, our position is that additional safety action is required to fully mitigate the residual risks associated with the deficiencies identified in six out of eight recommendations in this category. Probably our greatest concerns relate to (1) wire testing and (2) the continuation in service of materials that would fail the Radiant Panel Test.
During the Swissair investigation, the TSB issued five recommendations associated with in-flight, firefighting issues.
The regulatory agencies readily concurred with the thrust of the recommendations, and acknowledged that significant deficiencies existed.
The deficiencies identified were catalysts in the establishment of a Flight Safety Foundation (FSF) Symposium to address the challenge of flight crew response to smoke, fire, and fumes (SFF) in the aircraft.
TSB's recommendations were also accepted by the International Aircraft Systems Fire Protection Working Group (IASFPWG). Participants in the FSF Symposium and the IASFP Working Group included civil aviation authorities, airlines, manufacturers, and safety associations.
In addition, Transport Canada and the Flight Safety Foundation co-sponsored an International Air Transport Association (IATA) workshop on smoke and fire cockpit checklist procedures.
The participation and cooperation of so many people and organizations within the aviation community was indeed heartening.
So, what has been done to address the firefighting deficiencies?
For three of the five recommendations, the results of the Symposium, Working Group and Workshop, as well as Transport Canada's deliberations with other civil aviation authorities, resulted in significant safety action and follow-on plans.
TSB recommended (A00-18) landing an aircraft expeditiously as the appropriate course of action when odour or smoke from an unknown source appears in an aircraft. In response, Transport Canada and other regulatory agencies now require that the emergency/abnormal procedures contained in aircraft flight manuals direct crews to prepare to land the aircraft without delay.
We recommended (A00-19) that odour and smoke checklists be designed so that the appropriate troubleshooting procedures are completed quickly and effectively. In response, the IATA workshop developed generic, industry-wide guidance material on smoke and fire cockpit checklist procedures, which in turn resulted in various aircraft manufacturers making improvements to their respective Aircraft Flight Manuals.
For example, Bombardier Aerospace amended its Aircraft Flight Manual and emergency checklist procedures in January 2007. And I understand that Boeing is in the process of producing amendments covering all of its current product lines.
TSB recommended (A00-20) that aircraft crews be prepared to respond immediately, effectively and in a coordinated manner to any in-flight fire, including inaccessible spaces such as attic areas.
In response, Transport Canada, in cooperation with other regulatory agencies, established a multi-faceted action plan to improve the current in-flight firefighting standards. These initiatives, along with other complementary activities, such as TC's Policy Letter 153: Practical Training - Emergency Procedure Training for Pilots, when fully implemented, will significantly reduce the deficiency identified in this recommendation.
Notwithstanding these successes, additional work is required to completely address a number of the recommendations.
Recommendation A00-17 asked the regulatory authorities to review the methodology for establishing designated fire zones within the pressurized portion of the aircraft, and provide improved fire-detection and fire suppression capabilities.
This recommendation was discussed between regulatory agencies and within the FSF symposium and IATA workshop. However, TSB is not aware of any action taken or action planned that would specifically relate to this recommendation.
Although the generic, industry-wide guidance material on smoke/fire cockpit checklist procedures created by the FSF symposium has the potential to address the urgency factor for completing checklists, the use of the template is voluntary.
Also, there is no indication that manufacturers outside North America have adopted the use of the FSF emergency checklist template, or that foreign regulatory authorities have or intend to mandate its use. Until the timeliness is prioritized in checklists on a mandated basis, the risks associated with the deficiency will continue to exist.
In this context it should be noted that NTSB issued recommendation A07-97 as part of its final report into the circumstances of an in-flight fire on a UPS DC-8 (DCA06MA022 refers). The recommendation issued on December 17, 2007 makes direct reference to the adequacy of checklists, the delayed detection of the fire, the delayed decision to land, as well as the previous industry initiatives to mitigate the consequences of an in-flight fire.
Returning to Swissair, in Recommendation A00-16, the Board called for the interrelationship between individual firefighting measures be assessed with a view to developing an improved in-flight firefighting system. Both the FAA and TC agreed with the recommendation, but to date, these regulators have only implemented single facetted initiatives, such as new checklists.
Over all, the Board's position is that a systemic approach must:
- comprehensively identify fire zones,
- implement fire detection systems,
- provide fire-suppression equipment and systems,
- mandate checklist design criteria, and
- require appropriate training.
Otherwise, the residual risks associated with deficiencies identified in these three firefighting recommendations will not be adequately addressed.
