Air transportation safety recommendation A18-02
Assessment of the response to TSB Recommendation A18-02
De-icing and anti-icing equipment
On 13 December 2017, an Avions de Transport Régional (ATR) 42-320 aircraft (registration C‑GWEA, serial number 240), operated by West Wind Aviation LP (West Wind) as flight 282 (WEW282), departed from Fond-du-Lac (CZFD), Saskatchewan, on an instrument flight rules flight to Stony Rapids (CYSF), Saskatchewan. On board were 3 crew members (2 pilots and 1 flight attendant) and 22 passengers. Shortly after takeoff from Runway 28 at CZFD, WEW282 collided with trees and terrain approximately 1400 feet west of the departure end of Runway 28. Nine passengers and 1 crew member received serious injuries, and the remaining 13 passengers and 2 crew members received minor injuries. One of the passengers who had received serious injuries died 12 days after the accident. The aircraft was destroyed.
At the time of issuing this recommendation, the Transportation Safety Board of Canada's (TSB) investigation into this accident (A17C0146) is ongoing, and the investigation team is completing its analysis of the information collected. However, the investigation team identified safety deficiencies in need of urgent attention. As a result, the Board made the following recommendation in advance of final report publication.
TSB Recommendation A18-02 (December 2018)
The duration of cold weather and icing conditions varies widely across Canada. Many remote northern airports have an icing season of 10 months or more. Icing conditions can be both severe and persistent.
Thousands of flights take off every year from remote northern airports. Some airports serve as hubs, experience higher traffic volumes, and may have better equipment.
The risks of adverse consequences likely vary from airport to airport. Identifying high-risk locations for immediate mitigation has the potential to quickly reduce the likelihood of aircraft taking off with frost, ice, or snow adhering to any critical surface at those locations.
Transport Canada, air operators, and airport authorities have the capacity to identify high‑risk locations, analyze them for hazards and risks, and take mitigating action.
Therefore, the Board recommended that
the Department of Transport collaborate with air operators and airport authorities to identify locations where there is inadequate de-icing and anti-icing equipment and take urgent action to ensure that the proper equipment is available to reduce the likelihood of aircraft taking off with contaminated critical surfaces.
TSB Recommendation A18-02
Transport Canada's response to Recommendation A18-02 (April 2019)
Transport Canada (TC) agrees with the recommendation and is collaborating with air operators and airport authorities to take urgent action to address this safety risk.
TC recognizes the need for additional actions to address the safety risks posed by icing. Immediately in response to this recommendation, TC gathered information to create an accurate account of the de-icing and anti-icing resources that are currently available.
On January 22, 2019, TC requested that its regional offices reach out to air operators and airport authorities in order to consolidate information on the de-icing and anti-icing services available at the airports. Specific emphasis was placed on remote and northern airports, and how operators conduct their operations at these locations.
Overall, the information gathered indicates that very few northern or remote airports in any of the regions have de-icing and anti-icing equipment available. Those that do often have very limited capabilities. Air operators will often carry their own de-icing equipment, or have access to portable equipment at certain locations, but capacity is limited. Given that access to aircraft surfaces (e.g., wings and tail) and appropriate space to perform de-icing is often lacking at northern and remote airports, use of this equipment also presents challenges related to crew safety.
The results of the survey are concerning. The importance of this safety issue requires greater awareness and action by operators and airports. To achieve this, the Minister of Transport will issue a letter to all operators reiterating that it is the responsibility of the air operator and their pilots to comply with all requirements outlined in the Canadian Aviation Regulations (CARs) subsection 602.11(2), as well as Commercial Air Services Standards (CASS) 622.11. The letter will also ask operators to work with the airports they serve to increase the provision of adequate de-icing and anti-icing equipment. Finally, it will request that air operators submit their approved ground icing program (AGIP) plans no later than June 30, 2019. The submissions will be reviewed against industry-accepted standards and assist in identifying current deficiencies.
TC will also send a letter to airport authorities asking that they actively engage and collaborate with air operators on solutions to address the safety issue as it has a direct link to northern and remote airport operational realities.
In addition, TC will also meet with air operators and airport authorities at the April 2019 Northern Air Transport Association (NATA) Annual General Meeting (AGM) in Yellowknife, NT. The work done at this event will aim to identify initiatives in the short and medium-term to address this urgent safety risk. The outcomes of this collaboration will help direct immediate additional initiatives that will be taken by stakeholders in advance of the 2019-20 winter season.
Airports possessing de-icing and anti-icing equipment for operator use publish this capacity in the Canada Flight Supplement (CFS). This information is available to all aircraft operators. If an airport does not have de-icing and/or anti-icing services published in the CFS, air operators are to assume that the equipment or services are not available at that location. However, TC recognizes that many operators choose to avoid flying when icing is present instead of carrying or using their on‑board or portable de-icing equipment. While TC recognizes that this is one strategy in mitigating the risks associated with icing conditions, it also presents challenges in emergency situations and in ensuring reliable access to northern and remote communities.
