A93H0023-Aviation Safety Recommendations Concerning FDR AND CVR INADEQUACIES

Notwithstanding TC's intent as expressed in the draft AMAs, and considering that accident investigators frequently encounter flight data recorders (FDR) and cockpit voice recorder (CVR) which have not recorded the required information, the Board is not satisfied that current approval processes and maintenance procedures are adequate for flight recorders. Since the loss of information may preclude the timely identification of safety deficiencies, the Board recommends that:

The Department of Transport immediately verify through field audit that existing FDR and CVR installations meet current regulatory requirements, and make public its findings; and (TSB A94-01)

The Department of Transport revise its approval and monitoring process to ensure that all future FDR and CVR installations continue to meet regulatory requirements." (TSB A94-02)

Transport Canada Response:

Transport Canada supports these recommendations. Current requirements for installations and maintenance of Flight Data Recorders (FDR) and Cockpit Voice Recorders (CVR) are contained in the Department Engineer and Inspection (E&I) Manual, Part II, Chapter III, Sections 3.9 and 3.10. If an operator's approved maintenance programs adequately address these requirements, then installed recorders should maintain an acceptable serviceability rate.

However, in view of the TSB investigations which resulted in the above recommendations, the Department has initiated a program to review compliance with flight recorder requirements. Regional offices are being required to review air carrier's Maintenance Control Manuals (MCMs).  The following categories of carriers will be required to confirm compliance of their flight recorder installation to approved data, and proper recording of all parameters:

  1. Those whose MCMs are found deficient regarding the maintenance program for flight recorders;
  2. Those who contract their recorder maintenance to other organizations; and
  3. Those operating aircraft with foil and wire type FDRs.

A sampling review of carriers identified above will be conducted by the regional offices. A summary of the results of the review will be made available to the TSB.

Should the review show that there are deficiencies, further measures will be undertaken to ensure compliance with flight recorder installations, maintenance and verification requirements, and consideration will be given of to revision of approval and monitoring procedures.

Legislation

The present Canadian regulations for flight recorders came into effect in 1969.  Subsequently, only minor changes have been made. In 1985, the International Civil Aviation Organization (ICAO) issued new Standards and Recommended Practices (SARPs) for flight recorders. Canada endorsed the SARPs and formed a Flight Recorder Standards Review Group in 1986. Since the primary purpose of flight recorders is for occurrence investigations, in 1987 the Canadian Aviation Safety Board (CASB) forwarded to TC a Statement of Requirements (SOR) for FDRs and CVRs as perceived at that time.

Subsequently, after consultation with the Canadian aviation industry, TC stated its intention to issue new legislation which would closely correspond to new U.S. rules for flight recorders issued in July 1988.

In 1991, following the report of an investigation into an accident involving a Beechcraft King Air A-100 air ambulance (A88Ø0491), the underlying causes of which could not be determined, the TSB reviewed the Canadian flight recorder requirements. The Board noted that the U.S. rules and the planned Canadian legislation would meet neither the ICAO SARPs nor the CASB's Statement of Requirements. Nevertheless, the Board believed that new rules were needed in the near term to provide information necessary for occurrence investigations and effective corrective measures.  Therefore, despite the limitations of the proposed legislation and the prospect of better hardware to come, the Board recommended that, as an interim measure, the Department of Transport expedite legislation for upgrading the flight recorder requirements for Canadian-registered aircraft (TSB A91-13).

TC responded that it had accorded the highest priority to the processing of the FDR/CVR Orders and had advised the Department of Justice of the importance of expediting the promulgation of these Orders. Two and one-half years have elapsed since Recommendation A91-13; new legislation for FDR/CVRs has not been promulgated.

Many aircraft that are involved, or are capable of being involved, in commercial passenger operations continue to be exempt from the requirement to install any recorders. The recent accident at Tuktoyaktuk, 03 December 1993, involving a Britten-Norman Islander (in which seven person were fatally injured) is an example of an aircraft capable of carrying 10 persons but which is not required by regulations to be outfitted with any type of flight recorder (TSB file A93W0204).

In summary, many Canadian commercial aircraft continue flight operations with inadequate or unserviceable flight recorders, or no flight recorders at all.  Shortcomings in the current legislation, regulatory processes, and enforcement action for flight recorders continue to thwart efficient accident investigation. Since investigators are being deprived of critical safety information, thereby putting the aviation community and traveling public at risk, the Board recommends that:

The Department of Justice and Transport promulgate the new Orders on flight recorders without further delay. (A94-03)

Transport Canada Response :

Transport Canada Aviation (TCA) is rewriting the existing regulations, including the updating of the FDR/CVR Orders, into the Canadian Aviation Regulations on a priority basis as part of the Regulatory Renewal Project. The Project team includes Department of Justice lawyers on site to ensure timely that the new Regulations will come into law early in 1995.

While it is recognized that the industry will require a period of time to equip their aircraft with recorders, TCA will issue an Air Carrier Advisory Circular and an Aeronautical Information Circular informing the aviation industry of the implementing requirements and notification that industry will be required to comply within one year after promulgation.

Notwithstanding that the promulgation of the proposed legislation is of utmost importance, the TSB believes that Canadian flight recorder legislation must keep pace with advances in aircraft and recorder technology. This technology has progressed significantly since the CASB's 1987 SOR ad TC's decision to adopt the new U.S. based regulations. Modern aircraft incorporate computer technology for flight management systems (FMS) and data link communications; recorders offer expanded recording capability, and enhanced reliability and survivability. It is understood that the proposed TC legislation does not take into account such recent progress in technology; hence, investigations into occurrences involving the latest generation of aircraft registered in Canada may be denied time-critical evidence.

Recognizing a requirement for improved data collection to accommodate present and new generations of aircraft, the European Organization for Civil Aviation Electronics (EUROCAE) published a document (ED55) in May 1990 containing the data parameters considered to be essential for aeroplances and helicopters. The adoption of ED55 as a requirement has been proposed to member nations following the Joint Airworthiness Regulations.  The International Society of Air Safety Investigators (ISASI) has proposed to ICAO that ED55 be considered when its SARPs are amended. Both TC and the TSB have participated in EUROCAE meetings; as well, the TSB is currently updating its SORs for recorders.

If the TSB is to adequately, investigate occurrences involving advanced technology aircraft, Canadian aircraft must incorporate flight recorders capable of providing investigators wit the pertinent information. Given that the proposed Canadian legislation does not yet provide for these latest generation of aircraft, and given Canada's history of delays in updating flight recorder legislation, the Board recommends that:

The Department of Transport streamline its processes to facilitate the timely Canadian implementation of updated flight recorder requirements. (A94-04)

Transport Canada Response :

The Regulatory Renewal Project is incorporating existing regulations in a new regulatory structure consisting of regulations with standards incorporated be reference. The intent is that the standards will be contained in an incorporated document that is much more easily amended than the regulation.

Concerning the revised recorder regulations, we have a consensus with industry that agrees to full harmonization with the Federal Aviation Regulations (FAR) of the U.S.A. hence, the draft regulations have been finalized. The regulation section will stipulate briefly which aircraft require FDRs and CVRs. The standards section will list parameters, operational requirements and other technical specifications.

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