2016 - Air Recommendations

A16-01 – “The Department of Transport require all Canadian-registered aircraft and foreign aircraft operating in Canada that require installation of an emergency locator transmitter (ELT) to be equipped with a 406-MHz ELT in accordance with ICAO Standards.”

A16-05 – “The Department of Transport establish rigorous ELT system crash survivability standards that reduce the likelihood that an ELT system will be rendered inoperative as a result of impact forces sustained during an aviation occurrence.”

A16-07 – “The Department of Transport prohibit the use of hook-and-loop fasteners as a means of securing an emergency locator transmitter to an airframe.”

A16-08 – “The Department of Transport amend the regulations to clearly define the visual references (including lighting considerations and/or alternate means) required to reduce the risks associated with night VFR flight.”

A16-09 – “The Department of Transport establish instrument currency requirements that ensure instrument flying proficiency is maintained by instrument rated pilots, who may operate in conditions requiring instrument proficiency.”

A16-10 – “The Department of Transport require terrain awareness and warning systems for commercial helicopters that operate at night or in instrument meteorological conditions.”

A16-11 – “The Department of Transport establish pilot proficiency check standards that distinguish between, and assess the competencies required to perform, the differing operational duties and responsibilities of pilot-in-command versus second-in-command.”

A16-12 – “The Department of Transport require all commercial aviation operators in Canada to implement a formal safety management system.”

A16-13 – “The Department of Transport conduct regular SMS assessments to evaluate the capability of operators to effectively manage safety.”

A16-14 – “The Department of Transport enhance oversight policies, procedures and training to ensure the frequency and focus of surveillance, as well as post-surveillance oversight activities, including enforcement, are commensurate with the capability of the operator to effectively manage risk.”

Transport Canada Response to Aviation Safety Recommendations A16-01, A16-05 and A16-07 to A16-14 issued by the Transportation Safety Board of Canada

Summary

On 31 May 2013, at approximately 0011 Eastern Daylight Time, the Sikorsky S-76A helicopter (registration C-GIMY, serial number 760055), operated as Lifeflight 8, departed at night from Runway 06 at the Moosonee Airport, Ontario, on a visual flight rules flight to the Attawapiskat Airport, Ontario, with 2 pilots and 2 paramedics on board. As the helicopter climbed through 300 feet above the ground toward its planned cruising altitude of 1000 feet above sea level, the pilot flying commenced a left-hand turn toward the Attawapiskat Airport, approximately 119 nautical miles to the northwest of the Moosonee Airport. Twenty-three seconds later, the helicopter impacted trees and then struck the ground in an area of dense bush and swampy terrain. The aircraft was destroyed by impact forces and the ensuing post-crash fire. The helicopter’s satellite tracking system reported a takeoff message and then went inactive. The search-and-rescue satellite system did not detect a signal from the emergency locator transmitter. At approximately 0543, a search-and-rescue aircraft located the crash site approximately 1 nautical mile northeast of Runway 06, and deployed search-and-rescue technicians. However, there were no survivors.

Transportation Safety Board of Canada Recommendation A16-01

“The Department of Transport require all Canadian-registered aircraft and foreign aircraft operating in Canada that require installation of an emergency locator transmitter (ELT) to be equipped with a 406-MHz ELT in accordance with ICAO Standards.”

Transport Canada Response to Recommendation A16-01

Transport Canada agrees with this recommendation and is continuing on the regulatory path to mandate the carriage of 406 MHz capable emergency beacons for Canadian registered aircraft and foreign aircraft operating in Canada. Transport Canada anticipates these regulations to be published in 2017.

Transportation Safety Board of Canada Recommendation A16-05

“The Department of Transport establish rigorous ELT system crash survivability standards that reduce the likelihood that an ELT system will be rendered inoperative as a result of impact forces sustained during an aviation occurrence.”

Transport Canada Response to Recommendation A16-05

Transport Canada agrees in principle with this recommendation.

