Annual Report to Parliament 2003-2004

AIR

Occurrence Statistics and Investigations

ANNUAL STATISTICS

The number of accidents involving ultralights increased from 36 in 2002 to 46 in 2003. However, the number of fatal accidents decreased from 9 accidents with 12 fatalities in 2002 to 7 accidents with 9 fatalities in 2003.

The number of foreign-registered aircraft involved in accidents in Canada increased from 13 in 2002 to 30 in 2003. Fatal accidents increased from 1 accident with 2 fatalities in 2002 to 6 accidents with 8 fatalities in 2003.

In 2003, a total of 834 incidents were reported in accordance with TSB mandatory reporting requirements. This represents a 4% decrease from the 2002 total of 865, but a 7% increase from the 1998-2002 average of 783.

AIR INVESTIGATIONS STARTED IN 2003-2004

The following information is preliminary. Final determination of events is subject to the TSB's full investigation.

Date	Location	Aircraft Type	Occurrence No.
2003.04.07	Lake Temagami, Ont.	Found Brothers FBA-2C1	A03O0088
2003.04.09	CYPE Peace River, 13 nm SE, Alta.	Robinson Helicopter R44	A03W0074
2003.04.23	CYPA Prince Albert (Glass Field), 6 nm SW, Sask.	Beech 99	A03C0094
2003.05.22	CJS9 Lac du Bonnet (North), Man	de Havilland DHC-3	A03C0118
2003.05.22	Active Pass, B.C.	de Havilland DHC-3 Sikorsky S-76A	A03P0113
2003.05.31	CYCW Chilliwack, 7.5 nm E, B.C.	Cessna 182	A03P0133
2003.06.05	Lake Wicksteed, Ont.	de Havilland DHC-6-300	A03O0135
2003.06.06	Lillooet, 30 nm NW, B.C.	Bell Helicopter 206B	A03P0136
2003.06.17	Gisborne, New Zealand	Convair 340/580	A03F0114
2003.06.24	Wasaga Beach, 5 mi WSW, Ont.	Mooney 20 E	A03O0156
2003.06.26	A036 Buchans, 25 nm SE, N.L.	Polskie Zaklady Lotnicze PZL-18	A03A0076
2003.07.04	Lac Boucher, Que.	Bell Helicopter 206B	A03Q0092
2003.07.07	CYTZ Toronto/City Centre, Ont.	Beech 58	A03O0171
2003.07.13	Manning, 75 nm NE, Alta.	Bell Helicopter 204B	A03W0148
2003.07.16	Cranbrook, 9 nm SE, B.C.	Lockheed 188A	A03P0194
2003.07.18	Harrison Hot Springs, 24 nm NNW, B.C.	Cessna 172M	A03P0199
