Recommendations

The Canadian Transportation Accident Investigation and Safety Board Act requires that federal Ministers provide formal responses to the TSB as to action taken or planned in response to our recommendations.

The Board also makes recommendations to other organizations and will assess all these responses and evaluate the degree to which they address the safety issues and deficiencies using an Assessment Rating Guide.

For recommendations and assessments made prior to January 1, 2005, please refer to our Annual Reports.

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Air

Recommendation A09-06
The Department of Transport ensure that the Canadian Business Aviation Association implement an effective quality assurance program for auditing certificate holders. (A07A0134)
Response      Assessment
Rating: Satisfactory Intent

Recommendation A09-05
The Canadian Business Aviation Association set safety management system implementation milestones for its certificate holders. (A07A0134)
Response      Assessment
Rating: Satisfactory Intent

Recommendation A09-04
The Department of Transport require training on visual glide slope indicator (VGSI) systems so pilots can determine if the system in use is appropriate for their aircraft. (A07A0134)
Response      Assessment
Rating: Satisfactory in Part

Recommendation A09-03
The Department of Transport ensure that eye-to-wheel height information is readily available to pilots of aircraft exceeding 12 500 pounds. (A07A0134)
Response      Assessment
Rating: Satisfactory Intent

Recommendation A09-02
The Department of Transport require commercial air operators to provide contemporary crew resource management (CRM) training for Canadian Aviation Regulations (CARs) subpart 703 air taxi and CARs subpart 704 commuter pilots. (A07C0001)
Response      Assessment
Rating: Satisfactory Intent

Recommendation A09-01
The Department of Transport require air carriers to incorporate bounced landing recovery techniques in their flight manuals and to teach these techniques during initial and recurrent training. (A08O0189)
Response      Assessment
Rating: Satisfactory in Part

Recommendation A08-03
The Department of Transport, in coordination with NAV CANADA, take steps to substantially reduce the risk of collision between visual flight rules aircraft operating in Class E airspace surrounding the Toronto/Lester B. Pearson International Airport. (A06O0206)
Response      Assessment
Rating: Satisfactory in Part

Recommendation A08-02
The Department of Transport ensure that balloons carrying fare-paying passengers have an emergency fuel shut-off. (A07C0151)
Response      Assessment
Rating: Satisfactory Intent

Recommendation A08-01
The Department of Transport ensure that passenger carrying commercial balloon operations provide a level of safety equivalent to that established for other aircraft of equal passenger carrying capacity. (A07C0151)
Response      Assessment
Rating: Satisfactory Intent

Recommendation A07-08
The Department of Transport take into account all propulsion system failures when assessing the safety of single-engine commercial operations. (A06P0010)
Response      Assessment
Rating: Satisfactory Intent

Recommendation A07-07
The Department of Transport require that passenger safety briefings include clear direction to leave all carry-on baggage behind during an evacuation. (A05H0002)
Response      Assessment/Reassessment
Rating: Satisfactory Intent

Recommendation A07-06
The Department of Transport require all Code 4 runways to have a 300 m runway end safety area (RESA) or a means of stopping aircraft that provides an equivalent level of safety. (A05H0002)
Response      Assessment/Reassessment
Rating: Satisfactory in Part

Recommendation A07-05
The Department of Transport and other civil aviation authorities require crews to establish the margin of error between landing distance available and landing distance required before conducting an approach into deteriorating weather. (A05H0002)
Response      Assessment
Rating: Satisfactory Intent

Recommendation A07-04
France's Direction Générale de l'Aviation Civile and other civil aviation authorities mandate training for air transport pilots to better enable them to make landing decisions in deteriorating weather. (A05H0002)
Response      Assessment
Rating: Satisfactory Intent

Recommendation A07-03
The Department of Transport mandate training for all pilots involved in Canadian air transport operations to better enable them to make landing decisions in deteriorating weather. (A05H0002)
Response      Assessment
Rating: Satisfactory Intent

