Reassessment of the response to Aviation Safety Recommendation A94-04
Updated flight data recorder and cockpit voice recorder requirements
On 10 November 1993, a Hawker Siddeley HS 748 aircraft operated by Air Manitoba departed Winnipeg, Manitoba, at 1438 Central Standard Time (CST) for Sandy Lake, Ontario. On arrival at Sandy Lake at approximately 1549 CST, the crew attempted to land but were unable to because of the low ceiling and visibility. They then diverted to St. Theresa Point, Manitoba, landing at 1630 CST. After a normal turnaround, the flight returned to Sandy Lake and landed at approximately 1745 CST. The aircraft took off from runway 29 at Sandy Lake at approximately 1805 CST and immediately entered a right turn. After turning through about 120 degrees, the aircraft descended into 100-foot trees and crashed. All seven occupants of the aircraft were fatally injured, and the aircraft was destroyed.
The Board determined that, after take-off, the crew most likely lost situational awareness and, as a result, did not detect the increasing deviation from their intended flight path. Contributing to the loss of situational awareness was the lack of AC power to some of the flight instruments; the reason for the lack of AC power could not be determined.
Immediately following the occurrence, the flight recorders were recovered in a serviceable condition; however, no data was recorded with respect to the occurrence flight. In the past, the Board has made recommendations concerning deficiencies on the retrieval and quality of recorded data and on the lengthy process required to update flight recorder legislation. Notwithstanding the emphasis that the Board has put on the importance of flight recorders for investigation and accident prevention processes, there has not been any significant progress in addressing these flight recorder deficiencies.
The Board concluded its investigation and released report A93H0023 on 14 March 1995.
Board Recommendation A94-04 (January 1994)
Flight recorder information is often invaluable in the investigation of occurrences and it most certainly would have assisted in determining the events leading to this accident. In the past, the Board has made recommendations concerning deficiencies on the retrieval and quality of recorded data and on the lengthy process required to update flight recorder legislation. Notwithstanding the emphasis that the Board has put on the importance of flight recorders for investigation and accident prevention processes, there has not been any significant progress in addressing these flight recorder deficiencies.
Therefore, the Board adopted the following recommendation:
The Department of Transport streamline its processes to facilitate the timely Canadian implementation of updated flight recorder requirements.TSB Recommendation A94-04
Transport Canada's response to Recommendation A94-04 (April 1994)
Legislation (Recommendation A94-04)
The Regulatory Renewal Project is incorporating existing regulations in a new regulatory structure consisting of regulations with standards incorporated by reference. The intent is that the standards will be contained in an incorporated document that is much more easily amended than the regulation.
Concerning the revised recorder regulations, we have a consensus with industry that agrees to full harmonization with the Federal Aviation Regulations (FAR) of the U.S.A. Hence, the draft regulations have been finalized. The regulation section will stipulate briefly which aircraft require FDRs and CVRs. The standards section will list parameters, operational requirements and other technical specifications.
Board assessment of the response to Recommendation A94-04 (no date on document)
In response to these recommendations, Transport Canada (TC) has undertaken a program to review operator compliance with existing recorder requirements in order to identify areas of the monitoring and approval processes that need revision. In addition, TC stated its intention in April 1994 to issue two interim circulars to facilitate industry adjustment to the new recorder regulation expected to come into law in early 1995. With respect to streamlining the recorder legislation process, TC stated that a new regulatory structure will have regulations which incorporate standards by reference in order to facilitate amendment in a timely way. TC's new approach to use standards to keep pace with changing requirements in aviation, and in particular flight recorder technology, is an important improvement in the regulatory process. Also, TC has reached consensus with industry to harmonize with the U.S. Federal Aviation Regulations (FAR) in finalizing the draft Canadian regulations.
The new regulation will state which aircraft will require FDRs and CVRs; the standards section will list parameters, operational requirements, and other technical specifications. The Department of Justice has advised that it is prepared to carry out its regulatory functions as quickly as possible to ensure the regulations proposed by TC can be promulgated with the least possible delay.
Revised legislation process (Recommendation A94-04)
TC indicates that the new regulatory structure will have regulations which will incorporate standards by reference, thus facilitating amendments in a timely way. Also, TC has reached consensus with industry to harmonize with the U.S. Federal Aviation Regulations (FAR).
The approach by TC to use standards to keep pace with changing requirements in aviation, and in particular flight recorder technology, is an important improvement in the regulatory process.
Therefore this response is considered as having Satisfactory Intent.
Board reassessment of the response to Recommendation A94-04 (April 1999)
Current CVR/FDR standards (CARs 625.33 refers) were adopted despite observations by TSB (DGIO letter dated 27 Sep 95) that warned they were outdated. TSB continues to participate within CARAC to develop more relevant Canadian Aviation Regulations (CARs). Recommendation A90-55 raises similar issues.
Therefore, the response is assessed as Satisfactory Intent.
Board reassessment of the response to Recommendation A94-04 (February 2004)
Amending those recorder requirements by “Standards” seems more efficient; however, those aspects which require regulatory change may still involve a lengthy process. The Board suggests “Further Action Unwarranted” at this time (however, this recommendation should be tracked in conjunction with Swissair recommendations A99-01 and A99-02).