2003.07.26	CYQB Québec/Jean Lesage Intl, 6 nm E, Que.	Cessna 172M	A03Q0109
2003.08.05	London, 40 nm NE, Ont.	Boeing 767-200 Fokker F-28 MK 100	A03O0213
2003.08.10	CYDC Princeton, B.C.	Cessna 210 A	A03P0239
2003.08.11	CYZT Port Hardy, 26 nm W, B.C.	Boeing 757-200 Boeing 747-400	A03P0244
2003.08.17	Bonaparte Lake, B.C.	Bell Helicopter 204B	A03P0247
2003.08.23	Vernon, B.C.	Airbus A319-100	A03P0259
2003.08.29	Penticton, 10 nm N, B.C.	de Havilland DHC-2	A03P0265
2003.09.03	CYHC Vancouver Harbour, B.C.	de Havilland DHC-6-200	A03P0268
2003.09.11	CJV7 Summer Beaver, 3 nm W, Ont.	Cessna 208 B	A03H0002
2003.09.16	Mayo, 80 nm N, YT	Bell Helicopter 206B	A03W0194
2003.09.23	CYYC Calgary, 49 nm S, Alta.	Cessna 414 A	A03W0202
2003.09.26	CYYZ Toronto/Lester B. Pearson Intl, Ont.	Israel Aircraft (IAI) Astra SPX	A03O0273
2003.09.27	CYGP Gaspé, 2 nm NE, Que.	Piper PA-31	A03Q0151
2003.10.04	Linda Lake, B.C.	Piper PA-18-150	A03W0210
2003.10.09	CYKZ Toronto/Buttonville Municipal, 2 nm SSE, Ont.	Cessna 172N	A03O0285
2003.11.04	CYOW Ottawa/MacDonald-Cartier Intl, Ont.	de Havilland DHC-8-100	A03O0302
2003.11.06	CYVR Vancouver Intl, B.C.	Airbus A330-300	A03P0332
2003.12.16	Jellicoe, Ont.	de Havilland DHC-3	A03O0341
2004.01.13	La Grande, 160 nm SSW, Que.	Boeing 777-200 Boeing 767-300	A04Q0003
2004.01.15	CYHD Dryden Regional, Ont.	Fairchild SA-227-AC	A04C0016
2004.01.17	CYPT Pelee Island, 0.5 nm W, Ont.	Cessna 208 B	A04H0001
2004.01.19	CYYZ Toronto/Lester B. Pearson Intl, Ont.	Airbus A321	A04O0016
2004.01.26	CYYZ Toronto/Lester B. Pearson Intl, Ont.	Boeing 767-200	A04O0020
2004.02.20	Prince Rupert, 40 nm SSE, B.C.	Robinson Helicopter R22 Mariner	A04P0033
2004.02.25	CYEG Edmonton Intl, Alta.	Boeing 737-200	A04W0032
2004.03.03	CYVR Vancouver Intl, B.C.	Boeing 737-200 Cessna 182D	A04P0047
2004.03.04	Swift Current, 3.8 nm SW, Sask.	Bell Helicopter 206B	A04C0051
2004.03.08	CTG2 St-Hubert Helicraft, Que.	Schweizer 269C (300C)	A04Q0026
2004.03.12	Nanaimo, 20 nm NW, B.C.	Cessna 185E Cessna 185F	A04P0057
2004.03.20	Ralf, Sask.	Baby Bell Helicopter	A04C0064

