Air transportation safety recommendation A18-01
Assessment of the response to TSB Recommendation A18-01
Mandatory installation of lightweight flight recording systems
On 13 October 2016, a privately operated Cessna Citation 500 (registration C-GTNG, serial number 500-0169), departed Kelowna Airport (CYLW), British Columbia, on an instrument flight rules night flight to Calgary/Springbank Airport (CYBW), Alberta. The pilot and 3 passengers were on board. Shortly after departure, at about 2135 Pacific Daylight Time, the aircraft made a tight right turn as it was climbing through 8600 feet above sea level, and then entered a steep descending turn to the right until it struck the ground. All of the occupants were fatally injured. Impact forces and a post-impact fire destroyed the aircraft. No emergency call was made, and no emergency locator transmitter signal was detected.
The Board concluded its investigation and released report A16P0186 on 26 April 2018.
TSB Recommendation A18-01 (February 2018)
Following a fatal accident with no survivors or witnesses, an investigation may never be able to determine the exact causes and contributing factors unless the aircraft is equipped with an on-board recording device. The benefits of recorded flight data in aircraft accident investigations are well known and documented.
Currently, flight data recorders (FDRs) and cockpit voice recorders (CVRs) are considered the most comprehensive methods of capturing large amounts of flight data and can assist investigators in determining the reasons for an accident. FDRs record information such as altitude, airspeed, heading, and other aircraft parameters, many times per second. CVRs record radio transmissions and ambient cockpit sounds, such as pilot voices, alarms, and engine noises.
In Canada, FDR and CVR regulations are specified in section 605.33 of the Canadian Aviation Regulations (CARs)—Flight Data Recorder and Cockpit Voice Recorder. Under this provision, the requirements for CVR and FDR equipment in aircraft are based primarily on the number and type of engines, number of passenger seats, and type of operation. Given the design characteristics and configurations, many aircraft flown by private operators, including the occurrence aircraft, are not required by regulation to be equipped with either an FDR or a CVR.
To provide an accessible and feasible means of recording valuable flight data information, regardless of the type of aircraft and operation flown, several lightweight FDR systems currently manufactured can record combined cockpit image, cockpit audio, aircraft parametric data, and/or data-link messages.
In 2016, the International Civil Aviation Organization (ICAO) amended Annex 6 of its Standards and Recommended Practices to recommend that certain categories of aircraft and helicopters flown by commercial operators carry lightweight flight recorders. ICAO Annex 6 also establishes the minimum specifications for such systems. To comply with recent amendments to ICAO Annex 6 and to address 12 safety recommendations issued by 7 different investigation bodies in Europe, the European Aviation Safety Agency published a Notice of Proposed Amendment in 2017, under which new regulations would prescribe lightweight flight recorders for some categories of commercially operated aircraft and helicopters.
Although there are currently no regulations in Canada requiring any aircraft to be equipped with lightweight FDR systems, these devices provide a potential cost-effective alternative for some sectors of the civil aviation industry.
In 2013, following its investigation into a fatal in-flight breakup occurrence in March 2011 northeast of Mayo, Yukon, the TSB concluded there was a compelling case for implementing lightweight FDR systems for all commercial operators, and recommended that
the Department of Transport work with industry to remove obstacles to and develop recommended practices for the implementation of flight data monitoring and the installation of lightweight flight recording systems by commercial operators not currently required to carry these systems.
Transportation Safety Recommendation A13-01
TC has acknowledged that flight data monitoring programs would enhance safety and has taken the following actions to address the safety deficiency identified in Recommendation A13‑01:
- In 2013, after conducting a risk assessment to evaluate alternative approaches to flight-data monitoring (FDM), TC informed the TSB that it supported Recommendation A13-01. In 2015, TC informed the TSB that it intended to revisit this risk assessment.
- In 2013, TC informed the TSB that it would develop an Advisory Circular outlining recommended practices for FDM programs.
- In 2013, TC informed the TSB that it would incorporate its analysis and review of Recommendation A13-01 into its planned assessment for FDRs and CVRs, which was scheduled to begin in 2014–2015.
