Aviation news release 2009
TSB # A06/2009
"EFFECTIVE OVERSIGHT VITAL TO AVIATION SAFETY," SAYS THE TSB
(Gatineau, Quebec, November 10, 2009) - Citing ineffective oversight by the Canadian Business Aviation Association (CBAA), the Transportation Safety Board of Canada (TSB) has released its final report into the 2007 landing accident in Fox Harbour, Nova Scotia. The accident injured 10 people when the private jet skidded off the runway, stopping 1000 feet from its initial touchdown point, close to neighbouring homes.
In its investigation (A07A0134), the TSB reported that private operators regulated by the CBAA were not held to the same standard that Transport Canada (TC) implemented for commercial operators. TC regulations require commercial airline companies to implement safety management systems (SMS) in stages, on a fixed timeline, while the CBAA was free to implement SMS for its operators on its own terms with no fixed timeframe.
In 2003, TC transferred regulatory responsibility for some aviation operators to the CBAA but prior to this accident failed to exercise effective oversight of the CBAA programs.
"This is a serious problem," said Kathy Fox, Board Member for the TSB. "Safety can be compromised when SMS plans are vague, deadlines are flexible, and critical oversight is lacking. Without proper milestones or auditing," she added, "SMS cannot function properly and the risks increase."
In two key recommendations, the Board calls for the CBAA to set SMS implementation milestones for its certificate holders and for TC to ensure the CBAA has an effective quality assurance program in place to audit its certificate holders.
In the course of the investigation, the TSB also found that many pilots were not aware of the limitations of the visual guidance systems used to conduct safe approaches and landings. These guidance systems, known as visual glide slope indicators (VGSI), use ground-based light beams to show pilots when they are too high or too low on approach but many pilots don't realize that some VGSI should not be used when flying larger aircraft.
Information on the distance between the cockpit and the landing gear (eye-to-wheel height) is needed to know which VGSI to use but the Board revealed this information is not readily available to pilots.
To address these issues, the Board made two additional recommendations requiring TC to make eye-to-wheel height information available to pilots, and that better training also be provided to them on VGSI so they have the information they need to land safely.
"Although both TC and the CBAA have taken steps since the accident," added Board Member Fox, "raising the safety standard will take an ongoing commitment from TC, the CBAA and the operators. The recommendations we've made today are the next step in this direction."
The complete text of the four recommendations from the TSB report can be found in the backgrounder.
The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
For more information, contact:
Transportation Safety Board of Canada
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