AIR REPORTS RELEASED IN 2003-2004

Date	Location	Aircraft Type	Event	Report No.
2001.02.15	VCBI Colombo, Sri Lanka	Airbus A330-300	Loss of engine power	A01F0020
2001.04.03	Sydney, 12 nm W, N.S.	de Havilland DHC-8-100	Multiple engine flame-outs	A01A0030
2001.04.04	CYYT St. John's Intl, N.L.	Boeing 737-200	Runway overrun	A01A0028
2001.06.05	CCH4 Charlottetown, P.E.I.	Piper PA-31-310	Collision with terrain	A01A0058
2001.06.27	Roberval, 80 nm N, Que.	Bell Helicopter 212	Fuel exhaustion - hard landing	A01Q0105
2001.07.22	Abbotsford Parachute Centre, 1.5 nm SW, B.C.	Pilatus PC-6T	Loss of engine power - forced landing	A01H0003
2001.10.08	CYYY Mont-Joli, 22 nm SE, Que.	Piper PA-23	Loss of control - stall - collision with terrain	A01Q0165
2001.11.08	Buhl Creek, B.C.	Aerospatiale SA 315B	Loss of engine power - collision with terrain	A01P0282
2002.02.01	CYXX Abbotsford, B.C.	Boeing 737-200	In-flight engine nose dome detachment	A02P0021
2002.03.04	CYYR Goose Bay, N.L.	Fairchild SA-227-AC	Loss of directional control - collision with snowbank	A02A0030
2002.03.26	CEK4 Blairmore (Forestry), 12 nm N, Alta.	Eurocopter AS 350D	Loss of control - hard landing	A02W0057
2002.04.18	SU34 Hare Field, Ont.	Schweizer 269C (300C)	Loss of control - collision with terrain	A02O0105
2002.04.25	Stephenville, 38 nm ESE, N.L.	Beech 1900D	Window failure - rapid depressurization	A02A0046
2002.04.25	Saskatoon, 63 nm E, Sask.	Boeing 747-200 Boeing 747-400	Risk of collision	A02C0079
2002.05.21	CCW4 Stanley, N.S.	Schempp-Hirth KG Cirrus	Seat failure - loss of control	A02A0065
2002.05.27	CZJN Swan River, Man.	Cessna TU206 F	Loss of engine power - forced landing	A02C0105
2002.06.02	Tobin Lake, Sask.	Bell Helicopter 205A-1	In-flight engine fire - forced landing	A02C0114
2002.06.06	Needle Peak, B.C.	Cessna 182P	Visual flight rules (VFR) flight into adverse weather - collision with terrain	A02P0109
2002.06.11	Winnipeg, Man.	Piper PA-31-350	Fuel exhaustion - collision with terrain	A02C0124
2002.06.14	EDDF Frankfurt/Rhein-Main Intl, Germany	Airbus A330-343	Tail strike on take-off	A02F0069
2002.06.19	Kamloops, B.C.	McDonnell Douglas Helicopter 369D (500D)	Main rotor blade failure	A02P0126
2002.06.20	North Atlantic (Cymon Intersection)	Boeing 747-400 Boeing 767 Boeing 767-300	Loss of separation - risk of collision	A02A0079
2002.06.27	CYQF Red Deer (Vicinity), Alta.	British Aerospace Jetstream 3112 Fairchild SA227-DC	Loss of separation - risk of collision	A02W0115
2002.06.28	Sasaginnigak Lake, 10 nm S, Man.	de Havilland DHC-2 MK I	Loss of engine power - forced landing	A02C0143
2002.06.29	Engemann Lake, Sask.	Cessna 185 F	Collision with water	A02C0145
2002.07.01	CZBB Boundary Bay, B.C.	Cessna 172 N	Aircraft stall on take-off - collision with terrain	A02P0136
2002.08.08	Wendle Creek, B.C.	Sikorsky S-61L	Loss of main rotor drive - collision with terrain	A02P0169
2002.08.18	CYYR Goose Bay, N.L.	Bell Helicopter 212	Loss of control - collision with terrain	A02A0098
2002.09.04	CZHP High Prairie, 7 nm SE, Alta.	Piper PA-34-220T	Collision with terrain	A02W0173
2002.09.18	CYYZ Toronto/Lester B. Pearson Intl, Ont.	Piper PA-44-180 de Havilland DHC-8	Loss of separation	A02H0002
2002.09.28	Natashquan, 57 nm N, Que.	de Havilland DHC-3	Collision with terrain	A02Q0130
2002.10.15	Porcher Inlet, B.C.	McDonnell Douglas Helicopter 369D (500D)	Collision with water	A02P0256
2002.11.12	CYZP Sandspit, B.C.	Cessna 550	Gear-up landing	A02P0290
2002.11.20	CYVR Vancouver Intl, B.C.	Boeing 747-200 Shorts SD3-60	Loss of separation - risk of collision	A02P0299
2003.01.11	CYYT St. John's Intl, N.L.	Beech 1900D	Collision with windrow	A03A0002
2003.01.29	CYPM Pikangikum, 2 nm SW, Ont.	Beech 99	Collision with terrain	A03C0029
2003.02.02	CYHZ Halifax Intl Airport, N.S.	Boeing 737-200	Loss of directional control	A03A0012
2003.02.04	Badger, 19 nm WNW, N.L.	Cessna 188 B	Fuel starvation - forced landing	A03A0013
2003.02.11	CYQG Windsor, Ont.	Airbus A320-200	Runway excursion	A03O0034
2003.05.22	CJS9 Lac du Bonnet (North), Man.	de Havilland DHC-3	Engine failure - forced landing	A03C0118