- In 2014, TC informed the TSB that it would consider adding FDM principles in future regulatory initiatives and amendments.
- In 2015, TC informed the TSB that it would prepare an issue paper on the use of FDM, providing factual information on FDM, including its benefits, costs, and challenges.
Due to other ministerial commitments, TC has not initiated its work for any of these undertakings.
In February 2018, TC conducted a focus group with industry stakeholders, including the Canadian Business Aviation Association, to evaluate the challenges and benefits of installing lightweight flight recording systems on aircraft that are not currently required to carry these systems.
However, until the focus group reaches conclusions concerning these challenges and benefits in small aircraft, and TC provides the TSB with its plan of action following those conclusions, it is unclear when or how the safety deficiency identified in Recommendation A13-01 will be addressed. The TSB is concerned that very few concrete actions are being taken to address Recommendation A13-01 and that this could lead to protracted delays, as observed on numerous other recommendations.
In a recent occurrence investigated by the TSB, a privately operated Mitsubishi MU-2B-60 aircraft struck terrain on its final approach to Îles-de-la-Madeleine Airport, Quebec. All 7 occupants were fatally injured. A lightweight FDR system was on board the occurrence aircraft, although it was not required by regulation. By recovering the recorder and extracting its data for analysis, the investigation was able to better understand the sequence of events that led to the aircraft's departure from controlled flight. Had a recording system not been on board, crucial information to understand the circumstances and events leading up to this occurrence would not have been available to the investigation.
In contrast, the information normally contained in FDR systems was not available to this investigation. The investigation could not determine why the aircraft departed controlled flight and collided with terrain. Because the occurrence aircraft was not equipped with any type of FDR or CVR, the lack of flight data precluded investigators from fully identifying and understanding the sequence of events and the accident's underlying causes and contributing factors.
Although Recommendation A13-01 targeted commercial operators, the contrast in available evidence demonstrated between the Îles-de-la-Madeleine accident and this occurrence highlights the value of installing lightweight FDR systems on privately operated aircraft. This investigation demonstrates that investigators are at a disadvantage in determining the root causes of an occurrence when there are no flight data available, regardless of whether the investigation involves an aircraft operated commercially under CARs Part VII or a business aircraft operated privately under CARs Subpart 604.
There is compelling evidence that the lack of recording devices on board commercial aircraft and private aircraft operated under CARs Subpart 604 continues to impede the TSB's ability to advance transportation safety.
Therefore, the Board recommended that
the Department of Transport require the mandatory installation of lightweight flight recording systems by commercial operators and private operators not currently required to carry these systems.
Transportation Safety Recommendation A18-01
This new recommendation supercedes Recommendation A13-01, which has been closed.
Transport Canada's response to Recommendation A18-01 (July 2018)
Transport Canada (TC) agrees in part with the aviation safety recommendation (A18-01).
Aviation safety is of paramount importance to TC. To that end, TC is committed to continuing to strengthen aviation safety by working in consultation with our stakeholders to examine the potential use and installation of lightweight recording systems for Canadian aircraft that fall outside the scope of the current requirements under the Canadian Aviation Regulations (CARs). TC is committed to building upon its established regulatory aviation safety initiatives while striking a proper balance between the benefits and costs of any possible new requirements
TC is addressing this recommendation by undertaking a number of initiatives:
TC's further policy analysis of flight data management
TC is undertaking a thorough policy analysis of the possible approaches to expanding safety data collection in Canadian aviation. This work includes extensive consultations with industry stakeholders, including the creation of a focus group to respond to a previous Transportation Safety Board (TSB) recommendation on the issue of flight data monitoring (Recommendation A13-01).
Over the course of this process, two principal approaches have been identified as most appropriate to achieve this objective:
- Voluntary installation of flight data recorders (FDRs) and lightweight data recorders (LDRs)
This would include a TC-led advisory circular and ongoing guidance to operators looking to improve their data collection. This option would allow for timelier implementation and provide operators flexibility in the adoption of Flight Data Management (FDM) systems, building on existing industry practices. A voluntary approach would secure a high level of industry support and allow stakeholder associations to work with their members, while permitting the TSB to access more data during incident investigations in the future. This would allow for the opportunity to develop guidance material regarding FDM system parameters. These parameters will be fully compliant and aligned with International Civil Aviation Organization (ICAO) standard ED155 on FDM. The advisory circular will be made available through TC's website, the Global Aviation Safety Plan, and all relevant publications.
Industry groups have similarly been proactive in analyzing this issue in order to develop recommended practices on the voluntary adoption of FDM systems. The Air Transport Association of Canada (ATAC), for example, founded its own Flight Data Working Group focused solely on the subject of FDM. This internal working group is exploring the voluntary implementation of FDM by ATAC member's fleets of aircraft and is working to monitor the progress of the member aircraft involved thus far. TC is continuing to work with industry stakeholders to ascertain the full extent of operators that have voluntarily adopted FDM systems to date. As part of its cost benefit analysis, TC will also consult with insurance companies and underwriters regarding the possibility of implementing insurance benefits to operators who voluntarily adopt FDM systems.
- Incorporation of FDRs or LDRs into newly-manufactured aircraft:
TC plans to introduce regulations to require that manufacturers incorporate FDRs/LDRs into all new aircraft. TC would determine which sectors of the Canadian aviation landscape would be subject to this certification requirement – including commercial and private operators – as well as an appropriate date by which new requirements would come into effect. All certification requirements will be, at minimum, fully aligned with ICAO standard ED155.
TC will also take into account the standards put in place by our international partners in other civil aviation authorities. This option represents a flexible, forward-looking approach to FDM and would guarantee new aircraft are equipped with FDRs/LDRs, while avoiding the burden to operators of retrofitting FDRs into current their aircraft.
As part of its continued engagement with the Canada aviation industry, TC is committed to re-evaluating these two principle approaches by further assessing the number of operators that have voluntarily adopted FDM systems and addressing any gaps which may be determined. Consideration would be given to other measures, including a regulatory solution, if the results of the voluntary approach prove insufficient.
TC's continued engagement and collaboration with the Canadian aviation industry
A crucial focus of TC's ongoing analysis of FDM involves engaging the Canadian aviation industry to develop recommended practices and determine key obstacles in the adoption and installation of flight data systems.
In February 2018, TC led a focus group of representatives from the aviation industry to address TSB Recommendation A13-01. The recommendation from the TSB called for TC to work with industry to remove obstacles and develop recommended practices for the implementation of FDM and the installation of LDRs for commercial operators not required to carry these systems. The focus group included representation from seven separate industry organizations. The concerted approach of the focus group has since been highlighted by participating organizations as a positive example of collaboration between TC and industry stakeholders.
Throughout this process, industry stakeholders raised several concerns related to the adoption and installation of flight data management systems, whether it be traditional FDRs or LDRs. The concerns centred on the economic burden of retrofitting aircraft with FDRs, which is extremely costly and, from a technical perspective, there is limited ability to physically retrofit aircraft to carry an FDR due to all the required sensors and instruments. In addition, LDRs, while less costly than traditional FDRs, are also less robust and less likely to survive a crash. Industry stakeholders expressed that there are limited safety benefits to LDRs, and that it would be more beneficial to use financial resources and efforts to prevent accidents at the outset.
Industry also raised concerns that any new requirements regarding FDM cannot be developed as a one-size-fits-all solution for the entire Canadian aviation industry. TC will continue its ongoing analysis with stakeholders on FDM and will build on the success of the focus group through continued engagement and collaboration with the Canadian aviation industry to promote voluntary adoption of FDRs and LDRs. TC will also continue to explore the possibility of mandating the installation of FDRs or LDRs into newly-manufactured aircraft. As part of TC's consultative process, it will engage in regular contact with the TSB throughout, in order to better ensure that the department is kept abreast of all developments moving forward.
Additional aviation safety measures underway
TC and the aviation industry are working together to promote aviation safety as part of the "General Aviation Safety Campaign". The campaign, launched by TC in 2017, represents the collaborative efforts between the aviation industry, government, and industry partners to provide input, advice, and to help TC reach out to the general aviation community in promoting aviation safely. This initiative involves several internal working groups whose recommendations will be used to advance aviation safety in private and commercial sectors of aviation.
