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GEN - 3.0 TRANSPORTATION SAFETY BOARD OF CANADA

3.1 Aviation Safety Investigation

The purpose of an aviation safety investigation into an aircraft accident or incident is to prevent a recurrence; it is not to determine or apportion blame or liability. The TSB, established under the Canadian Transportation Accident Investigation and Safety Board Act, is responsible for investigating all aviation occurrences in Canada involving civil aircraft registered both in Canada and abroad. A team of investigators is on 24-hr standby.

3.2 Definitions

“aviation occurrence” means

(a) any accident or incident associated with the operation of aircraft; and

(b) any situation or condition that the Board has reasonable grounds to believe could, if left unattended, induce an accident or incident described in paragraph (a).

“dangerous goods” means dangerous goods as defined in the Transportation of Dangerous Goods Act.

“reportable aviation accident” means an accident resulting directly from the operation of an aircraft, where

(a) a person sustains a serious injury or is killed as a result of

(i) being on board the aircraft,

(ii) coming into contact with any part of the aircraft or its contents, or

(iii) being directly exposed to the jet blast or rotor downwash of the aircraft;

(b) the aircraft sustains damage or failure that adversely affects the structural strength, performance or flight characteristics of the aircraft and that requires major repair or replacement of any affected component part; or

(c) the aircraft is missing or inaccessible.

“reportable aviation incident” means an incident resulting directly from the operation of an airplane having a maximum certificated take-off weight greater than 5 700 kg, or from the operation of a rotorcraft having a maximum certificated take-off weight greater than 2 250 kg, where

(a) an engine fails or is shut down as a precautionary measure;

(b) a transmission gearbox malfunction occurs;

(c) smoke or fire occurs;

(d) difficulties in controlling the aircraft are encountered owing to any aircraft system malfunction, weather phenomena, wake turbulence, uncontrolled vibrations or operations outside the flight envelope;

(e) the aircraft fails to remain within the intended landing or take-off area, lands with all or part of the landing gear retracted or drags a wing tip, an engine pod or any other part of the aircraft;

(f) any crew member whose duties are directly related to the safe operation of the aircraft is unable to perform the crew member’s duties as a result of a physical incapacitation that poses a threat to the safety of any person, property or the environment;

(g) depressurization occurs that necessitates an emergency descent;

(h) a fuel shortage occurs that necessitates a diversion or requires approach and landing priority at the destination of the aircraft;

(i) the aircraft is refuelled with the incorrect type of fuel or contaminated fuel;

(j) a collision, a risk of collision or a loss of separation occurs;

(k) a crew member declares an emergency or indicates any degree of emergency that requires priority handling by an air traffic control unit or the standing by of emergency response services;

(l) a slung load is released unintentionally or as a precautionary or emergency measure from the aircraft; or

(m) any dangerous goods are released in or from the aircraft.

 

3.3 Reporting an Aviation Occurrence

3.3.1

Where a reportable aviation accident occurs and it has not yet been reported to the TSB, the pilot-in-command, operator, owner and any crew member of the aircraft involved shall report the following information to the Board as soon as possible thereafter and by the quickest means of communication available:

(a) the type, model and nationality and registration marks of the aircraft;

(b) the names of the owner, operator and, where applicable, the hirer of the aircraft;

(c) the name of the pilot-in-command;

(d) the date and time of the accident;

(e) the last point of departure and the point of intended landing of the aircraft, including the date and time of the departure;

(f) the location of the aircraft by reference to an easily defined geographical point, or by latitude and longitude;

(g) the number of crew members, passengers and other persons that were killed or sustained serious injury;

(h) a description of the accident and the extent of any resulting damage to the aircraft, the environment and other property;

(i) a description of any dangerous goods on board, or released from, the aircraft; and

(j) the name and address of the person making the report.

3.3.2

Where an aircraft is missing or inaccessible and the accident has not yet been reported to the TSB, the owner and the operator of the aircraft shall report the following information to the Board by the quickest means of communication available:

(a) the type, model and nationality and registration marks of the aircraft;

(b) the names of the owner, operator and, where applicable, the hirer of the aircraft;

(c) the name of the pilot-in-command;

(d) the last point of departure and the point of intended landing of the aircraft, including the date and time of the departure;

(e) the date and time of the last known takeoff of the aircraft;

(f) the last known position of the aircraft by reference to an easily defined geographical point, or by latitude and longitude, including the date and time of that position;

(g) the names of crew members and passengers on board the aircraft;

(h) the action being taken to locate, or gain access to, the aircraft;

(i) a description of any dangerous goods on board the aircraft; and

(j) the name and address of the person making the report.

3.3.3

Where a reportable incident occurs and the incident has not yet been reported to the TSB, the owner, operator, pilot-in-command, any crew member of the aircraft, and, where the incident involves a loss of separation or a risk of collision, any air traffic controller having knowledge of the incident shall report the following information to the Board as soon as possible thereafter and by the quickest means of communication available:

(a) the type, model and nationality and registration marks of the aircraft;

(b) the names of the owner, operator and, where applicable, the hirer of the aircraft;

(c) the name of the pilot-in-command;

(d) the date and time of the incident;

(e) the last point of departure and the point of intended landing of the aircraft, including the date and time of the departure;

(f) the location of the incident by reference to an easily defined geographical point, or by latitude and longitude;

(g) the number of crew members, passengers and other persons that were killed or sustained serious injury;

(h) a description of the incident and the extent of any resulting damage to the aircraft, the environment and other property;

(i) a description of any dangerous goods on board, or released from, the aircraft; and

(j) the name and address of the person making the report.

3.3.4

Any other incident indicative of a deficiency or discrepancy in the Canadian air transportation system may be reported in writing to the TSB. Sufficient details concerning the incident should be provided to enable the identification of action required to remedy the deficiency or discrepancy. 