Again, some of the residual action required here in Canada is for Transport Canada to complete its harmonization with FAA regulations and certification standards.
It is sometimes suggested that - for us - this is a wholly self-serving issue. Flight recorders of all types do make the investigator's job substantially easier. But within the aviation community, there is a long-established recognition that access to good data leads to better investigation results, which in turn leads to enhanced safety. I can only wish that this recognition was as prevalent in the rail and marine modes.
The on-going battles in these other modes are to:
- achieve crash survivability of locomotive recorders, and
- make voyage data recorders mandatory on domestic vessels.
Suffice it to say that our recently-completed investigation into the sinking of the Queen of the North would have been much more straight forward had she been equipped with a voyage data recorder.
During the Swissair investigation, the TSB issued eight recommendations dealing with on-board recorders.
You probably remember that both the CVR and the FDR on Swissair 111 ceased to function some five and a half minutes before impact. Consequently in this investigation, as with many others conducted by the TSB, the availability of quality data severely hampered our efforts to validate some of the primary safety deficiencies.
Two of our recommendations dealt with increasing CVR recording capacity from 30 minutes to at least two hours.
Two recommendations dealt with enhancing the survivability of recorders by requiring separate generator buses for the FDR and CVR, plus a dedicated ten minute independent power supply for CVRs. (A99-03, and A99-04)
Three recommendations dealt with data enhancement, these were:
- action to enhance the quality and intelligibility of CVR recordings (A03-06);
- requiring that the additional data already being recorded on other recorder media on the aircraft be recorded in the crash-survivable FDRs (A03-07); and
- fitting aircraft with image recording systems (A03 08).
The eighth recommendation dealt with increasing the protection of cockpit voice and image recordings used for safety investigations (A03-09).
So what has been done to address the recorders deficiencies?
At the instigation of the FAA, the Future Flight Data Collection Committee was formed under the auspices of the USA Radio Technical Commission for Aeronautics (RTCA). The committee's findings fed into the FAA's Notice of Proposed Rule Making (NPRM) process.
Meanwhile, Transport Canada has either taken action or indicated that it intends to take action, which should address many of the identified deficiencies. However, in its responses to the TSB, Transport Canada has indicated that full compliance is dependent on international harmonization, and especially action on the part of the Federal Aviation Administration.
Consequently, it is now almost 10 years since the Swissair accident, and the risks identified in all but one of these recorder recommendations have yet to be addressed.
That said, on 7 March 2008, the FAA issued its Final Rule entitled Revisions to Cockpit Voice Recorder and Digital Flight Data Recorder Regulations stating that by 7 April 2012, CVRs on all turbine engine-powered airplanes
- must have a 2 hour recording capacity (A99-02 refers),
- must have an independent power supply that provides 10 minutes of electrical power (A99-03 refers), and
- any single electrical failure must not result in disabling both the CVR and the FDR (A99-04 refers).
Given that the FAA has recently published its final rule, the Board anticipates (and hopes) that Transport Canada will speedily complete its drafting of the required Notice of Proposed Amendments. And that TC and industry partners in the CARAC process will cooperatively take action to expedite harmonization of the CARs with these new FAA certification standards.
This is real progress.
But there are notable outstandings within the recorder recommendation group.
Dare I say image recorders?
If you were to go back to the Swissair investigation report, you would note that our recommendation on image recorders is explicitly paired with our recommendation on harmonizing the international treatment of cockpit voice recorders and image recorders. We continue to believe that image recorders are highly desirable. But we fully understand the concerns that have been expressed, notably by ALPA.
Perhaps I can digress for a moment. I have been a Board Member at the TSB for eight years. During that time I have participated in more than 1,200 Board reviews of investigative reports. It has become ingrained in my psyche that:
- on board recordings (voice or image) are privileged, and
- witness statements are privileged.
On board recordings are investigative tools. In Canada, the contents of on board voice recordings can be used in an investigative report if - and only if - they are necessary for transportation safety.
The Board interprets this very strictly. Use must go directly to a finding. In the context of publication, they have no other use. In applying our legislation (which is actually very clear) we, as Board Members, don't care if the inclusion of information obtained from a voice recorder makes for a better or more complete story. If it doesn't go to a finding, it isn't in. And you certainly won't find a CVR transcript in an appendix to a TSB report.
Would that many other countries came anywhere close to the Canadian position?
I believe that international harmonization at the level applied in Canada is the way to go. Is that achievable? ICAO is undoubtedly the appropriate forum. Is this not something that the aviation community as a whole could put its weight behind?
