A93P0131 - Runway Excursion - Tofino, British Columbia - 21 July 1993

Safety Action Taken
(as presented in the TSB Report)

Regulatory Audits and Surveillance

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

The Department of Transport amend the Manual of Regulatory Audits 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)

Flight Recorder Legislation

Over the years, the Board has made several recommendations concerning deficiencies in the retrieval and quality of flight recorded data and in 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 purposes, there has not been significant progress in addressing these flight recorder deficiencies. Therefore, the Board recommended, inter alia, that:

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, TC has indicated that it intends to issue two interim circulars to facilitate industry adjustment to the new flight recorder regulation expected to come into law in early 1995. Also, TC stated that new regulations will refer to associated standards, which should facilitate amendment action in a timely way. The Department of Justice has advised that it is prepared to carry out its regulatory functions as quickly as possible to ensure that the regulations proposed by TC can be promulgated with the least possible delay.

Safety Action Required
(as presented in the TSB Report)

Crew Resource Management and Decision Making

Several factors led to the accident aircraft not being in the required position on final approach from which a safe landing could be executed. However, the accident could have been prevented if a decision had been made to discontinue the landing.

The Board has investigated several recent occurrences where inappropriate decisions have been made by aircrew, although cues were available which should have alerted them to potentially dangerous situations. While this occurrence at Tofino hinged upon a pilot decision at a critical point in the approach and landing phase, inappropriate decisions occur in almost all aspects of flight operations. See Appendix D (HTML or PDF ) for some examples of aviation occurrences with probable decision-making implications.

The Board recognizes that there are pressures in commercial aviation to "get the job done" and that these pressures undoubtedly affect decision making. Nevertheless, informed operators and trained aircrew should be able to handle these day-to-day operational decisions safely. In this vein, it is understood that crew training under real-world decision-making situations increases the likelihood of safe operational decisions. Subsequent to a DC-8 runway excursion at Moncton, New Brunswick (A91A0198), the involved carrier undertook several corrective measures, including the use of simulator training to assist crews in the decision-making process during approaches in reduced visibilities (such as the conditions encountered in the occurrence). In its final report on the occurrence, the Board encouraged such preventive action taken by the aviation community independent of regulatory requirements. However, the Board also expressed concern that other operators and aircrew without benefit of similar training programs and guidelines on the handling of critical decisions might continue to place their aircraft in unsafe situations.

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