Air Transportation Safety Recommendation A18-02, A18-03

The Honourable Marc Garneau, P.C., M.P.
Minister of Transport
Transport Canada
Place de Ville, Tower C-29
330 Sparks Street
Ottawa, Ontario
K1A 0N5

14 December 2018

Dear Minister,

Re:
Air transportation safety recommendations in advance of final report publication
TSB Investigation A17C0146
Fond-du-Lac, Saskatchewan
13 December 2017

Background

On 13 December 2017, an Avions de Transport Régional ATR 42-320 aircraft (registration C-GWEA, serial number 240), operated by West Wind Aviation LP (West Wind) as flight 282 (WEW282), conducted an instrument flight rules flight from Prince Albert (Glass Field) Airport (CYPA), Saskatchewan, to Fond‑du-Lac Airport (CZFD), Saskatchewan. During the descent, the aircraft encountered icing conditions and the crew activated the anti-icing and de-icing systems. When the de-icing and anti-icing systems were turned off 9 minutes later, while the aircraft was on final approach, residual ice remained on portions of the aircraft.

After landing, WEW282 exited the runway and shut down on the ramp at CZFD, at 1727 Central Standard Time. Some passengers disembarked and some cargo and baggage were removed from the aircraft; other passengers boarded and outbound cargo and baggage were loaded onto the aircraft. After the passengers had boarded, 1 pilot conducted a pre-flight inspection of the aircraft and subsequently advised the other pilot that the aircraft had ice on it. West Wind had some de-icing equipment in the terminal building at CZFD; however, the aircraft was not de-icedFootnote 1 before takeoff.

At 1812:03, the takeoff was initiated with ice contamination on the aircraft.

At 1812:30, WEW282 lifted off from Runway 28, bound for Stony Rapids Airport (CYSF), Saskatchewan, with 3 crew members (2 pilots and 1 flight attendant) and 22 passengers on board.

At 1812:47, the aircraft collided with trees and terrain approximately 1400 feet west of the departure end of Runway 28.

Nine passengers and 1 crew member received serious injuries, and the remaining 13 passengers and 2 crew members received minor injuries. One of the passengers who had received serious injuries died 12 days after the accident. The aircraft was destroyed.

As a part of its ongoing investigation into this occurrence (A17C0146), the TSB has identified a key safety issue that must be addressed to improve the safety of air transportation in Canada, namely aircraft taking off from remote northern airports with frost, ice, or snow adhering to critical surfaces.Footnote 2

Aircraft taking off with frost, ice, or snow adhering to any critical surface

Adverse consequences

Conducting a takeoff with contaminants adhering to aircraft critical surfaces will result in aerodynamic degradation, which can lead to difficulty controlling the aircraft or to a loss of control and collision with terrain.

Defence analysis

A major component of a safe transportation system is the set of defences put in place to protect people, property, and/or the environment. These defences can be used to

  • reduce the probability of unwanted events; and
  • reduce the negative consequences associated with unwanted events.

The regulatory provision underpinning the defences against takeoff in contaminated aircraft is Canadian Aviation Regulations (CARs) subsection 602.11(2), which states, “No person shall conduct or attempt to conduct a take-off in an aircraft that has frost, ice or snow adhering to any of its critical surfaces.”Footnote 3

To assist aviation personnel in complying with this provision, there is an administrative framework of

  • Transport Canada regulations and standards;
  • flight crew operating manuals and airplane flight manuals produced by aircraft manufacturers;
  • programs, policies, and procedures established by air operators; and
  • training provided to pilots and ground staff.

However, this framework can be ineffective without sufficient oversight at the regulatory and operational levels, and/or with operating conditions such as

  • active ground icing conditions;
  • absent, inaccessible (Figure 1), or inadequate inspection or de‑ice/anti-ice equipment;
  • very short holdover timesFootnote 4 for Type I de-icing fluidsFootnote 5; or
  • an absence of anti-icingFootnote 6 capability.
Figure 1. Exemplar de-icing equipment in a snowbank at another remote airport
Exemplar de-icing equipment in a snowbank at another remote airport

In this occurrence, one of the operating conditions was the equipment available to the pilots of WEW282 at CZFD. Neither of the available ladders (Figure 2 and Figure 3) was high enough to permit an inspection or de-icing of the ATR 42 wing or horizontal stabilizer.Footnote 7The West Wind de-icing equipment (Figure 4) was a hand-held spray system with a small-capacity heated fluid reservoir, and a 20 L container of additional Type I fluid. Another air operator also had a small, heated hand-held spray system (Figure 5) in the terminal building. These systems, even if combined, had insufficient fluid capacity to de‑ice an ATR 42.

Figure 2. One of the available step ladders at CZFD, height 11.3 feet / 3.44 m; maximum standing height 9.1 feet / 2.77 m
One of the available step ladders at CZFD
Figure 3. The other available step ladder at CZFD, height 6 feet /1.83 m; maximum standing height 3.7 feet / 1.3 m
The other available step ladder at CZFD
Figure 4. West Wind's de-icing equipment at CZFD
West Wind's de-icing equipment at CZFD
Figure 5. De-icing equipment of another air operator at CZFD
De-icing equipment of another air operator at CZFD

No anti-icing equipment was available at CZFD. None of the available ladders or de-icing equipment were used by the crew of WEW282.

Compliance with the administrative framework would have prevented WEW282 from taking off with contaminants on its critical surfaces. However, some of the organizational defences in place, such as equipment, were inadequate. Moreover, taking off with contaminants on the aircraft breached a number of otherwise adequate administrative defences, such as prohibitions in the ATR 42 Flight Crew Operating Manual, the company's operations manual, and the company's ATR 42 standard operating procedures.

Assessment of the risk

To assess the systemic risk posed by the circumstances present in this occurrence, in July and August 2018, the TSB sent a questionnaire to commercial pilots currently employed by air operators in Canada operating at remote northern airports under Part VI or Part VII of the CARs.

The TSB distributed pilot questionnaire invitations to 83 Canadian commercial air operators that, on 31 May 2018, operated under subparts 604, 702, 703, 704, and 705 of the CARs.Footnote 8 The selected operators were those likely to have flights taking off from the airports in Figure 6, below. The questionnaire deliberately excluded large national airline operators that operate primarily from airports in southern Canada.

Figure 6. Remote northern airports (Source: Office of the Auditor General, 2017 Spring Reports, Report 6—Civil Aviation Infrastructure in the North—Transport Canada)
Remote northern airports

Invitations were also sent to several pilot unions representing pilots employed by the selected operators, and to an aviation industry association of air operators.

All organizations that received the invitation had access to the questionnaire questions, and were able to choose whether to forward the invitation to their pilots. Questionnaire participation was both voluntary and anonymous; the questionnaire did not request location information or operator identities.

The selected air operators that provided staffing information employed 2768 pilots. Air operators that did not provide pilot numbers are estimated to employ an additional 500 pilots. It is not known how many pilots received invitations forwarded by their operator or union.

Completed questionnaire responses were received from 655 pilots. Preliminary analysis of questionnaire responses indicates that, at remote northern airports in Canada, aircraft operating under CARs Part VI or Part VII frequently take off with contaminated critical surfaces. Some respondents reported negative consequences, such as degraded takeoff and climb performance or difficulty controlling the aircraft.

Respondents reported seeing, within the past 5 years, transport category jets and turboprops, commuter turboprops, and all types of air taxi aircraft take off with contaminants adhering to the critical surfaces.

Questionnaire respondents were not asked to indicate where they had seen contaminated aircraft take off; however, some did so, indicating a wide geographic distribution of events across Canada. Some respondents reported seeing events regularly at some remote northern airports.

Many questionnaire respondents answered that they rarely have access to adequate inspection equipment and de-icing equipment (Appendix A). The unavailability of adequate equipment is a significant underlying factor that prevents pilots from being able to conduct a proper pre-flight inspection for contaminants and from de-icing an aircraft that is contaminated. Only 37% of respondents reported that they are able to have their aircraft de-iced effectively at remote airports.

Most questionnaire respondents answered that they rarely have access to adequate anti‑icing equipment. Only 15% of respondents reported that they are able to have their aircraft anti-iced effectively at remote northern airports. Where anti-icing is not available, flights operating in active ground icing conditions can experience Type I fluid failureFootnote 9 because of its short holdover time.

As demonstrated by this occurrence, losses of control and collisions with terrain can result in destruction of the aircraft and death. Similar occurrences investigated by the TSB and other agencies over the past 36 years (appendices B and C) indicate that this catastrophic consequence still occurs occasionally. Canada is substantially exposed to the risk of accident recurrence, with a large and diverse fleet of aircraft operating at remote northern airports when icing conditions are present.

The combined probability and severity of this safety deficiency pose a high risk to transportation safety.

Identification of high-risk locations for immediate mitigation

The duration of cold weather and icing conditions varies widely across Canada. Many remote northern airports have an icing season of 10 months or more. Icing conditions can be both severe and persistent.

Thousands of flights take off every year from remote northern airports. Some airports serve as hubs, experience higher traffic volumes, and may have better equipment.

The risks of adverse consequences likely vary from airport to airport. Identifying high-risk locations for immediate mitigation has the potential to quickly reduce the likelihood of aircraft taking off with frost, ice, or snow adhering to any critical surface at those locations.

Transport Canada, air operators, and airport authorities have the capacity to identify high-risk locations, analyze them for hazards and risks, and take mitigating action.

Therefore, the Board recommends that

the Department of Transport collaborate with air operators and airport authorities to identify locations where there is inadequate de-icing and anti-icing equipment and take urgent action to ensure that the proper equipment is available to reduce the likelihood of aircraft taking off with contaminated critical surfaces.
TSB Recommendation A18-02

Improving compliance

TSB pilot questionnaire responses indicate that the absence of adequate equipment increases the likelihood that pilots will conduct a takeoff in an aircraft that has frost, ice, or snow adhering to any of its critical surfaces. Additionally, the responses indicate that, in the absence of adverse consequences, taking off with contamination on critical surfaces is a deviation that has become normalized. Therefore, providing adequate de-icing and anti-icing equipment may not be sufficient to reduce the likelihood of aircraft taking off with contaminated critical surfaces.

This occurrence and the pilot questionnaire responses indicate that some of the current defences used by the Canadian air transportation system to prevent aircraft from taking off with frost, ice, or snow adhering to any critical surface are less than adequate.

TSB questionnaire responses show that takeoffs with contaminated critical surfaces occur in substantial numbers across the spectrum of aircraft and operating categories at remote northern airports.

Non-compliance with CARs subsection 602.11(2), flight crew operating manuals, company operations manuals, and company standard operating procedures can be a single point of failure of defence framework. To mitigate this, Transport Canada and air operators must take urgent action to ensure better compliance.

Organizations can audit equipment (to inspect, de-ice, and anti-ice aircraft), policies (such as ground icing operations programs and contingencies for situations where resources are not available), training (for pilots and ground staff), and operations (procedures, compliance, deviations). Air operators could incorporate questions in before-start and before-takeoff checklists with a requirement for a clean aircraft or a mitigation response from the pilot-in-command.

Accidents related to contaminated aircraft will continue to occur until the industry and the regulator approach the issue as systemic and take action to eliminate underlying factors that can negatively affect pilot compliance.

Therefore, the Board recommends that

the Department of Transport and air operators take action to increase compliance with Canadian Aviation Regulations subsection 602.11(2) and reduce the likelihood of aircraft taking off with contaminated critical surfaces.
TSB Recommendation A18-03

Next steps

At this time, the TSB investigation into this accident is ongoing and the investigation team is completing its analysis of the information collected. The investigation will then move into the report phase and a draft report will be prepared and sent out for review and submission of representations by the designated reviewers, per our standard practice. As the investigation proceeds, should the TSB identify any additional safety deficiencies in need of urgent attention, the Board may make further recommendations or issue other safety communications.

In accordance with subsection 24(6) of the Canadian Transportation Accident Investigation and Safety Board Act, we hereby ask that you advise the Board in writing within the next ninety days of any action taken or proposed to be taken in response to the two enclosed recommendations.

Yours sincerely,

The original version was signed by
Kathleen Fox
Chair

Enclosures: Appendices A, B, and C

Cc:

A. McCrorie, A/ADMSS
N. Girard, A/Associate ADM
N. Robinson, A/DG, CIV/AVI
F. Collins, A/DG, SAF-GRO
P. Juneau, Dir., CIV/AVI

Appendices

Appendix A – Pilot questionnaire responses (n = 655)

Question Never Rarely Sometimes Usually Always Does not apply
When I am at a remote airport, I have access to ground equipment that enables effective inspection of all of the aircraft’s critical surfaces for contamination. 26 177 174 178 96 4
When I am at a remote airport, I have access to ground equipment that enables adequate de‑icing of the aircraft’s critical surfaces before takeoff. 41 191 177 165 77 4
When I am at a remote airport, I have access to ground equipment that enables adequate anti-icing of the aircraft’s critical surfaces before takeoff. 207 206 98 83 45 16
I am able to have my aircraft de-iced effectively at remote airports. 37 216 152 180 65 5
I am able to have my aircraft anti-iced effectively at remote airports. 231 213 89 68 29 25
Question Yes No
In the past 5 years, I have seen pilots take off with contaminated critical surfaces. 483 172

Appendix B – Similar occurrences in Canada

Occurrence number Date Aircraft type Location Comments
N/A 1989-03-10 Fokker F-28 Dryden, ON Accident. Commercial operation. Contaminated critical surfaces before takeoff. Collision with terrain after takeoff. 24 fatalities. Moshansky Commission of Inquiry made many recommendations.
A98Q0057 1998-04-25 DHC-8-102 Québec, QC Incident. Commercial operation. Contamination before takeoff froze and resulted in jammed elevators during cruise. No injuries.
A98Q0194 1998-12-07 Britten-Norman BN2A-26 Point-Lebel, QC Accident. Commercial operation. Contaminated critical surfaces before takeoff. Loss of control and collision with terrain after takeoff. 6 fatalities, 1 person missing, 3 serious injuries.
A99P0181 1999-12-28 Cessna 208 Abbotsford, BC Accident. Private operation. Contaminated critical surfaces before takeoff. Loss of control and collision with terrain after takeoff. 3 serious injuries, 3 minor injuries.
A03O0088 2003-04-07 Found FBA-2C1 Lake Temagami, ON Accident. Private operation. Contamination before takeoff, loss of control and collision with terrain after takeoff. 2 fatalities.
A03O0302 2003-11-04 DHC-8-102 Ottawa, ON Incident. Commercial operation. Aircraft de-iced before takeoff. Control restrictions during takeoff, rejected takeoff. No injuries.
A04H0001 2004-01-17 Cessna 208B Pelee Island, ON Accident. Commercial operation. Contaminated critical surfaces before takeoff, loss of control, and collision with terrain after takeoff. 10 fatalities.
A09C0017 2009-02-04 DHC-6 La Ronge, SK Accident. Commercial operation. Contaminated critical surfaces before takeoff. Loss of control and collision with terrain after takeoff. 7 minor injuries.
A12C0154 2012-11-18 Cessna 208B Snow Lake, MB Accident. Commercial operation. Contaminated critical surfaces before takeoff, loss of control and collision with terrain after takeoff. 1 fatality, 7 serious injuries.
A13W0201 2013-12-17 Boeing 737-300 Fort MacKay / Albian Aerodrome, AB Incident. Commercial operation, Aircraft de-iced and anti-iced before departure. Insufficient quantity of Type IV fluid used for anti-icing. Difficulty controlling the aircraft after takeoff. No injuries. The TSB issued an aviation safety advisory to Transport Canada on 10 September 2014.

Appendix C – Similar occurrences outside Canada

Occurrence number Date Aircraft type Location Comments
DCA82AA011 1982-01-13 B737 Washington, D.C. Contaminated critical surfaces. 78 fatalities.
DCA88MA004 1987-11-15 DC-9-14 Denver, Colorado Contaminated critical surfaces. 28 fatalities.
A02F0002 2002-01-04 CL600-2B16 Birmingham, UK Frost contamination before takeoff. 5 fatalities.
A04F0207 2004-11-28 CL60 Montrose, Colorado Contaminated critical surfaces before takeoff. 3 fatalities, 3 seriously injured.
A04F0202 2004-11-21 CL600-2B19 Baotou, China Contaminated critical surfaces before takeoff. 53 fatalities.
A05F0023 2005-01-31 Cessna 208 Helsinki, Finland Contaminated critical surfaces before takeoff.
N/A 2007-01-25 Fokker 100 Pau, France Contaminated critical surfaces before takeoff.
A08F0020 2008-01-31 CL-600-2B19 Oslo, Norway Leading edge contamination during takeoff run. No injuries.
A08F0026 2008-02-14 CL-600-2B19 Yerevan, Armenia Contaminated critical surfaces before takeoff. 7 serious injuries.
N/A 2008-04-09 BAe Jetstream 41 Aberdeen, UK Contaminated critical surfaces before takeoff. Incident. No injuries.
A12F0033 2012-04-02 ATR72-201 Tyumen, Russia Contaminated critical surfaces before takeoff. 33 fatalities.
N/A 2013-03-04 Beechcraft Premier 1A Annemasse, France Contaminated critical surfaces before takeoff. 2 fatalities.
N/A 2016-03-04 ATR 72-212A Manchester, UK Contaminated critical surfaces before takeoff. Incident. No injuries.
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