Recommendations and Assessments

The Canadian Transportation Accident Investigation and Safety Board Act requires that federal Ministers provide formal responses to the TSB as to action taken or planned in response to our recommendations.

The Board also makes recommendations to other organizations and will assess all these responses and evaluate the degree to which they address the safety issues and deficiencies using an Assessment Rating Guide.

Recommendations and Assessments of Responses Relating to Investigation A98H0003 (SR111)

2003

Recommendation A03-09
That regulatory authorities harmonize international rules and processes for the protection of cockpit voice and image recordings used for safety investigations.(A98H0003)
Response     Asssessment/Reassessment
Rating: Satisfactory Intent

Recommendation A03-08
That regulatory authorities develop harmonized requirements to fit aircraft with image recording systems that would include imaging within the cockpit.(A98H0003)
Response     Asssessment/Reassessment
Rating: Satisfactory Intent

Recommendation A03-07
That regulatory authorities require, for all aircraft manufactured after 1 January 2007 which require an FDR, that in addition to the existing minimum mandatory parameter lists for FDRs, all optional flight data collected for non-mandatory programs such as FOQA/FDM, be recorded on the FDR. (A98H0003)
Response     Asssessment/Reassessment
Rating: Unsatisfactory

Recommendation A03-06
That regulatory authorities, in concert with the aviation industry, take measures to enhance the quality and intelligibility of CVR recordings. (A98H0003)
Response     Asssessment/Reassessment
Rating: Satisfactory in Part

Recommendation A03-05
That regulatory authorities establish the requirements and industry standard for circuit breaker resetting.(A98H0003)
Response     Asssessment/Reassessment
Rating: Fully Satisfactory

Recommendation A03-04
That regulatory authorities require that every system installed through the 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.(A98H0003)
Response     Asssessment/Reassessment
Rating: Satisfactory in Part

Recommendation A03-03
That 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.(A98H0003)
Response     Asssessment/Reassessment
Rating: Fully Satisfactory

Recommendation A03-02
That 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.(A98H0003)
Response     Asssessment/Reassessment
Rating: Satisfactory in Part

Recommendation A03-01
That regulatory authorities quantify and mitigate the risks associated with in-service thermal acoustic insulation materials that have failed the Radiant Panel Test.(A98H0003)
Response     Asssessment/Reassessment
Rating: Unsatisfactory

2001

Recommendation A01-04
That as a prerequisite to certification, all aircraft systems in the pressurized portion of an aircraft, including their sub-systems, components, and connections, be evaluated to ensure that those systems whose failure could exacerbate a fire in progress are designed to mitigate the risk of fire-induced failures.(A98H0003)
Response     Asssessment/Reassessment
Rating: Satisfactory in Part

Recommendation A01-03
That a certification test regime be mandated that evaluates aircraft electrical wire failure characteristics under realistic operating conditions and against specified performance criteria, with the goal of mitigating the risk of ignition.(A98H0003)
Response     Asssessment/Reassessment
Rating: Satisfactory in Part

Recommendation A01-02
That for the pressurized portion of an aircraft, flammability standards for material used in the manufacture of any aeronautical product be revised, based on realistic ignition scenarios, to prevent the use of any material that sustains or propagates fire.(A98H0003)
Response     Asssessment/Reassessment
Rating: Fully Satisfactory

2000

Recommendation A00-20
That appropriate regulatory authorities review current in-flight firefighting standards including procedures, training, equipment, and accessibility to spaces such as attic areas to ensure that aircraft crews are prepared to respond immediately, effectively and in a coordinated manner to any in-flight fire.(A98H0003)
Response     Asssessment/Reassessment
Rating: Satisfactory Intent

Recommendation A00-19
That appropriate regulatory authorities ensure that emergency checklist procedures for the condition of odour/smoke of unknown origin be designed so as to be completed in a timeframe that will minimize the possibility of an in-flight fire being ignited or sustained.(A98H0003)
Response     Asssessment/Reassessment
Rating: Satisfactory in Part

Recommendation A00-18
That appropriate regulatory authorities take action to ensure that industry standards reflect a philosophy that when odour/smoke from an unknown source appears in an aircraft, the most appropriate course of action is to prepare to land the aircraft expeditiously.(A98H0003)
Response     Asssessment/Reassessment
Rating: Fully Satisfactory

Recommendation A00-17
That appropriate regulatory authorities, together with the aviation community, review the methodology for establishing designated fire zones within the pressurized portion of the aircraft, with a view to providing improved detection and suppression capability.(A98H0003)
Response     Asssessment/Reassessment
Rating: Satisfactory Intent

Recommendation A00-16
That appropriate regulatory authorities, in conjunction with the aviation community, review the adequacy of in-flight firefighting as a whole, to ensure that aircraft crews are provided with a system whose elements are complementary and optimized to provide the maximum probability of detecting and suppressing any in-flight fire.(A98H0003)
Response     Asssessment/Reassessment
Rating: Satisfactory in Part

1999

Recommendation A99-08
That on an urgent basis, regulatory authorities validate all thermal acoustical insulation materials in use, or intended for use, in applicable aircraft, against test criteria that are more rigorous than those in Appendix F of FAR 25.853, and similar regulations, and that are representative of actual in-service system performance.(A98H0003)
Response     Asssessment/Reassessment
Rating: Satisfactory in Part

Recommendation A99-07
That regulatory authorities confirm that sufficient action is being taken, on an urgent basis, to reduce or eliminate the risk associated with the use of metallized PET-covered insulation blankets in aircraft.(A98H0003)
Response     Asssessment/Reassessment
Rating: Satisfactory in Part

Recommendation A99-04
That aircraft required to have two flight recorders be required to have those recorders powered from separate generator buses.(A98H0003)
Response     Asssessment/Reassessment
Rating: Satisfactory Intent

Recommendation A99-03
That as of 01 January 2005, for all aircraft equipped with CVRs having a recording capacity of at least two hours, a dedicated independent power supply be required to be installed adjacent or integral to the CVR, to power the CVR and the cockpit area microphone for a period of 10 minutes whenever normal aircraft power sources to the CVR are interrupted.(A98H0003)
Response     Asssessment/Reassessment
Rating: Satisfactory Intent

Recommendation A99-02
That as of 01 January 2005, all aircraft that require both an FDR and a CVR be required to be fitted with a CVR having a recording capacity of at least two hours.(A98H0003)
Response     Asssessment/Reassessment
Rating: Satisfactory Intent

Recommendation A99-01
That as of 01 January 2003, any CVR installed on an aircraft as a condition of that aircraft receiving an original certificate of airworthiness be required to have a recording capacity of at least two hours.(A98H0003)
Response     Asssessment/Reassessment
Rating: Fully Satisfactory