Air transportation safety recommendation A95-18
Reassessment of response to Aviation Safety Recommendation A95-18
On 03 December 1993, a Britten-Norman Islander BN2A-20 aircraft, operated by Arctic Wings and Rotors, was involved in a fatal accident at Tuktoyaktuk, Northwest Territories. The Board determined that a magneto impulse coupling, worn beyond the prescribed limits, resulted in the failure of the right engine. Following the engine failure, the pilot mistrimmed the rudder and was unable to maintain control of the aircraft.
The Board made 6 Aviation Safety Recommendations as a result of the accident. Transport Canada's (TC) response to these recommendations has now been received; the extent to which the safety deficiencies are being resolved is assessed below.
The Board concluded its investigation and released Aviation Investigation Report A93W0204 on 18 October 1995.
TSB Recommendation A95-18 (October 1995)
In January 1993, following the investigation of a twin-engine turbo-prop aircraft accident at Moosonee (TSB report A90H0002) in which neither of the pilots involved had received the required night training and the regional Transport Canada inspectors had not observed that the training had not been conducted, the Board recommended that
TC responded in August 1993 that the Manual of Regulatory Audits (MRA) (published since occurrence A90H0002) directed the audit staff to check the companies' ﬂight training programmes. In addition, TC notified the regional Air Carrier staff of this matter and instructed its Quality Assurance Review team to ensure that the verification of night training did occur.
This occurrence is another example of a night accident in which the pilot had not received the required night training. Notwithstanding Transport Canada's continuing efforts to strengthen its processes for regulatory audit and surveillance, some commercial pilots are still not receiving the required night training.
While TC audit procedures continue to miss inadequacies in the night training of commercial pilots, it is recognized that TC inspectors cannot be continuously on site to ensure that operators are providing this training. Individual operators must be held accountable for any failure to provide mandatory training.
Therefore the Board recommends that
The Department of Transport evaluate the effectiveness of its current practices for dealing with those operators who are not providing mandatory training for pilots.
Transportation Safety Recommendation A95-18
Transport Canada's response to Recommendation A95-18 (September 1996)
Transport Canada, in reviewing this accident report along with other recent fatal accidents in air taxi operations, has set up a Task Force to review the safety of air taxi operations, including night VFR. The Safety of Air Taxi Operations Task Force (SATOPS) will commence early in 1996 and will examine all aspects of this aviation environment, including the effectiveness of surveillance and inspection by Transport Canada, the regulatory setting, pilot licensing, training and checking requirements, and human factors such as company management attitudes toward safety. An Air Carrier Advisory Circular will be released to advise industry about SATOPS.
TSB assessment of Transport Canada's response to Recommendation A95-18 (November 1996)
In its reply, TC indicated that it has set up a Safety of Air Taxi Operations Task Force (SATOPS) to review air taxi operations in Canada. TSB staff recently confirmed that the Task Force is presently defining its terms of reference and that by the fall of 1996, the industry will be invited to provide input to the Task Force.
The consultative process of the task force has the potential, in the long term, to identify many more issues affecting air taxi operations than those addressed by the Board recommendations. However, the reply from TC does not indicate any interim action to correct the deficiencies already identified by the Board. Of particular concern are those safety deficiencies that prompted Recommendations A95-17 and A95-18. These recommendations were a follow-up to previous recommendations on night flying requirements and the effectiveness of regulatory follow-up to audits. Occurrence investigations continue to uncover shortcomings in TC's overview of the smaller air carriers, such as the ineffective verification of mandatory pilot training; yet, TC has indicated no plans to address this in the short term.
Given that the SATOPS Task Force could deal with the issue of safety in commercial night VFR operations, the reply to Recommendation A95-16 is assessed as having Satisfactory Intent. However, because there is no indication by TC to take interim action to address the perennial issues of lack of pilot night training and non-compliance by operators, the replies to Recommendations A95-17 and A95-18 are assessed as being Unsatisfactory.
TSB reassessment of Recommendation A95-18 (November 1997)
No indication by Transport Canada to take interim action to address the issue of non-compliance by operators. Reference to the effectiveness of the surveillance program is made in the SATOPS final report to be released in early 1998.
Therefore the assessment remains as Unsatisfactory.
TSB reassessment of Recommendation A95-18 (January 1998)
SATOPS will examine the effectiveness of surveillance and inspection by Transport Canada, the regulatory settings, pilot training and checking requirements. A SATOPS Implementation Plan is being developed which may address the safety deficiency but no change yet.
Therefore the assessment remains as Satisfactory Intent.
TSB reassessment of Recommendation A95-18 (February 2004)
Transport Canada published (February 2001) a new Inspection and Audit Manual extensively detailing "audit follow-up" procedures for audit follow-up Office of Primary Interest (OPI). Apparently, the audit is not closed until all follow-up actions are completed.
Therefore, the response to Recommendation A95-18 is assessed as Satisfactory in Part.
As such, Further Action is Unwarranted with respect to A95-18 and the status is set to Inactive.
TSB review of Recommendation A95-18 deficiency file status (April 2014)
The Board requested that A95-18 be reviewed to determine if the deficiency file status was appropriate. After an initial evaluation, it was determined that the safety deficiency addressed by Recommendation A95-18 is also addressed by the previous Recommendation A93-05.
It is therefore appropriate to follow the progress on mandatory training safety issues through Recommendations A95-18 and A95-17.
Therefore, the assessment remains as Satisfactory in Part.
Consequently, the status of Recommendation A95-18 is changed to Active.
Transport Canada's response to Recommendation A95-18 (August 2017)
This recommendation was issued prior to the CARs coming into effect. The CARs require commercial operators to follow more stringent training and checking requirements which address the concern. CARs 703.98 is the training regulation and CARs 723.98 is the training standard.
All training programs must be submitted to and approved by TC, and validated during PVIs. The Oversight Program ensures this training has been completed. CARs 703.98 and 723.98 address all aspects of the risks associated with this recommendation.
TC believes that more comprehensive regulation of training requirements and followed-up by appropriate surveillance address the possibility of operators not providing required training.
TSB reassessment of Transport Canada's response to Recommendation A95-18 (February 2018)
TC has taken a number of actions to address the safety deficiency identified in Recommendation A95-18, regarding its procedures for dealing with air carriers who do not provide the required multi-engine night training. These include the following:
- The Canadian Aviation Regulations (CARs) have replaced the Air Navigation Orderswith more rigorous flight crew training requirements;
- Under CARs Part VII, commercial air operators engaged in multi-engine night operations must establish and maintain an initial and recurrent ground and flight training program to validate the multi-engine night proficiency of their pilots; and
- Through its surveillance program, TC audits flight crew training records by utilizing system and process level surveillance procedures, which verify and validate operator compliance with multi-engine night training requirements under CARs Part VII.
The Board believes that the actions taken by TC have substantially reduced the risks associated with the safety deficiency identified in Recommendation A95-18.
Therefore, the Board considers response to Recommendation A95-18 to be Fully Satisfactory.
Next TSB action
This deficiency file is Closed.
- Date modified: