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Backgrounder: A12Q0216-20150629A

Recommendations from investigation of Perimeter Aviation Flight 993 crash in Sanikiluaq, Nunavut in December 2012


On 22 December 2012, Perimeter Aviation Flight 993 crashed while attempting to land in Sanikiluaq, Nunavut. The aircraft had come in too high, too steep, and too fast, striking the ground 525 feet past the end of the runway after an unsuccessful attempt to reject the landing. The 2 crew and 6 adult passengers, secured by their seatbelts, suffered injuries ranging from minor to serious. A lap-held infant – not restrained by any device or seatbelt – was fatally injured.


1. Commercial air carriers track and report data on the number of infants and children travelling

Currently, under the Transportation Information Regulations, Canadian air carriers must provide a wide range of information on their overall operations to the Minister of Transport. However, information on the number of infant (under 2 years) and child (2 to 12 years) passengers travelling by air is not required to be reported. Data is needed to conduct research, to assess risks, and to outline emerging trends related to the carriage of infants and children on board Canadian commercial aircraft.

Therefore, the Board recommends that:

Transport Canada require commercial air carriers to collect and report, on a routine basis, the number of infants (under 2 years old), including lap-held, and young children (2 to 12 years old) travelling.
Transportation Safety Recommendation A15-01

2. Child restraint systems (CRS) for infants and young children travelling on commercial aircraft

Restraint of infants and young children

Research has shown that, due to differences in body proportions, including height, weight, head size, and pelvic development between adults and children, the standard aircraft lap belt is not suited for the safe restraint of small children (those under 4 years of age). In the event of in-flight turbulence or an emergency landing, lap belt-restrained children may slide (or “submarine”) under the seatbelt and/or sustain severe belt-induced abdominal and/or spinal injuries.

In the event of an emergency landing, given their small size, young children may not be able to assume the recommended brace position for adults. If young children are not adequately restrained in age- and size-appropriate child restraint systems (CRS), there is a risk that injuries sustained will be more severe.

'Lap-held' infants

Research has found that, due to limitations in human clasping strength, it is not always possible for adults to restrain infants and small children adequately in their laps by holding onto them. Lap-held infants on aircraft are therefore exposed to undue risks of injury when seated on an adult's lap.

Much effort and many recommendations have been made, particularly by the U.S. National Transportation Safety Board (NTSB), to mandate the use of age- and size-appropriate CRS for children and infants. However, in most countries around the world, including Canada, infants are not required to be restrained in appropriate CRS at any time during a flight. Despite having published safety information on in-flight turbulence events and the risk of death or injury to passengers if objects are not restrained during takeoff and landing, Transport Canada has not implemented requirements for CRS on aircraft. If a lap-held infant is ejected from its guardian's arms during a flight, there is an increased risk the infant may be injured, or cause injury or death to other occupants.

Because there is no requirement for infants and young children to be restrained in age- and size-appropriate CRS while travelling by air, these passengers do not receive an equivalent level of safety compared to adult passengers.

Therefore, the Board recommends that:

The Department of Transport work with industry to develop age- and size-appropriate child restraint systems for infants and young children travelling on commercial aircraft, and mandate their use to provide an equivalent level of safety compared to adults.
Transportation Safety Recommendation A15-02