ASSESSMENT OF RESPONSES TO AIR RECOMMENDATIONS ISSUED IN 2002-2003

Recommendation	Response Summary	Board Assessment of Response	Safety Action Taken
Peggy's Cove, Nova Scotia - 2 September 1998 Smoke in the Cockpit - Swissair MD-11HB-IWF			Occurrence No. A98H0003
A03-01 Regulatory authorities quantify and mitigate the risks associated with in-service thermal acoustic insulation materials that have failed the Radiant Panel Test (RPT).	TC's response contends that a material's failure to pass the RPT is not, in and of itself, indicative of an unsafe material. Rather TC argues that metallized polyethylene terephthalate, the only thermal acoustic insulation cover material which has been deemed to be unsafe by the Federal Aviation Administration (FAA), was so designated because of both its ease of ignition from a small ignition source and propensity to propagate fire.	Unsatisfactory	No action taken to date.
A03-02 Regulatory authorities develop a test regime that will effectively prevent the certification of any thermal acoustic insulation materials that, based on realistic ignition scenarios, would sustain or propagate a fire.	An advisory circular (AC) designed to complement the rule change implementing the RPT is under development by the FAA. TC intends to adopt the RPT and will be reviewing this FAA AC for application to its own relevant regulations.	Satisfactory intent	No action taken to date.
A03-03 Regulatory authorities take action to ensure the accurate and consistent interpretation of the regulations governing material flammability requirements for aircraft materials so as to prevent the use of any material with inappropriate flammability characteristics.	TC intends to contact the FAA to request that this issue be considered by its International Aircraft Materials Fire Test Working Group. The group, which involves Civil Aviation Authorities (CAAs), including TC, and the international aviation industry, is the prime focus for the development of aircraft materials' flammability test criteria and standards.	Satisfactory intent	No action taken to date.
A03-04 Regulatory authorities require that every system installed through the supplementary type certificate (STC) process undergo a level of quantitative analysis to ensure that it is properly integrated with aircraft type-certified procedures, such as emergency load-shedding.	TC did not agree that a quantitative assessment is always required for every system installed through the STC process, and stated that the regulatory requirements are in place to deal with the approval of STCs. TC plans to develop advisory material emphasizing the need to verify that system integration requirements are adequately addressed during the STC process, to initiate awareness training for industry delegates and TC certification engineers, focussing on "non-essential, non-required" systems, and to continue its harmonization efforts related to US Federal Aviation Regulation 25.1309.	Unsatisfactory	No action taken to date.
A03-05 Regulatory authorities establish the requirements and industry standard for circuit breaker resetting.	TC concurred with the TSB recommendation. TC plans to submit a request that the FAA's Aviation Rulemaking Advisory Committee's Transport Aircraft and Engines Issues Group establish the requirements and industry standards for circuit breaker resetting. The objective would be to produce harmonized standards for use by the Civil Aviation Authorities (e.g. FAA, Joint Aviation Authorities and TC) of major aircraft manufacturing states.	Satisfactory intent	No action taken to date
A03-06 Regulatory authorities, in concert with the aviation industry, take measures to enhance the quality and intelligibility of cockpit voice recorder (CVR) recordings.	TC concurred with the intent of this recommendation. TC acknowledged that the clarity of the CVR recording is improved when the flight crew uses the boom microphones; however, their continuous usage can lead to crew fatigue. To improve the quality of the CVR recording, TC plans to develop a Notice of Proposed Amendment (NPA), to amend the regulatory requirement for the use of boom microphones from a maximum altitude of 10,000 feet to 18,000 feet above sea level.	Satisfactory intent	No action taken to date.
A03-07 Regulatory authorities require, for all aircraft manufactured after 1 January 2007 which require a flight data recorder (FDR), that in addition to the existing minimum mandatory parameter lists for FDRs, all optional flight data collected for non-mandatory programs such as flight operational quality assurance or Flight Data Monitoring, be recorded on the FDR.	TC's response did not support the deficiency in recommendation A03-07. Rather, it stated that it plans to work with all concerned to enhance the FDR capability as requirements change. There is no indication in its response to suggest any technical objection to supplementing the current FDR parameters. TC has expressed a concern that any attempt to capture Flight Data Monitoring (FDM) data on FDRs would jeopardize the FDM safety initiative. However, it does not explain why requiring FDRs to be easily augmented with additional parameters and routinely and readily accessed without requiring re-certification would put the FDM program at risk.	Unsatisfactory	No action taken to date.
A03-08 Regulatory authorities develop harmonized requirements to fit aircraft with image recording systems that would include imaging within the cockpit.	TC supported the recommendation concerning the installation of image recording systems to supplement the current flight recording requirements. It stated an intention to work with other CAAs to develop a harmonized approach to image recorder system standards and to take regulatory action to implement the requirement to install video imaging equipment in cockpits of transport category aeroplanes in commercial service.	Satisfactory intent	No action taken to date.
A03-09 Regulatory authorities harmonize international rules and processes for the protection of cockpit voice and image recordings used for safety investigations.	TC agreed that all cockpit voice and image recordings used for safety investigations should be protected; that the appropriate forum to gain the necessary international agreement and harmonized implementation of this recommendation is the International Civil Aviation Organization (ICAO). TC plans to bring this recommendation to the attention of the ICAO through Canada's representative.	Satisfactory intent	No action taken to date.