Additionally, TC has begun incorporating private operators into its inspection plan and activities, both to promote compliance with existing safety regulations and to learn more about the safety practices of private operators in an effort to continue to advance the safety of private air operations. This inspection campaign will be administered to 66 private operators in 2018, with private operation inspections forming a key part of its planned activities every year moving forward.
TC undertook several additional measures to strengthen aviation safety in Canada. Working in consultation with the aviation industry, TC updated existing regulations to improve the use of Cockpit Voice Recorders (CVRs). This work was, in part, a response to TSB Recommendation A99-03. The amendments mandate that there must be a back-up power supply for CVRs and increases recording time from 30 minutes to 2 hours. This regulatory change was published in Canada Gazette, Part I (CGI) in December 2017 and is expected to be published in Canada Gazette, Part II (CGII) in the fall of 2018. These changes align with revised ICAO standards and measures taken by international partners.
TC will continue its ongoing work and collaboration with industry stakeholders to examine additional regulatory initiatives in response to emerging trends and technology, TSB recommendations, and ICAO standards moving forward.
TSB assessment of TC's response to Recommendation A18-01 (September 2018)
Recommendation A18-01 supercedes Recommendation A13-01, which has been closed. Upon publishing Recommendation A18-01, the Board urged Transport Canada (TC) to build upon the work done on Recommendation A13-01 to expedite the implementation of safety actions in response to Recommendation A18-01.
In its response to Recommendation A18-01, TC indicated that it agrees in part with Recommendation A18-01, and that it would undertake the following actions:
- As a follow-up to its focus group held with industry in February 2018, in support of Recommendation A13-01, TC is undertaking a policy analysis of flight data management. Two approaches have been identified:
- The voluntary installation of flight data recorders (FDRs) and lightweight data recorders (LDRs), as well as the publication of an advisory circular and guidance to operators; and
- The possible introduction of regulations for the installation of FDRs and LDRs into newly-manufactured aircraft. TC indicated that the sectors of the Canadian aviation landscape that would be subject to this certification requirement are yet to be determined. TC also indicated that all certification requirements will be, at minimum, fully aligned with ED155, the European Organisation for Civil Aviation Equipment (EUROCAE) Minimum Operational Performance Specification for lightweight flight recording systems, referenced in ICAO Annex 6.
TC has indicated that it will re-evaluate these two approaches by further assessing the number of operators that have voluntarily adopted flight data monitoring systems. Consideration would be given to other measures, including a regulatory solution, if the results of the voluntary approach prove insufficient.
- TC intends to continue to engage and collaborate with industry to develop recommended practices and determine key obstacles in the adoption and installation of flight data systems.
In addition to TC's response, the TSB received information from the Canadian Business Aviation Association (CBAA) regarding actions taken following the publication of Recommendation A18-01. In its letter, the CBAA informed the TSB that it will continue to promote FDR fitment and analysis of data derived from the FDR through the CBAA Partners-in-Safety Program. Additionally, the CBAA has signed an agreement with a supplier to provide CBAA members with flight data analysis services. Finally, the CBAA informed the TSB that it will support a regulatory approach requiring FDRs on private aircraft, if supported by a cost–benefit analysis. However, it noted that the retro-fit of business aircraft may not always be possible due to cost and technical constraints.
The Board appreciates that TC is committed to working with industry to promote the voluntary installation of flight data recorders (FDRs) and lightweight data recorders (LDRs) for Canadian aircraft that fall outside the scope of the current Canadian Aviation Regulations (CARs) requirements. However, no specific timeline has been provided for the proposed actions. Although the proposed actions could mitigate the risk once implemented, until TC provides the TSB with a more detailed plan of action for moving forward, it is unclear when or to what extent the safety deficiency identified in Recommendation A18-01 will be addressed.
Therefore, the response to Recommendation A18-01 is assessed to be Satisfactory in Part.
Next TSB action
The TSB will ask TC to provide a timeline for the proposed actions and will monitor the progress of TC's actions to mitigate the risks associated with the safety deficiency identified in Recommendation A18-01.
This deficiency file is Active.
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