Therefore, in the short-term, TC is working with air operators and airport authorities to increase the awareness and understanding of the regulatory requirements. Using the information from the survey of northern and remote airports, air operator AGIP submissions, existing information available in the CFS, and looking to potential methods for predicting icing conditions will help inform risk-based actions that target areas where icing is most likely to occur.
TC believes that the targeted education of pilots, air operators (including all those involved with air operations, such as dispatchers, etc.) and airport operators is the most effective short-term method to increase compliance with the CARs and encourage the provision of adequate de-icing and anti-icing equipment. Planned actions related to education of pilots and operators are described below in the response to Recommendation A18-03.
In the medium term, in fiscal year 2019-20, the department will initiate an in-depth regulatory examination of the issue. TC will establish a working group (made up of key stakeholders including: air operators, airport authorities, communities, and pilot associations) to conduct a risk assessment and examine measures, including additional education and awareness campaigns, policy, standards and/or regulations to further reduce the likelihood of aircraft taking off with contaminated surfaces. This work will aim to bring a full scope of impacted stakeholders together, including the TSB, to ensure all views and possible approaches are considered to address this important aviation safety risk. The complete report and recommendations advanced by the working group will be finalized by fall 2020. This report will be provided to the TSB once finalized.
In recognition of the urgent action that is required to address the safety risks posed by icing, the actions outlined above have begun or will begin before the beginning of the 2019-20 winter season. The intent of these actions will be to further build on the Canadian regulatory requirements in place to reduce the likelihood of aircraft taking off with contaminated crucial surfaces. CAR subsection 602.11(2) establishes that the responsibility to ensure an ice-free surface is with the operator and flight crew. These regulations are similar to the operational requirements that are found within the Federal Aviation Regulations (FAR) 121.629 in the United States, the European Air Regulations (Air OPS regulation (EU) 965/2012), CAT.OP.MPA.250 as mandated by EASA and other National Aviation Authorities.
Update to Transport Canada's response to Recommendation A18-02 (May 2019)
At the April 2019 Northern Air Transport Association (NATA) Annual General Meeting, Transport Canada officials used their regulatory presentation session to highlight the TSB recommendations, plans for addressing them and called on attendees to provide comments and suggestions on how to improve conditions at Northern and Remote Airports. While the session did not produce a great deal of feedback from those in attendance, TC officials had additional conversations following the session with attendees including airport, air operator and ground support organizations to discuss possible options and considerations regarding improved anti-icing /de-icing operations. As a follow-up, TC is set to discuss options and considerations at the upcoming NATA Board of Directors meeting in June 2019. Part of this discussion will be to formalize how additional input could be generated from aviation stakeholders operating in northern and remote communities.
TSB assessment of Transport Canada's response to Recommendation A18-02 (August 2019)
In its response, Transport Canada (TC) indicated that it agrees with Recommendation A18-02.
To address the safety deficiency identified in Recommendation A18-02, regarding the identification of locations where there is inadequate de-icing and anti‑icing equipment and the requirement for urgent action to ensure that the proper equipment is available to reduce the likelihood of aircraft taking off with contaminated critical surfaces, TC has taken the following short-term actions:
- In early 2019, TC commenced collaborative action with air operators, airport authorities, as well as the Northern Air Transport Association (NATA) and its members, to mitigate the risks identified in Recommendation A18-02.
- In January 2019, TC requested that its regional offices reach out to air operators and airport authorities in order to consolidate information on the de-icing and anti-icing services available at airports, with specific emphasis placed on remote and northern airports. This initiative confirmed that de‑icing and anti-icing capability is only available at very few remote and northern airports.
- In April 2019, TC highlighted TSB's recommendations A18-02 and A18-03 and the plans for addressing these two recommendations during its regulatory presentation at the NATA Annual General Meeting.
- In June 2019, TC's Director General Civil Aviation attended the NATA Board of Directors meeting, where icing was discussed.
- In July 2019, TC sent a letter to airport authorities asking them to actively engage and collaborate with air operators to find solutions to address the safety deficiency identified in Recommendation A18-02.
As a mid-term action, TC is also planning to establish, in fiscal year 2019-20, a working group comprised of various stakeholders to examine the safety risks and identify measures, including additional education and awareness campaigns, policy, standards and/or regulation, to further reduce the likelihood of aircraft taking off with contaminated critical surfaces. TC indicated that the results of this effort will be available by fall 2020.
The Board is encouraged that TC has completed some actions and that it is planning additional actions in the near future, including the creation of a stakeholder working group. These actions, when implemented, have the potential to substantially mitigate the risk associated with the safety deficiency identified in Recommendation A18-02, by identifying locations where there is inadequate de-icing and anti‑icing equipment, and by increasing the provision of such equipment to reduce the likelihood of aircraft taking off with contaminated critical surfaces.
Therefore, the response to Recommendation A18-02 is assessed as Satisfactory Intent.
Next TSB action
The TSB welcomes the opportunity to share information with the stakeholder working group, and will monitor the progress of TC's actions to mitigate the risks associated with the safety deficiency identified in Recommendation A18-02 on an annual basis or when otherwise warranted.
This deficiency file is Active.
For more information, see the investigation page.
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