Air transportation safety recommendation A18-03
Assessment of the response to TSB Recommendation A18-03
Compliance with Canadian Aviation Regulations subsection 602.11(2)
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 is making the following recommendation in advance of final report publication.
TSB Recommendation A18-03 (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 absence of adequate equipment increases the likelihood that pilots will conduct a takeoff in an aircraft that has frost, ice, or snow adhering to any of its critical surfaces. Additionally, in the absence of adverse consequences, taking off with contamination on critical surfaces is a deviation that has become normalized. Therefore, providing adequate de-icing and anti-icing equipment may not be sufficient to reduce the likelihood of aircraft taking off with contaminated critical surfaces.
Some of the current defences used by the Canadian air transportation system to prevent aircraft from taking off with frost, ice, or snow adhering to any critical surface are less than adequate. Takeoffs with contaminated critical surfaces occur in substantial numbers across the spectrum of aircraft and operating categories at remote northern airports.
Non-compliance with Canadian Aviation Regulations subsection 602.11(2), flight crew operating manuals, company operations manuals, and company standard operating procedures can be a single point of failure of defence framework. To mitigate this, Transport Canada and air operators must take urgent action to ensure better compliance.
Organizations can audit equipment (to inspect, de-ice, and anti-ice aircraft), policies (such as ground icing operations programs and contingencies for situations where resources are not available), training (for pilots and ground staff), and operations (procedures, compliance, deviations). Air operators could incorporate questions in before-start and before-takeoff checklists with a requirement for a clean aircraft or a mitigation response from the pilot-in-command.
Accidents related to contaminated aircraft will continue to occur until the industry and the regulator approach the issue as systemic and take action to eliminate underlying factors that can negatively affect pilot compliance.
Therefore, the Board recommended that
the Department of Transport and air operators take action to increase compliance with Canadian Aviation Regulations subsection 602.11(2) and reduce the likelihood of aircraft taking off with contaminated critical surfaces.
TSB Recommendation A18-03
Transport Canada's response to Recommendation A18-03 (April 2019)
Transport Canada (TC) agrees with the recommendation; efforts to increase compliance with Canadian Aviation Regulations (CARs) subsection 602.11(2) and reduce the likelihood of aircraft taking off with contaminated critical surfaces will focus on a two-pronged targeted risk-based inspection campaign, and an education and awareness campaign.
In the winter of 2019-20, TC will conduct an inspection campaign to increase compliance with CARs subsection 602.11(2)Footnote 1 and reduce the likelihood of aircraft taking off with contaminated critical surfaces.
First, inspections will be targeted based on risk using the information gathered from the survey of northern and remote airports available de-icing and anti-icing services; the approved ground icing program (AGIP) submissions from operators; the information on icing equipment availability included in the Canada Flight Supplement; and, information on the likelihood of icing / historical reporting of icing conditions from airport authorities.
Second, TC will gather intelligence based on reporting by airport authorities, the public, and other potential sources (e.g., SECURITAS reports) to target inspections where there is reporting of non-compliance. This will aid in focusing resources where they are most likely able to identify and address potential non-compliance by air operators.
TC will conduct an evaluation of the impact of these targeted campaigns at the end of winter 2019-20. In consultation with associations including the Air Transport Association of Canada (ATAC) and the Northern Air Transport Association (NATA), TC will examine additional targeted inspection approaches and promotional measures based on the outcomes of this evaluation, and TC will update the TSB on the results and additional actions taken. Further, any outcomes of this evaluation will be considered, in part, with the recommendations of the working group referenced in A18-02.
To complement and inform this two-pronged inspection campaign, TC will also conduct an education and awareness campaign that will focus on two different communities:
- airline operators and pilots; and,
- the travelling public.
As an immediate measure, information was sent to all air operators and airport associations on February 1, 2019. The purpose was to remind associations and operators of recommended practices and procedures for de-icing, and provide links to the relevant TC guidance material. It also called on operators to verify that the training portion of their AGIP meets the most recent industry-accepted standards. TC inspectors will follow-up with operators during the summer and fall of 2019 to ensure continued compliance with the AGIP.