Emergency Locator Transmitter (ELT) technology and its development is an international effort. In Canada, ELTs in use typically meet FAA TSO-C91a and/or TSO-C126 or later revision, which incorporates by reference the consensus-based standards of RTCA/DO-204. These standards are paralleled in Europe by EASA’s ETSO-2C126, incorporating EUROCAE ED-62. ELTs meeting the latest TSO-C126b standard must meet the test criteria for shock and crash safety of RTCA/DO-204A, sections 2.3.4.1 and 2.6.3.2.

Transport Canada has recently joined the RTCA Special Committee SC-229, which is tasked to update the DO-204 standards to address the latest design, performance, installation and operational issues for emergency beacons. In parallel to crash survivability requirements, the SC-229 will consider the need to develop standards for pre-accident automatic ELT activation.

Transportation Safety Board of Canada Recommendation A16-07

“The Department of Transport prohibit the use of hook-and-loop fasteners as a means of securing an emergency locator transmitter to an airframe.”

Transport Canada Response to Recommendation A16-07

Transport Canada agrees in principle with the intent of this recommendation. As concluded in 2012, Transport Canada agrees with both FAA and EASA that inconsistent installation and reinstallation practices can lead to the hook and loop style fastener not having necessary tension to perform its intended function. Additionally, the retention characteristics of the hook and loop style fastener may degrade over time due to wear and environmental degradation from vibration, temperature, or contamination. Concern increases further when the ELT instructions for continued airworthiness (ICA) do not have specific instructions for inspecting the hook and loop style fasteners or a replacement interval. ELTs mounted with hook and loop style fasteners have detached from their aircraft mounting, causing the antenna connection to sever and rendering the ELT ineffective. Commensurately, the use of hook and loop fasteners to secure ELTs is no longer permitted for ELTs meeting the minimum performance specifications of TSO-C126b.

Further, Transport Canada understands that manufacturers of ELT designs incorporating hook and loop fasteners that have failed to perform their intended function in accidents either have revised or are in the process of revising their designs, minimizing the need to cancel the airworthiness approval of previously approved ELTs. Similarly, designs incorporating hook and loop fasteners have not been determined to represent an unsafe condition in the fleet, to the extent that an Airworthiness Directive is warranted.

On May 23, 2012, the FAA issued SAIB HQ-12-32 to provide recommendations for previously installed ELTs. The Transport Canada Feedback magazine, at issue 3/2012, advised Canadian industry on the publication of the SAIB, providing ELT installation and maintenance guidance and advising of the new TSO–C126b to eliminate hook and loop fasteners from future TSO designs. On March 10, 2015, the U.S. Federal Register published an FAA Notice recommending voluntary change to the securing of existing ELTs, asking those aircraft owners/operators with ELTs secured with hook and loop fasteners in their aircraft to voluntarily switch to a metal strap type restraint method.

In response to this safety recommendation, Transport Canada will carry out further safety promotion to educate the Canadian aviation community with respect to the risks with hook and loop fasteners.

Transportation Safety Board of Canada Recommendation A16-08

“The Department of Transport amend the regulations to clearly define the visual references (including lighting considerations and/or alternate means) required to reduce the risks associated with night VFR flight.”

Transport Canada Response to Recommendation A16-08

Transport Canada agrees with this recommendation.

TC will address this recommendation in two steps; first with safety promotion and education activities as early as fall 2016; and secondly, by initiating a regulatory amendment project in 2017 including consultation with our key stakeholders. Safety promotion and education will leverage TC’s recently published Advisory Circular No. 603-001 – Use of Night Vision Imaging Systems.

Transportation Safety Board of Canada Recommendation A16-09

“The Department of Transport establish instrument currency requirements that ensure instrument flying proficiency is maintained by instrument rated pilots, who may operate in conditions requiring instrument proficiency.”

Transport Canada Response to Recommendation A16-09

Transport Canada agrees with this recommendation.

TC plans to address this recommendation via a regulatory amendment and will engage the aviation community on the subject in summer 2017.

Transportation Safety Board of Canada Recommendation A16-10

“The Department of Transport require terrain awareness and warning systems for commercial helicopters that operate at night or in instrument meteorological conditions.”

Transport Canada Response to Recommendation A16-10

Transport Canada agrees in principle with this recommendation.

TC will engage the helicopter community in 2017 to inform the department on how to address this recommendation.

Transportation Safety Board of Canada Recommendation A16-11

“The Department of Transport establish pilot proficiency check standards that distinguish between, and assess the competencies required to perform, the differing operational duties and responsibilities of pilot-in-command versus second-in-command.”

Transport Canada Response to Recommendation A16-11

Transport Canada agrees with the recommendation. In fact, independent of the tragic accident, TC conducted a thorough review of the Approved Check Pilot (ACP) Manual this past year and is planning to publish a revision before spring 2017.

The 10th edition of the ACP Manual will have a consolidated and strengthened set of guidance on non-technical skills to be assessed. Under the 4-Point Marking Scale Leadership and Managerial Skills will be added as one of four non-technical (CRM) skills. The sub elements of this skill assessment are as follows:

  1. Use of authority and assertiveness;
  2. Providing and maintaining standards;
  3. Planning and coordination; and
  4. Workload management.

A draft copy of the manual will be provided to the TSB in the fall 2016.

Transportation Safety Board of Canada Recommendation A16-12

“The Department of Transport require all commercial aviation operators in Canada to implement a formal safety management system.”

Transport Canada Response to Recommendation A16-12

Transport Canada agrees in principle with the recommendation.

TC already requires a safety management system in commercial air operators that represent approximately 95% of passenger miles. The department recognizes the added value of a safety management system.

TC will address this recommendation in two ways. First, by continuing to promote voluntary adoption of a safety management system among the balance of commercial air operators. To support this, the department will publish updated guidance material aimed at smaller sized-operations this year. Secondly, over the next year and a half, the department will be reviewing the policy, regulations and program related to safety management systems in civil aviation. The expected outcome of the review is a determination on the scope, regulatory instrument, applicability and oversight model.

This review will rely on the input of the department’s employees, as well as industry, international authorities and other specialists in this area.

Transportation Safety Board of Canada Recommendation A16-13

“The Department of Transport conduct regular SMS assessments to evaluate the capability of operators to effectively manage safety.”

Transport Canada Response to Recommendation A16-13

Transport Canada agrees in principle with this recommendation.

The suite of surveillance tools that TC uses, namely assessments, program validation inspections and process inspections, are effective in verifying compliance with the Canadian Aviation Regulations, including SMS requirements.

TC has adopted a systems-based approach to all its surveillance activities. In other words, TC has added management system principles and quality assurance techniques to surveillance activities across all sectors not just those subject to safety management system requirements. Under the systems-based approach, TC’s civil aviation safety inspectors use the systems as an entry point and sample end products to verify that the system is working effectively and is in compliance with the Canadian Aviation Regulations.

While TC continually evaluates its tools to ensure they continue to be effective and makes updates, as required, the department is confident in its approach of using a combination of surveillance tools to verify regulatory compliance.

Transportation Safety Board of Canada Recommendation A16-14

“The Department of Transport enhance oversight policies, procedures and training to ensure the frequency and focus of surveillance, as well as post-surveillance oversight activities, including enforcement, are commensurate with the capability of the operator to effectively manage risk.”

Transport Canada Response to Recommendation A16-14

Transport Canada agrees that it must continually enhance its oversight policies, procedures and training. In fact, independent to this accident or this recommendation, TC committed in its National Oversight Plan for 2016/2017 to conduct an evaluation of its surveillance program.

Further to that commitment, in July 2016, TC launched a Civil Aviation Surveillance Program Evaluation and Update Project. The purpose of this project is to analyse opportunities for improvement identified via inspector feedback, analyse lessons- learned, and leverage business intelligence to update the surveillance program. The goal of the project is to ensure the surveillance program effectively verifies regulatory compliance at appropriate intervals and is effective in carrying out enforcement action, as required. While the project is scheduled to complete in December 2017, the department will not hesitate to implement enhancements sooner, if warranted.

The Board’s recommendation A16-14 will be used as an input to this evaluation work.

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