During an investigation, the TSB works with all levels of government, transportation companies, equipment manufacturers and service providers, and we rely on these entities to help us conduct a thorough and effective investigation.
In its investigations, TSB endeavours to operate in an open manner, and communicates freely and promptly with those who can contribute to the TSB's mandate to advance transportation safety.
This openness allows stakeholders to take timely appropriate safety action. In this vein, a big safety payoff occurs when everyone agrees during the course of an investigation about what needs to be done, and where safety deficiencies are addressed quickly.
Board recommendations are only necessary to draw immediate attention to particular safety deficiencies that involve significant risk and that require immediate action, or in situations where voluntary action taken during the course of an investigation has not completely mitigated risks associated with a significant safety deficiency.
TSB recognizes the challenges regulators and industry face when working towards implementing the Board's recommendations and the significant effort that is required to change the aviation system for the better.
We also know that some of these recommendations can be addressed promptly, while others require much time and resources to develop an appropriate approach and to make the changes needed to completely mitigate the deficiency.
As you have heard, 10 years after the devastating Swissair accident, further action is still needed to mitigate the significant risks identified in 18 of 23 recommendations.
The TSB, for its part, will continue its dialogue with Transport Canada, other regulatory authorities, and industry stakeholders to encourage more effective and timely action to mitigate the residual risks associated with the deficiencies identified. And, this effort is particularly important for those responses that have been assessed as less than satisfactory.
Another initiative is that, on an annual basis, TSB follows up with TC and other regulators, to re-evaluate the existing aviation residual risks and to encourage on-going efforts to fully mitigate them. TSB reports these reassessments on this site.
This sometimes seems a repetitive and onerous task. It is what it is. And I would like to commend Transport Canada for its preparedness to join with the TSB in the process, and the steps TC has taken to publish the results on its web site.
Although TSB recommendations, for the most part, are addressed to the regulators of the transportation industry, the responsibility for mitigating the safety risks underlying our recommendations belongs with you in this room today.
Therefore, I encourage you to follow TSB air investigations closely. When safety concerns are identified, ask yourself: "What can I as a manufacturer, airline, or individual do to lessen the identified risk?" You do not necessarily need to wait for the regulator to take action before you make a change yourself.
I may be preaching to the converted, but most entities that genuinely adopt a strong safety culture recognize that safety is good for business, and that an effective safety management system is the key to implementing that commitment. The result - fewer accidents, enhanced productivity, greater professionalism, an improved loss ratio, an enhanced bottom line, reduced damage to the environment and enhanced safety for the traveling public.
Sometimes when we are discussing the minutia of CVR parameters, for example, or deciding whether or not wires should be tested bundled and live, or we get exasperated by a proposed change of emphasis in a checklist, it is easy to lose sight of what this is all about.
Because, in the final analysis, it is not about the minutia, nor the arcane. It is about preserving lives. It is about the safety of crew and passengers. And, in this case, it is about the 229 men, women and children who lost their lives on September 2, 1998.
A fire initiated by an electrical arc, that set alight materials believed to be non-flammable, and exacerbated by the failure of other material and systems. A fire that went undetected during those vital first few minutes, and that could not have been controlled by the firefighting capabilities of the aircraft and its crew. A fire that only extinguished when the aircraft plunged into the sea off Peggy's Cove.
A call for action seems appropriate at this point. In my view, the highest priorities are
- completion of the validation of all thermal acoustic insulation materials in use,
- the adoption of a wiring test regime based on realistic operating conditions,
- mandatory adoption internationally of the smoke fire and fumes checklist templates,
- adoption of more a systemic (or holistic) approach to in-flight fire fighting, and
- international harmonization of the protection afforded to cockpit voice and image recordings.
The action taken by the aviation community in response to the Swissair recommendations has been substantial. We salute Transport Canada, the FAA, the FSF, the NTSB, Boeing, Swissair, and everyone else who has contributed to that response. We recognize that the process can be slow and tortuous. It involves changes in how you operate; it affects your personnel, your management, and your organization and systems.
But let us not close the door on the remaining safety deficiencies. They need to be addressed.
I invite you to visit our website to look at the specific information on the Swissair accident. Everything the TSB issued on this investigation is accessible through one web page. When you get on the TSB website, enter the media room; select the TSB Major Investigations link, and then the Swissair item under the aviation mode category.
I welcome your comments and questions. I am also available to speak to you after this session should you wish to discuss collaboration opportunities.
Thank you for your attention.The Swissair accident investigation and an MPET burn test videos are also available on this site.
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