3.3.5

Reportable aviation accidents and incidents, and missing aircraft are to be reported to the Regional TSB office, using the telephone numbers listed in GEN 3.6. Alternatively, occurrences may be reported through a NAV CANADA ATS unit, which will forward the report to the appropriate TSB office.

For Canadian-registered aircraft operating outside of Canada, in addition to the reporting required by the state of occurrence, a report shall be made to the TSB Regional office nearest to the company’s headquarters or, for private aircraft, nearest to the aircraft’s home base.


 

3.4 Protection of Occurrence Sites, Aircraft, Components and Documentation

3.4.1

(1) Where a reportable accident or incident takes place, the owner, operator and any crew member shall, to the extent possible, and until otherwise instructed by a TSB investigator or except as otherwise required by law, preserve and protect any evidence relevant to the reportable accident or incident, including evidence contained in documents, except when taking necessary measures to ensure the safety of any person, property or the environment.

(2) Where evidence relevant to a reportable accident or incident has to be interfered with pursuant to paragraph (1), the person directing, supervising or arranging the interference shall, to the extent possible in the circumstances, and prior to the interference, record the evidence by the best means available. 

3.4.2

Where a reportable aviation accident occurs, the pilot-in-command, operator, owner and any crew member of the aircraft involved shall, to the extent possible, preserve and protect: 

(a) the aircraft or any component or contents thereof and the occurrence site until such time as an investigator otherwise authorizes;

(b) the flight data and cockpit voice recorders and the information recorded thereon; and

(c) all other records, documents and all materials of any kind pertaining to:

(i) the flight during which the accident occurred,

(ii) the crew members involved, and

(iii) the aircraft, its contents and components,

and shall surrender on demand the recorders, information, records, documents and materials referred to in (b) and (c) to an investigator.

3.4.3

Where a reportable aviation incident occurs, the pilot-in-command, operator, owner and any crew member of the aircraft involved shall, to the extent possible, preserve and protect: 

(a) the flight data recorders and the information recorded thereon; and

(b) all other records, documents and materials of any kind pertaining to:

(i) the flight during which the incident occurred,

(ii) the crew members involved, and

(iii) the aircraft, its contents and components,

and shall surrender on demand the recorders, information, records, documents and materials referred to in (a) and (b) to an investigator.


 

3.5 SECURITAS Program

The SECURITAS program provides a means for individuals to report incidents and potentially unsafe acts or conditions relating to the Canadian transportation system that would not normally be reported through other channels. It should be noted that this multi-modal confidential safety reporting system replaces the Confidential Aviation Safety Reporting Program (CARSP).

Each report is assessed by SECURITAS analysts. When a reported concern is validated as a safety deficiency, the TSB normally forwards the information, often with suggested corrective action, to the appropriate regulatory authority, or in some cases, the transportation company, organization, or agency. No information will be released that could reasonably be expected to reveal the reporter’s identity without the reporter’s written consent.

SECURITAS is primarily concerned with unsafe acts and conditions relating to commercial and public transportation systems. To submit a report, write, fax, e-mail, or telephone SECURITAS at: 

SECURITAS
P.O. Box 1996
Station B
Gatineau QC  J8Z 3Z2

Tel.: 1-800-567-6865
Fax:    819-994-8065
E-mail:   securitas@tsb-bst.gc.ca

3.6 Offices of the TSB

HEADQUARTERS:

Place du Centre, 4th Floor
200 Promenade du Portage
Gatineau QC  K1A 1K8

Toll-free (within Canada):  1-800-387-3557
Toll:      819-994-3741
Fax: 819-953-9586
TTY: 819-953-7287
E-mail:            airops@tsb-bst.gc.ca

REGIONAL OFFICES (AIR)

TSB—Pacific

Regional Manager, TSB-AIR
4-3071 Number Five Road
Richmond BC  V6X 2T4

Toll-free (within Canada):  1-800-387-3557
Toll:     819-994-3741
Fax: 604-666-7230
E-mail:           airnotifications.vancouver@tsb-bst.gc.ca

TSB—Western 

Regional Manager, TSB-AIR
17803 106A Avenue
Edmonton AB  T5S 1V8

Toll-free (within Canada): 1-800-387-3557
Toll:     819-994-3741
Fax: 780-495-2079
E-mail:           airnotifications.edmonton@tsb-bst.gc.ca

TBS—Central

Regional Manager, TSB-AIR
335-550 Century Street
Winnipeg MB  R3H 0Y1

Toll-free (within Canada):   1-800-387-3557
Toll:     819-994-3741
Fax: 204-983-8026
E-mail:              airnotifications.winnipeg@tsb-bst.gc.ca

TSB—Ontario 

Regional Manager, TSB-AIR
23 East Wilmot Street
Richmond Hill ON  L4B 1A3

Toll-free (within Canada): 1-800-387-3557
Toll:      819-994-3741
Fax: 905-771-7709
E-mail:               airnotifications.toronto@tsb-bst.gc.ca

TSB—Quebec

Regional Manager, TSB-AIR
185 Dorval Avenue, Suite 403
Dorval QC  H9S 5J9

Toll-free (within Canada): 1-800-387-3557
Toll:     819-994-3741
Fax: 514-633-2944
E-mail:              airnotifications.montreal@tsb-bst.gc.ca

TSB—Atlantic

Regional Manager, TSB-AIR
150 Thorne Avenue
Dartmouth NS  B3B 1Z2

Toll-free (within Canada): 1-800-387-3557
Toll:     819-994-3741
Fax: 902-426-5143
E-mail:           airnotifications.dartmouth@tsb-bst.gc.ca

 
Date modified:
2012-03-27