Therefore, the response is reassessed as Satisfactory in Part.
As such, Further Action is Unwarranted on this recommendation, the safety issue is addressed by Recommendation A99-02 and the status is now Inactive.
Board review of Recommendation A94-04 deficiency file status (April 2014)
The Board requested that Recommendation A94-04 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 A94-04 is addressed by the more recent Recommendation A99-02.
It is therefore appropriate to follow the progress on flight recorder safety issues through Recommendation A99-02.
Therefore, the assessment remains Satisfactory in Part.
Transport Canada's response to Recommendation A94-04 (March 2015)
Transport Canada agrees with the intent of the recommendation. It is anticipated that proposed regulations that address this recommendation will be pre-published in the Canada Gazette Part I in spring 2016.
TC indicated that delays are sometimes inevitable when higher priority tasks take up resources in the regulatory program. The defined criteria for assigning priority to regulatory initiatives are presented in the following table.
|Priority 1||Speech from the throne, Budget, Other High Level Government Commitment, initiatives related to the Red Tape reduction and Canada-U.S. Regulatory Cooperation Council|
|Priority 2||Ministerial priority, Urgency, Transportation Safety Board Watchlist Initiatives|
|Priority 3||High Strategic Outcome Priority, International/Federal-Provincial Obligations, Time Pressure, other TSB initiatives|
|Priority 4||Efficiency, Parliamentary, Stakeholder Priorities|
|Priority 5||Miscellaneous Amendments|
Note that the TSB Watchlist initiatives and other TSB initiatives are assigned Priority 2 and 3 respectively. These high ratings were assigned because the department takes TSB safety action very seriously. Occasionally, however, even important regulatory initiatives are shifted due to higher priority issues. The Board should be aware, however, that once Civil Aviation commits to regulatory action, timing may change, but the department will proceed with the initiative until is completed.
Board reassessment of the response to Recommendation A94-04 (March 2015)
In the Board's last re-assessment, the response to this recommendation was linked to Transport Canada's response to Recommendation A99-02. Transport Canada's response restates its support for the intent of Recommendation A99-02. Additionally, it advises that the proposed regulations contained in NPA 2011-010 are further delayed and will not be pre-published in the Canada Gazette, Part I until the first quarter of 2016. This further delay will undoubtedly push the implementation date of the proposed regulatory change well beyond the current target of 01 January 2016. In the meantime, the CARs will continue to lack harmonization with both the FAR requirement and the ICAO standard for 2-hour CVR.
Despite implementation delays, Transport Canada is proposing regulatory changes that, when fully implemented, will substantially reduce or eliminate the safety deficiency identified in Recommendation A99-02 which in turn will do the same for Recommendation A94-04. While Transport Canada's proposed measures are reasonable, the protracted delays are not.
Therefore, the assessment rating for this recommendation is changed to Unsatisfactory.
Transport Canada's response to Recommendation A94-04 (November 2015)
(Includes recommendations A91-13, A99-02, and A99-03.)
Transport Canada agrees with the intent of the recommendation.
It is anticipated that the proposed regulations that address this recommendation will be pre‑published in the Canada Gazette, Part I in 2016.
Board reassessment of the response to Recommendation A94-04 (March 2016)
The Board has linked the mitigation of the risks associated with Recommendation A94-04 to its assessment of Recommendation A99-02. Transport Canada's latest update repeats the statement that its proposed regulations to address the risks identified in Recommendation A99-02 are to be pre‑published in the Canada Gazette, Part I in 2016.
While Transport Canada's proposed regulatory changes are reasonable, the protracted delays are not.
Therefore, the assessment rating for this recommendation remains Unsatisfactory.
Transport Canada's response to Recommendation A94-04 (January 2017)
It is anticipated that the proposed regulations that address the CVR (2-hr recording capacity) component of this recommendation will be pre-published in the Canada Gazette, Part I, in summer 2017.
TSB reassessment of Transport Canada's response to Recommendation A94-04 (March 2017)
TC's latest update indicates that its proposed regulatory amendments, designed to mitigate the risks associated with the CVR component of Recommendation A94-04, is anticipated to be pre-published in the Canada Gazette, Part I, in summer 2017. Since 2011, this milestone has been revised three times, extending the anticipated pre-publishing in the Canada Gazette, Part I, from 2012 to 2017.
Progress toward mitigation of the risks associated with this recommendation has been slow. Such extended delays have prompted the TSB to add an item to its key safety issues Watchlist that calls for both TC and the Government of Canada to move towards an improved and accelerated process for taking action on TSB recommendations.
While TC's proposed regulatory changes are reasonable, the protracted delays are not.
Therefore, the response to Recommendation A94-04 is assessed as Unsatisfactory.
Next TSB action
The TSB will continue to monitor the progress of TC's proposed regulatory amendments to mitigate the risks associated with the safety deficiency identified in Recommendation A94-04, and will reassess the deficiency on an annual basis or when otherwise warranted.
This deficiency file is Active.
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