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Presentation to Cabin Operations Committee (ATAC 2015)

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Joe Hincke
Member, Transportation Safety Board of Canada
ATAC 2015 Annual Conference
Presentation to Cabin Operations Committee
2 November 2015

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Slide 1: Title Page

Slide 2: TSB investigation A12Q0216 - Sanikiluaq

Perimeter Aviation Flight 993 was originally scheduled to depart Winnipeg, Manitoba, for Sanikiluaq, Nunavut, on the morning of December 22, 2012. I'll give you a brief recap here, and then look at the associated recommendations that came from the TSB's investigation.

Slide 3: A12Q0216 (continued)

The crew's initial plan was to come in on a straight-in visual approach to land eastbound, into the wind on Runway 09. Weather conditions, however, did not permit this. As there was no published instrument approach procedure for Runway 09, they used the published procedure for Runway 27 and circled around visually to land on Runway 09, as wind favored landing in that direction. But visibility was insufficient, so they circled a second time, only to once more lose sight of the runway.

A weather update, meanwhile, showed that the alternate destination of Kuujjuarapik was no longer feasible. Since the weather was still technically acceptable for landing, the crew decided to continue attempting to land at Sanikiluaq. They made a second attempt, this time to land westbound on Runway 27. A tailwind, however, increased the aircraft's groundspeed, and they came in too high, too steep, and too fast, sighting the runway later than expected. By the time the captain decided to reject the landing it was too late, and the aircraft struck the ground.

Slide 4: A12Q0216 (continued)

The 2 crew and the 6 adult passengers, secured by their seat belts, suffered injuries ranging from minor to serious. A lap-held infant, not restrained by any device or seatbelt, was fatally injured.

Slide 5: Recommendations

Transport Canada must require commercial air carriers to collect and report, on a routine basis, the number of infants (under 2 years old), including lap-held, and young children (2 to 12 years old) travelling.

TSB Recommendation A15-01 (June 2015)

Slide 6: Recommendations (continued)

Transport Canada must work with industry to develop age- and size-appropriate child restraint systems (CRS) for infants and young children travelling on commercial aircraft, and mandate their use to provide an equivalent level of safety compared to adults.

TSB Recommendation A15-02 (June 2015)

Slide 7: Progress

On 23 September 2015, TC responded saying that it agreed that having more information “would enable the conduct of risk and cost-benefit analyses to support regulatory decision-making.”

TC also said that it is “working to determine what options exist for collecting the information, including stakeholder consultation to be completed by March 2016, which from their point of view is the best way to gather and report information.”

TC also said it will “explore ways to increase the range of child restrain systems (CRS) that parents can use on Canadian carriers. The intent is to allow not only the currently approved CRS but also those approved by foreign authorities to be accepted for use on Canadian aircraft.”

TC also said it is planning an awareness campaign for Fall 2015, aimed at ensuring ground agents and crew members are “well informed on permissible mitigation measures, as well as the travelling public.”

The TSB is now in the process of evaluating TC's response. Once we have completed our evaluation, we'll release it publicly, and post it on our website. We'll also follow up via our annual tracking process.

Slide 8: Progress (continued)

ICAO has now published its Manual on the Approval and Use of Child Restraint Systems.

This manual was developed with input from civil aviation authorities, airlines, aircraft manufacturers, training organizations

The manual contains guidance to help countries develop regulations and approval processes. It also provides guidance for operators when identifying CRS for use on board an aircraft, as well as guidelines for managing change through their safety management systems (SMS) to allow the use of CRS on board their aircraft.

The bottom line? Industry and states “should encourage the use of CRS by passengers travelling with infants or children.”

Slide 9: Questions?

Slide 10: Canada wordmark