A93H0023 -Controlled Flight into Terrain-Sandy Lake, Ontario 1 nm NW-10 November 1993

Safety Action Taken

(as presented in the TSB Report)

Transport Canada (TC) Special Inspection

In January 1994, TC conducted a special inspection of Air Manitoba's Flight Operations and Maintenance departments. The findings of this inspection, primarily with respect to maintenance shortcomings, resulted in removal of the company's maintenance certificate and suspension of its operating certificate. The company subsequently contracted its HS 748 maintenance to another carrier and regained its operating certificate.

Flight Recorders

Flight recorder information is often invaluable in the investigation of occurrences and it most certainly would have assisted in determining the events leading to this accident. In the past, the Board has made recommendations concerning deficiencies on the retrieval and quality of recorded data and on the lengthy process required to update flight recorder legislation. Notwithstanding the emphasis that the Board has put on the importance of flight recorders for investigation and accident prevention processes, there has not been any significant progress in addressing these flight recorder deficiencies. Therefore, the Board recommended that:

The Department of Transport immediately verify through field audit that all existing FDR and CVR installations meet current regulatory requirements, and make public its findings; (A94-01, issued January 1994)

The Department of Transport revise its approval and monitoring process to ensure that all future FDR and CVR installations continue to meet regulatory requirements; (A94-02, issued January 1994)

The Departments of Justice and Transport promulgate the new Orders on flight recorders without further delay; and (A94-03, issued January 1994)

The Department of Transport streamline its processes to facilitate the timely Canadian implementation of updated flight recorder requirements. (A94-04, issued January 1994)

In response to these recommendations, TC has undertaken a program to review operator compliance with existing recorder requirements in order to identify areas of the monitoring and approval processes that need revision. In addition, TC stated its intention in April 1994 to issue two interim circulars to facilitate industry adjustment to the new recorder regulation expected to come into law in early 1995.

With respect to streamlining the recorder legislation process, TC stated that a new regulatory structure will have regulations which incorporate standards by reference in order to facilitate amendment in a timely way. TC's new approach to use standards to keep pace with changing requirements in aviation, and in particular flight recorder technology, is an important improvement in the regulatory process. Also, TC has reached consensus with industry to harmonize with the U.S. Federal Aviation Regulations (FAR) in finalizing the draft Canadian regulations.

The new regulation will state which aircraft will require FDRs and CVRs; the standards section will list parameters, operational requirements, and other technical specifications.

The Department of Justice has advised that it is prepared to carry out its regulatory functions as quickly as possible to ensure the regulations proposed by TC can be promulgated with the least possible delay.

Static Inverter Installation

Anomalies were found in the static inverter installation which had replaced the original rotary inverter system of the occurrence aircraft. Given that other Canadian operators may also be operating HS 748s with similar electrical system discrepancies, a TSB Aviation Safety Advisory was forwarded to TC. The Advisory concerned the requirement to verify that the inverter systems of all Canadian HS 748 aircraft conform to the applicable installation drawings.

Undervoltage Protection

Significant importance has been afforded the issue of undervoltage protection for the HS 748 aircraft. It was determined that Service Bulletins (SB) 24/60 and 24/97 are considered to be mandatory. A TSB Aviation Safety Advisory forwarded to TC addressed the need to confirm that all Canadian HS 748 aircraft meet the current electrical system requirements for undervoltage protection.

Accidents Involving Controlled Flight into Terrain

The circumstances of this occurrence are typical of a Controlled Flight into Terrain (CFIT) accident. CFIT occurrences are those in which an aircraft, under the control of the crew, is flown into terrain (or water) with no prior awareness on the part of the crew of the impending disaster. The Board notes with concern that, over the 11-year period from 01 January 1984 to 31 December 1994, 68 commercially operated aircraft not including those conducting low-level special operations) were involved in CFIT accidents. In view of the frequency and severity of such accidents, the Board is currently conducting a study of CFIT accidents to identify related systemic deficiencies.

Regulatory Audits and Surveillance

Analysis and information from this investigation and 18 others led to the identification of shortcomings in the regulatory overview process of air carriers. In particular, it was found that TC's audits sometimes lacked depth, and that the verification of corrective action following the audits was sometimes inadequate. Therefore, the Board recommended that:

The Department of Transport amend the Manual of Regulatory Audits (MRA) to provide for more in-depth audits of those air carriers demonstrating an adverse trend in its risk management indicators; (A94-23, issued December 1994)

The Department of Transport ensure that its inspectors involved in the audit process are able to apply risk management methods in identifying carriers warranting increased audit attention; (A94-24, issued December 1994)

The Department of Transport develop, as a priority, a system to track audit follow-up actions; and (A94-25, issued December 1994)

The Department of Transport implement both short and long term actions to place greater emphasis on verification of required audit follow-up action and on enforcement action in cases of non-compliance. (A94-26, issued December 1994)

In response to these recommendations, TC has indicated that both Recommendations A94-23 and A94-24 will be taken into consideration during amendments to the MRA. Also, TC will ensure that the Audit Procedures training program for inspectors takes into account Recommendation A94-24 so that risk management methods are clearly understood and applied.

With respect to Recommendations A94-25 and A94-26, TC replied that the MRA will be reviewed to ensure clear policy direction is given to ensure effective audit follow-up systems are in place. Furthermore, an enhanced National Aviation Company Information System (NACIS) should be operational by September 1995 to track audit follow-up on a national basis. In the interim, a policy directive will be issued to regions to require a review of respective regional follow-up systems.

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