 

Recommendation	Response Summary	Board Assessment of Response	Safety Action Taken
Lester B. Pearson International Airport, Ontario - 13 May 2002 Cargo Bay Fire - Air Canada, Boeing 767-300			Occurrence No. A02O0123
A02-04 The Department of Transport take action to reduce the short-term risk and eliminate the long-term risk, of heater ribbon installation failures starting fires, and coordinate and encourage a similar response from other appropriate regulatory authorities.	TC indicates that it shares a similar concern and is working closely with the FAA, Boeing and other foreign civil aviation authorities to assess and study the short- and long-term risks of heater ribbon installations, and to determine an appropriate means of addressing the issue. The FAA indicates that it intends to issue a Service Bulletin and subsequent Airworthiness Directive for more reliable heater ribbons in open cargo bay areas on the Boeing 767 and 747 aircraft.	Satisfactory intent	No action taken to date.
A02-05 The Department of Transport take action to reduce the short-term risk and eliminate the long-term risk, of contaminated insulation materials and debris propagating fires, and coordinate and encourage a similar response from other appropriate regulatory authorities.	TC indicates that it shares a similar concern and is working closely with the FAA, Boeing and other foreign civil aviation authorities to assess and study the short- and long-term risks of heater ribbon installations, and to determine an appropriate means of addressing the issue in both the short and long term. The FAA indicates that it intends to implement a new maintenance process for airplane manufacturers to remove debris from wiring areas called Enhanced Zonal Analysis Procedure (EZAP). EZAP will result in more effective scheduled maintenance.	Satisfactory intent	No action taken to date.

OTHER AIR SAFETY ACTION TAKEN

• TC identified to NAV CANADA a safety deficiency concerning the degraded performance of anemometers due to ice accretion and has requested that NAV CANADA implement software changes that would suppress incorrect wind information under these conditions.
• NAV CANADA issued a station bulletin to all St. John's Flight Service Station personnel clarifying the procedure for reporting estimated winds in an aviation routine weather report. NAV CANADA also issued a bulletin to all units informing air traffic services units personnel to be vigilant during icing conditions and the actions to be taken if they suspect the anemometer is affected by ice accretion.
• Following an accident involving an input freewheel unit failure, TC published an article entitled "Freewheel Units" in Vortex, Issue 2/2002. The operator reduced the inspection interval for the component to 400 hours and the aircraft manufacturer issued a Safety Alert reminding operators of the maintenance manual's requirement for a specific inspection requirement for the part.
• Following an in-flight engine nose dome detachment, TC communicated with the FAA regarding a possible Airworthiness Directive to have all engine accessory supports replaced with modified accessory supports that have been strengthened.
• WestJet Airlines carried out a fleet-wide campaign to replace all engine accessory supports with modified accessory supports.
• TC is conducting a review of the applicable Bell 205A-1 instructions for continuing airworthiness to determine if action is necessary regarding the instructions for the installation of starters/generators and fuel lines.
• Following an accident involving fuel exhaustion followed by collision with terrain, TC conducted a post-accident regulatory audit and - at the request of the company -a systems safety review.
• Following a loss of separation occurrence, NAV CANADA Toronto ACC revised control procedures to include the requirement of matching radar targets to flight data strips as part of sector hand-over procedures.
• Following a collision with terrain accident, TC recommended that the company amend its standard operating procedures to state that after take-off, no turns will be performed below 1,000 feet above ground level unless instructed to do so by air traffic control.
• In response to a series of engine failures, the operator's Flight Operations Training Department amended the training program in areas specifically dealing with the recognition of turbine engine malfunctions, Extended Range Twin-Engined Aircraft Operations diversion procedures and in-flight communications. The engine manufacturer issued two Alert Service Bulletins to provide inspection procedures for specific engine parts.
• Following a double engine flame-out in the presence of ice on the lower engine nacelle cowl, the aircraft manufacturer issued a revised ground procedure training guide containing a more detailed description of the areas to be inspected and cleaned, and issued a Customer Special Installation on enlarging drain holes in the engine air inlet ducts. The operator incorporated the revised procedures into its training program.
• Following an aircraft window failure in flight, the operator issued a Quality Assurance Bulletin changing the inspection schedule from 1,200 hours to 200 hours. TC reviewed the operator's standard operating procedures to determine if improvements could be recommended.
• NAV CANADA issued an Operations Bulletin to personnel in the Edmonton Area Control Centre, drawing their attention to the necessity of following ATC MANOPS in matters pertaining to strip marking for aircraft operating at altitudes inappropriate for direction of flight. NAV CANADA also issued a Notice to Airmen and made permanent corrections to an en route pilotage chart which had depicted inaccurate information regarding an airway.
• Following a gear-up landing occurrence, the operator decided to require the fitting of a Ground Proximity Warning System on all fixed wing aircraft operated on their behalf by contracted carriers.
• TC proposed an amendment to the Canadian Aviation Regulations, which would require passenger-carrying aircraft of the class involved in the gear-up landing occurrence to be equipped with specific types of terrain avoidance warning systems.
• As a result of a loss of separation occurrence at Vancouver International Airport, NAV CANADA revised the Vancouver Tower Class C airspace procedures to require all arriving and departing aircraft operating under visual flight rules to obtain discreet transponder codes so that all aicraft tracked by radar might be correlated with flight number and flight plan information and be more conspicuous on the radar display.

APPENDIX A: GLOSSARY

Accident	In general, a transportation occurrence that involves serious personal injury or death, or significant damage to property, in particular to the extent that safe operations are affected (for a more precise definition, see the Transportation Safety Board Regulations)
Incident	In general, a transportation occurrence whose consequences are less serious than those of an accident, or that could potentially have resulted in an accident (for a more precise definition, see the Transportation Safety Board Regulations)
Occurrence	A transportation accident or incident
Recommendation	A formal way to draw attention to systemic safety issues, normally warranting ministerial attention
Safety Advisory	A less formal means for communicating lesser safety deficiencies to officials within and outside of government
Safety Information Letter	A letter that communicates safety-related information, often concerning local safety hazards, to government and corporate officials

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Footnotes

1 While the Board's operations are for the 2003-2004 fiscal year, occurrence statistics are for the 2003 calendar year. Comparisons are generally to the last 5 or 10 years. For definitions of terms such as accident, incident and occurrence, see Appendix A.

2 In a live database, the occurrence data are constantly being updated. Although an occurrence may happen during a given fiscal year, the decision to undertake an investigation may be taken later as a result of a more thorough analysis of preliminary data.

3 Investigations are considered complete after the final report has been issued.

4 For definitions of terms such as recommendation, safety advisory and safety information letter, see Appendix A.

5 Also includes responses to recommendations issued in the previous fiscal year.

6 1018 joules - a joule is a unit of work or energy equal to the work done by a force of one newton acting through a distance of one metre.

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