Recommendation A07-02
France's Direction Générale de l'Aviation Civile and other civil aviation authorities establish clear standards limiting approaches and landings in convective weather. (A05H0002)
Response      Assessment
Rating: Satisfactory in Part

Recommendation A07-01
The Department of Transport establish clear standards limiting approaches and landings in convective weather for all air transport operators at Canadian airports. (A05H0002)
Response      Assessment
Rating: Satisfactory Intent

Recommendation A06-10
To reduce the number of post-impact fires in impact-survivable accidents involving existing production aircraft weighing less than 5700 kg, Transport Canada, the Federal Aviation Administration, and other foreign regulators conduct risk assessments to determine the feasibility of retrofitting aircraft with the following:

• selected technology to eliminate hot items as a potential ignition source;
• technology designed to inert the battery and electrical systems at impact to eliminate high-temperature electrical arcing as a potential ignition source;
• protective or sacrificial insulating materials in locations that are vulnerable to friction heating and sparking during accidents to eliminate friction sparking as a potential ignition source; and
• selected fuel system crashworthiness components that retain fuel. (SII A05-01)

Response      Assessment
Rating: Unsatisfactory

Recommendation A06-09
To reduce the number of post-impact fires in impact-survivable accidents involving new production aeroplanes weighing less than 5700 kg, Transport Canada, the Federal Aviation Administration, and other foreign regulators include in new aeroplane type design standards:

• methods to reduce the risk of hot items becoming ignition sources;
• technology designed to inert the battery and electrical systems at impact to eliminate high-temperature electrical arcing as a potential ignition source;
• requirements for protective or sacrificial insulating materials in locations that are vulnerable to friction heating and sparking during accidents to eliminate friction sparking as a potential ignition source;
• requirements for fuel system crashworthiness;
• requirements for fuel tanks to be located as far as possible from the occupied areas of the aircraft and for fuel lines to be routed outside the occupied areas of the aircraft to increase the distance between the occupants and the fuel; and
• improved standards for exits, restraint systems, and seats to enhance survivability and opportunities for occupant escape. (SII A05-01)

Response      Assessment
Rating: Unsatisfactory

Recommendation A06-08
Transport Canada, together with the Federal Aviation Administration and other foreign regulators, revise the cost-benefit analysis for Notice of Proposed Rule Making 85-7A using Canadian post-impact fire statistics and current value of statistical life rates, and with consideration to the newest advances in post-impact fire prevention technology. (SII A05-01)
Response      Assessment
Rating: Satisfactory in Part

Recommendation A06-07
The Department of Transport, in conjunction with the International Civil Aviation Organization, the Federal Aviation Administration, the European Aviation Safety Agency, and other regulatory organizations, establish a requirement for transport category aircraft to be equipped with a take-off performance monitoring system that would provide flight crews with an accurate and timely indication of inadequate take-off performance. (A04H0004)
Response      Assessment/Reassessment
Rating: Satisfactory Intent

Recommendation A06-06
The European Aviation Safety Agency, in coordination with other involved regulatory authorities and industry, urgently develop and implement an inspection program that will allow early and consistent detection of damage to the rudder assembly of aircraft equipped with part number A55471500 series rudders. (A05F0047)
Response (22 November 2006)     Response (17 January 2007)
Assessment/Reassessment
Rating: Fully Satisfactory

Recommendation A06-05
The Department of Transport, in coordination with other involved regulatory authorities and industry, urgently develop and implement an inspection program that will allow early and consistent detection of damage to the rudder assembly of aircraft equipped with part number A55471500 series rudders. (A05F0047)
Response      Assessment/Reassessment
Rating: Fully Satisfactory

Recommendation A06-04
The Federal Aviation Administration require that Cessna 208 operators maintain a minimum operating airspeed of 120 knots during icing conditions and exit icing conditions as soon as performance degradations prevent the aircraft from maintaining 120 knots. (A05C0187)
Response      Assessment
Rating: Fully Satisfactory

Recommendation A06-03
The Federal Aviation Administration take action to revise the certification of Cessna 208, 208A, and 208B aircraft to prohibit flight into forecast or in actual icing meteorological conditions exceeding "light," until the airworthiness of the aircraft to operate in such conditions is demonstrated. (A05C0187)
Response      Assessment/Reassessment
Rating: Fully Satisfactory

Recommendation A06-02
The Department of Transport require that Canadian Cessna 208 operators maintain a minimum operating airspeed of 120 knots during icing conditions and exit icing conditions as soon as performance degradations prevent the aircraft from maintaining 120 knots. (A05C0187)
Response      Assessment
Rating: Fully Satisfactory

Recommendation A06-01
The Department of Transport take action to restrict the dispatch of Canadian Cessna 208, 208A, and 208B aircraft into forecast icing meteorological conditions exceeding "light," and prohibit the continued operation in these conditions, until the airworthiness of the aircraft to operate in such conditions is demonstrated. (A05C0187)
Response      Assessment/Reassessment
Rating: Fully Satisfactory

Recommendation A04-04
The Department of Transport ensure the continued airworthiness of Canadian-registered aircraft fitted with the CFM56-5 series engine by developing an appropriate safety assurance strategy to make certain that, in the event of a permanent magnet alternator failure, the electronic control unit will revert to aircraft power. (A02P0261)
Response      Assessment
Rating: Fully Satisfactory

Recommendation A04-03
The Direction Générale de l'Aviation Civile and the Federal Aviation Administration issue airworthiness directives to require the implementation of all CFM56-5 series jet engine service bulletins whose purpose is to incorporate software updates designed to ensure that, in the event of a permanent magnet alternator failure, the electronic control unit will revert to aircraft power. (A02P0261)
Response      Assessment/Reassessment
Rating: Fully Satisfactory

Recommendation A04-02
The Department of Transport re-evaluate the standard weights for passengers and carry-on baggage and adjust them for all aircraft to reflect the current realities. (A04H0001)
Response      Assessment
Rating: Fully Satisfactory

Recommendation A04-01
The Department of Transport require that actual passenger weights be used for aircraft involved in commercial or air taxi operations with a capacity of nine passengers or fewer. (A04H0001)
Response      Assessment/Reassessment
Rating: Satisfactory Intent

Recommendation A03-09
Regulatory authorities harmonize international rules and processes for the protection of cockpit voice and image recordings used for safety investigations. (A98H0003)
Response     Assessment/Reassessment
Rating: Satisfactory Intent

Recommendation A03-08
Regulatory authorities develop harmonized requirements to fit aircraft with image recording systems that would include imaging within the cockpit. (A98H0003)
Response     Assessment/Reassessment
Rating: Satisfactory Intent

Recommendation A03-07
Regulatory authorities require, for all aircraft manufactured after 1 January 2007 which require an FDR, that in addition to the existing minimum mandatory parameter lists for FDRs, all optional flight data collected for non-mandatory programs such as FOQA/FDM, be recorded on the FDR. (A98H0003)
Response     Assessment/Reassessment
Rating: Unsatisfactory

Recommendation A03-06
Regulatory authorities, in concert with the aviation industry, take measures to enhance the quality and intelligibility of CVR recordings. (A98H0003)
Response     Assessment/Reassessment
Rating: Satisfactory in Part

Recommendation A03-05
Regulatory authorities establish the requirements and industry standard for circuit breaker resetting. (A98H0003)
Response     Assessment/Reassessment
Rating: Fully Satisfactory

Recommendation A03-04
Regulatory authorities require that every system installed through the STC process undergo a level of quantitative analysis to ensure that it is properly integrated with aircraft type-certified procedures, such as emergency load-shedding. (A98H0003)
Response     Assessment/Reassessment
Rating: Satisfactory in Part

Recommendation A03-03
Regulatory authorities take action to ensure the accurate and consistent interpretation of the regulations governing material flammability requirements for aircraft materials so as to prevent the use of any material with inappropriate flammability characteristics. (A98H0003)
Response     Assessment/Reassessment
Rating: Fully Satisfactory

Recommendation A03-02
Regulatory authorities develop a test regime that will effectively prevent the certification of any thermal acoustic insulation materials that, based on realistic ignition scenarios, would sustain or propagate a fire. (A98H0003)
Response     Assessment/Reassessment
Rating: Satisfactory Intent

Recommendation A03-01
Regulatory authorities quantify and mitigate the risks associated with in service thermal acoustic insulation materials that have failed the Radiant Panel Test. (A98H0003)
Response     Assessment/Reassessment
Rating: Unsatisfactory

Recommendation A02-05
The Department of Transport take action to reduce the short term risk and eliminate the long term risk of contaminated insulation materials and debris propagating fires, and coordinate and encourage a similar response from other appropriate regulatory authorities. (A02O0123)
Response     Assessment/Reassessment
Rating: Fully Satisfactory

Recommendation A02-04
The Department of Transport take action to reduce the short term risk and eliminate the long term risk of heater ribbon installation failures starting fires, and coordinate and encourage a similar response from other appropriate regulatory authorities. (A02O0123)
Response     Assessment/Reassessment
Rating: Satisfactory in Part

Recommendation A02-02
The Department of Transport take immediate action to implement regulations restricting pilots from conducting approaches where the ceiling does not provide an adequate safety margin for the approach or landing. (A99Q0151)
Response     Assessment/Reassessment
Rating: Satisfactory in Part

Recommendation A02-01
The Department of Transport expedite the approach ban regulations prohibiting pilots from conducting approaches in visibility conditions that are not adequate for the approach to be conducted safely. (A99Q0151)
Response     Assessment/Reassessment
Rating: Fully Satisfactory

Recommendation A01-05
The Bell 214B and Bell 205 flight manuals be modified to provide information regarding the inaccuracy of fuel quantity indications, thereby allowing pilots to make informed decisions in the event of a loss of fuel boost pump pressure. (A99P0075)
Response     Assessment/Reassessment
Rating: Satisfactory in Part

Recommendation A01-04
As a prerequisite to certification, all aircraft systems in the pressurized portion of an aircraft, including their sub-systems, components, and connections, be evaluated to ensure that those systems whose failure could exacerbate a fire in progress are designed to mitigate the risk of fire-induced failures. (A98H0003)
Response     Assessment/Reassessment
Rating: Unsatisfactory

Recommendation A01-03
A certification test regime be mandated that evaluates aircraft electrical wire failure characteristics under realistic operating conditions and against specified performance criteria, with the goal of mitigating the risk of ignition. (A98H0003)
Response     Assessment/Reassessment
Rating: Satisfactory in Part

Recommendation A01-02
For the pressurized portion of an aircraft, flammability standards for material used in the manufacture of any aeronautical product be revised, based on realistic ignition scenarios, to prevent the use of any material that sustains or propagates fire. (A98H0003)
Response     Assessment/Reassessment
Rating: Fully Satisfactory

Recommendation A01-01
The Department of Transport undertake a review of its safety oversight methodology, resources, and practices, particularly as they relate to smaller operators and those operators who fly in or into remote areas, to ensure that air operators and crews consistently operate within the safety regulations. (A99A0036)
Response     Assessment/Reassessment
Rating: Fully Satisfactory

Recommendation A00-20
Appropriate regulatory authorities review current in-flight firefighting standards including procedures, training, equipment, and accessibility to spaces such as attic areas to ensure that aircraft crews are prepared to respond immediately, effectively and in a coordinated manner to any in flight fire. (A98H0003)
Response     Assessment/Reassessment
Rating: Satisfactory Intent

Recommendation A00-19
Appropriate regulatory authorities ensure that emergency checklist procedures for the condition of odour/smoke of unknown origin be designed so as to be completed in a timeframe that will minimize the possibility of an in-flight fire being ignited or sustained. (A98H0003)
Response     Assessment/Reassessment
Rating: Satisfactory in Part

Recommendation A00-18
Appropriate regulatory authorities take action to ensure that industry standards reflect a philosophy that when odour/smoke from an unknown source appears in an aircraft, the most appropriate course of action is to prepare to land the aircraft expeditiously. (A98H0003)
Response     Assessment/Reassessment
Rating: Fully Satisfactory

Recommendation A00-17
Appropriate regulatory authorities, together with the aviation community, review the methodology for establishing designated fire zones within the pressurized portion of the aircraft, with a view to providing improved detection and suppression capability. (A98H0003)
Response     Assessment/Reassessment
Rating: Satisfactory Intent

Recommendation A00-16
Appropriate regulatory authorities, in conjunction with the aviation community, review the adequacy of in-flight firefighting as a whole, to ensure that aircraft crews are provided with a system whose elements are complementary and optimized to provide the maximum probability of detecting and suppressing any in-flight fire. (A98H0003)
Response     Assessment/Reassessment
Rating: Satisfactory in Part

Recommendation A00-13
The Department of Transport ensure that air operators store aircraft survival gear on aircraft in flame-resistant material and package emergency pyrotechnics and other highly flammable survival equipment at least to the standards required by International Air Transport Association (IATA) Dangerous Goods Regulations. (A99W0061)
Response     Assessment/Reassessment
Rating: Satisfactory in Part

Recommendation A00-06
The Department of Transport improve the quality of pilot decision making in commercial air operations through appropriate training standards for crew members. (A98A0067)
Response     Assessment/Reassessment
Rating: Satisfactory Intent

Recommendation A00-04
The Department of Transport require that single-engine instrument flight rules (SEIFR) operators have in place an automatic system or an approved program that will monitor and record those engine parameters critical to engine performance and condition. (A98A0067)
Response     Assessment/Reassessment
Rating: Fully Satisfactory

Recommendation A99-08
On an urgent basis, regulatory authorities validate all thermal acoustical insulation materials in use, or intended for use, in applicable aircraft, against test criteria that are more rigorous than those in Appendix F of FAR 25.853, and similar regulations, and that are representative of actual in-service system performance. (A98H0003)
Response     Assessment/Reassessment
Rating: Satisfactory in Part

Recommendation A99-07
Regulatory authorities confirm that sufficient action is being taken, on an urgent basis, to reduce or eliminate the risk associated with the use of metallized PET-covered insulation blankets in aircraft. (A98H0003)
Response     Assessment/Reassessment
Rating: Satisfactory in Part

Recommendation A99-05
The Department of Transport reassess Category I approach and landing criteria (re-aligning weather minima with operating requirements) to ensure a level of safety consistent with Category II criteria. (A97H0011)
Response     Assessment/Reassessment
Rating: Fully Satisfactory

Recommendation A99-04
Aircraft required to have two flight recorders be required to have those recorders powered from separate generator buses. (A98H0003)
Response     Assessment/Reassessment
Rating: Fully Satisfactory

Recommendation A99-03
As of 01 January 2005, for all aircraft equipped with CVRs having a recording capacity of at least two hours, a dedicated independent power supply be required to be installed adjacent or integral to the CVR, to power the CVR and the cockpit area microphone for a period of 10 minutes whenever normal aircraft power sources to the CVR are interrupted. (A98H0003)
Response     Assessment/Reassessment
Rating: Satisfactory Intent

Recommendation A99-02
As of 01 January 2005, all aircraft that require both an FDR and a CVR be required to be fitted with a CVR having a recording capacity of at least two hours. (A98H0003)
Response     Assessment/Reassessment
Rating: Satisfactory Intent

Recommendation A99-01
As of 01 January 2003, any CVR installed on an aircraft as a condition of that aircraft receiving an original certificate of airworthiness be required to have a recording capacity of at least two hours. (A98H0003)
Response     Assessment/Reassessment
Rating: Fully Satisfactory

Recommendation A95-10
The Department of Transport require the installation of GPWS on all turbine-powered, IFR-approved, commuter and airline aircraft capable of carrying 10 or more passengers. (A93H0023)
Response     Assessment/Reassessment
Rating: Satisfactory Intent