Contributor - Accidents and Regulations

Contributor - Accidents and Regulations

Gordon Gilbert

The Transportation Safety Board of Canada (TSB) is again recommending that Transport Canada (TC) require the installation of flight recording systems by “all commercial and private business operators” not currently required to carry them. While this is a reiteration of previous recommendations dating back more than 10 years, the TSB said in its latest proposal that “lightweight” and “lower cost” FDRs are now available and suitable for smaller aircraft.

 


Currently, in Canada, FDRs and CVRs are required on business, commercial, and private flight operations involving multi-engine turbine-powered aircraft configured with 10 or more passenger seats and on multi-engine turbine-powered aircraft with six or more passenger seats, and for which two pilots are required. This is basically the same requirement as the FAA. Under both TC and FAA rules, single-pilot turbine-powered and recip-powered aircraft are exempt. &nbsp;&nbsp;&nbsp;

 


The TSB's latest recommendation stems from an Oct. 13, 2016 accident in which a private Cessna Citation 500 operated by Norjet suffered a fatal loss-of-control crash during&nbsp;night IMC, killing the pilot and all three passengers. According to the TSB’s final report, at 9:35 p.m., about three minutes after departure, “the aircraft made a tight right turn as it was climbing through 8,600&nbsp;feet above sea level, and then entered a steep descending turn to the right until it struck the ground.”

 


Because there were no flight recording systems on the aircraft, the TSB could not determine the cause of the mishap. It concluded that the “most plausible scenario is that the pilot, who was likely dealing with a high workload associated with flying the aircraft alone, experienced spatial disorientation” during the takeoff climb.&nbsp;

 


The aircraft had an autopilot, but the TSB’s investigation could not verify whether the autopilot was on or off at the time of the accident. The aircraft was not equipped with a visual or aural stall warning system, but it did have an angle-of-attack indicator that “would have provided a visual cue of an impending stall,” the TSB report said.

 


Additionally, investigators found that the pilot did not have the recent night flying experience required by TC for carrying passengers at night. Nor did the operator have TC approval for single-pilot operations, although the pilot and aircraft were qualified. No difficulties with the quality of radio transmissions were noted. None of the radio communications between the pilot and controllers revealed any sense of urgency or any anomalies with the aircraft.

 


<h2 style="margin-left: 7.5pt;">FDR Benefits Emphasized</h2>

 


This report is the most recent of several over the years in which TSB investigators have been unable to find the reasons for an accident because of the lack of on-board recording devices. “The benefits of recorded flight data in aircraft crash investigations are well known and are documented,” the TSB said.

 


To provide an accessible and feasible means of recording valuable flight-data information, regardless of the type of aircraft and operation flown, the TSB said “several lightweight flight-data recording systems that can record combined cockpit image, cockpit audio, aircraft parametric data, and/or datalink messages” are currently being manufactured.

 


The TSB pointed to its investigation into the March 29, 2016 accident of a privately operated Mitsubishi MU-2B-60 that struck terrain on its final approach to Îles-de-la-Madeleine Airport, Quebec. All seven occupants were killed. A “lightweight” FDR was on board, although it was not required by regulation.

 


“By recovering the recorder and extracting its data for analysis, the investigation was able to better understand the sequence of events that led to the aircraft's departure from controlled flight,” the TSB said. “Had a recording system not been on board, crucial information to understanding the circumstances and events leading up to this occurrence would not have been available to the investigation.”

 


The TSB was also critical of Transport Canada’s business aviation oversight responsibilities. At the time of the Citation accident, TC’s approach to oversight for private operators relied entirely on “reactive surveillance processes.” In fact, on Aug. 17, 2016, two months before the Citation crash, TC advised its staff that it would temporarily exempt entire sectors of civil aviation, including business aviation, because these sectors present a “low risk for serious incidents or accidents.”

 


What’s more, during the course of its investigation into the Citation crash, the TSB found no record that Norjet had ever been inspected by TC or that the agency had undertaken any surveillance activities to oversee and monitor the company’s flight operations since they started in 2008. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;

 


<h2 style="margin-left: 7.5pt;">Targeted Inspections &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</h2>

 


In February, two months before the TSB released its Citation accident report, Transport Canada announced it would conduct a one-year program of “targeted inspections” of various aviation segments—including business aviation—in a move the agency describes as a “new process to evaluate specific safety priorities.” The Canadian Business Aviation Association contends some 65 private operators will be subject to the targeted inspections between April 2018 and March 2019.&nbsp;

 


Not yet determined by the TSB is precisely what smaller “private business aircraft” should be covered by an FDR requirement in terms of engine type, maximum takeoff weight, or number of passenger seats.

 


While Transport Canada has acknowledged for several years that flight data monitoring systems would enhance safety, the agency has yet to actually initiate work on previous recommendations that it has agreed with or on any other related undertakings. The TSB’s recommendations mirror similar NTSB recommendations that for some time have been elevated to the Safety Board’s Most Wanted List. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;

 


Meanwhile, Transport Canada must respond to the TSB by July 26.

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