During the summer of 2019, TC will develop an education and awareness campaign focused on passengers in more remote communities. This will serve as a “force-multiplier” to increase public knowledge and expectations about winter operations and help inform the targeted inspection planning that was referenced above. The passenger campaign will resemble previous campaigns such as the one developed for Seaplane Safety (http://www.tc.gc.ca/publications/bil/tp14346/pdf/hr/tp14346.pdf). Specific messaging and engagement will be targeted to occasional travelers and more frequent users (e.g., public officials who visit these communities on a regular basis).
In addition, by the fall of 2019, TC will conduct a targeted communications campaign to raise awareness of the available documents and information related to airframe icing. As part of this campaign, TC will also create an “icing landing page” on its website ahead of the next winter season with links to these materials and promote it to stakeholders through regular association meetings (e.g., NATA, ATAC, and the Canadian Business Aviation Association), by correspondence and through established distribution lists (e.g., the Canadian Aviation Regulatory Advisory Council, social media).
On an ongoing basis, TC continues to engage Canadian stakeholders on a biennial basis through the Standing Committee on Operations Under Icing Conditions (SCOUIC) meeting. SCOUIC is mandated with the promotion of safe aircraft operations and airworthiness procedures under icing conditions. TC will explore the potential for applying data models to better identify and predict potential icing conditions, thereby raising the real-time awareness of air operators and airport authorities of potential icing conditions on-site. The next meeting is planned for October 2019.
TSB assessment of Transport Canada's response to Recommendation A18-03 (August 2019)
In its response, Transport Canada (TC) indicated that it agrees with Recommendation A18-03 and will be taking the following twofold approach to address the safety deficiency identified in Recommendation A18-03:
- a two-pronged targeted risk-based inspection campaign;
- an education awareness campaign aimed at:
- pilots and air operators; and
- the travelling public.
As part of this twofold approach, TC reached out to air operators and airport authorities in February 2019, encouraging them to share links to TC's guidance material on aircraft de-icing with their members. Air operators were also asked to verify that the training portion of their approved ground icing programs (AGIP) met accepted standards and practices.
TC will also continue its engagement with stakeholders every two years through the Standing Committee on Operations under Icing Conditions (SCOUIC), with the next meeting scheduled for October 2019.
TC is also planning the following actions:
- During the summer of 2019, TC will develop an education and awareness campaign for passengers flying to and from remote communities.
- By the fall of 2019, TC will conduct a communications campaign to increase awareness of available icing-related information among aviation industry stakeholders.
- During the 2019-20 winter, TC will conduct an inspection campaign:
- by targeting risk locations using information gathered from the survey on available de-icing and anti-icing services in northern and remote airports, and using information from sources such as the Canada Flight Supplement, reports of icing conditions from airport authorities and safety intelligence reports of non-compliance;
- by targeting locations where non-compliance has been reported, based on intelligence reported by airport authorities, the public, and other potential sources.
- At the end of the 2019-20 winter, TC will evaluate the impact of the targeted inspection campaign and will then collaborate with industry stakeholders to assess the need for further targeted inspections and educational efforts.
The Board is encouraged that TC has initiated some actions and that it is planning additional actions in the near future. These actions, when implemented, have the potential to substantially mitigate the risk associated with the safety deficiency identified in Recommendation A18-03 by improving training and raising awareness, thereby improving compliance with CARs subsection 602.11(2) and reducing the likelihood of aircraft taking off with contaminated critical surfaces.
Therefore, the response to Recommendation A18-03 is assessed as Satisfactory Intent.
Next TSB action
The TSB will monitor the progress of TC's actions to mitigate the risks associated with the safety deficiency identified in Recommendation A18-03 on an annual basis or when otherwise warranted.
This deficiency file is Active.
For more information, see the investigation page.
- Date modified: