Recommendation A15-01

Reassesssment of the response to Aviation Safety Recommendation A15-01

Reporting of number of infant and child passengers travelling by air

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Background

On 22 December 2012, the Perimeter Aviation LP, Fairchild SA227-AC Metro III (registration C-GFWX, serial number AC650B), operating as Perimeter flight PAG993, departed Winnipeg/James Armstrong Richardson International Airport, Manitoba, at 1939 Coordinated Universal Time (1339 Central Standard Time) as a charter flight to Sanikiluaq, Nunavut. Following an attempted visual approach to Runway 09, a non-precision non-directional beacon (NDB) Runway 27 approach was conducted. Visual contact with the runway environment was made and a circling for Runway 09 initiated. Visual contact with the Runway 09 environment was lost and a return to the Sanikiluaq NDB was executed. A second NDB Runway 27 approach was conducted with the intent to land on Runway 27. Visual contact with the runway environment was made after passing the missed approach point. Following a steep descent, a rejected landing was initiated at 20 to 50 feet above the runway; the aircraft struck the ground approximately 525 feet beyond the departure end of Runway 27. The 406 MHz emergency locator transmitter activated on impact. The 2 flight crew and 1 passenger sustained serious injuries, 5 passengers sustained minor injuries, and 1 infant was fatally injured. Occupants exited the aircraft via the forward right overwing exit and were immediately transported to the local health centre. The aircraft was destroyed. The occurrence took place during the hours of darkness at 2306 Coordinated Universal Time (1806 Eastern Standard Time).

The Board concluded its investigation and released Aviation Investigation Report A12Q0216 on 29 June 2015.

Board Recommendation A15-01 (June 2015)

According to the International Civil Aviation Organization, in 2013, the number of passengers carried rose to 3.1 billion, which is 4.5% higher than for 2012Footnote 1. In terms of domestic scheduled air services, all regions experienced an increase in traffic, and markets overall grew by 5.1% in 2013. North America is still the world's largest domestic market with 45% of the world domestic scheduled traffic. There are no statistics on the number of infants and children travelling.

Transport Canada statistics show that passenger traffic at Canadian airports increased 2.9% in 2013, to reach 85.2 million enplaned and deplaned passengers. Domestic, Canada–U.S., and other international traffic increased year-over-year by 2.8%, 4.4%, and 1.6%, respectivelyFootnote 2. The number of infants and child passengers travelling by air is not available.

Currently, under the Transportation Information Regulations, Canadian air carriers must provide a wide range of information on their overall operations to the Minister of Transport. However, information on the number of infant and child passengers travelling is not required to be reported. Historical information supplied by Perimeter and 3 other air carriers in the course of this investigation indicated that infants 0 to 2 years old and children 2 to 12 years old made up nearly 14% of their total passenger loads.

Data relevant to the number of infants may be available but not stored for easy retrieval, and the number of children (under 12 years old) travelling is contained within the number of passengers. As a result, the exact number of infants and young children travelling on board an aircraft, and whether or not infants are carried on a guardian's lap or in a separate seat, is not available and makes it difficult to properly assess infant and child passenger exposure to air travel.

Until better data collection is required, the industry will be unable to conduct research, assess risks, and outline emerging trends related to the carriage of infants and children. If more complete data on the number of infants and children travelling are not available, there is a risk that their exposure to injury or death in the event of in-flight turbulence or a survivable accident will not be adequately assessed and mitigated.

Therefore, the Board recommends that:

The Department of Transport require commercial air carriers to collect and report, on a routine basis, the number of infants (under 2 years old), including lap-held, and young children (2 to 12 years old) travelling.
TSB Recommendation A15-01

Transport Canada's response to Recommendation A15-01 (September 2015)

The Department of Transport (TC) agrees that having more accurate information on the number of infants and young children travelling by air would enable the conduct of risk and cost-benefit analyses to support regulatory decision making. TC is working to determine what options exist for collecting the information, including stakeholder consultation to be completed by March 2016, which from their point of view is the best way to gather and report information.

Board assessment of Transport Canada’s response to Recommendation A15-01 (November 2015)

In its response, Transport Canada indicated that it is working on determining what options exist for collecting and reporting information on the number of infants and young children travelling by air.

Transport Canada’s proposed action indicates that, after consultation with appropriate stakeholders, the best way to gather and report the required data to Transport Canada will be determined. However, these actions do not indicate how and when industry will be required to report this information. While the actions proposed by Transport Canada constitute a first step in the right direction, much more work is required.

Therefore, at this time, the response to Recommendation A15-01 is assessed as Satisfactory Intent.

Transport Canada's response to Recommendation A15-01 (April 2016)

An exploratory meeting was held on April 11, 2016. TC is still actively consulting industry on data collection related to children and infants travelling by air.

Board reassessment of Transport Canada's response to Recommendation A15-01 (April 2016)

In its responses from September 2015 and April 2016, Transport Canada indicated that it is working on determining what options exist for collecting and reporting information on the number of infants and young children travelling by air.

Transport Canada's proposed action indicates that, after consultation with appropriate stakeholders, the best way to gather and report the required data to Transport Canada will be determined. Although Transport Canada has started consultations, there is no indication as to how and when industry will be required to report this information. While the actions proposed by Transport Canada constitute a first step in the right direction, much more work is required.

Therefore, at this time, the response to Recommendation A15-01 is assessed as Satisfactory Intent.

Transport Canada's response to Recommendation A15-01 (February 2017)

On 20 April 2016, TC met with industry organizations to discuss the acquisition of the data recommended by the TSB. The Canada Transportation Act (CTA) authorizes the Minister to collect transportation statistics. However, the Transportation Information Regulations do not currently provide for the collection of the information described in Recommendation A15-01. In 2017-18, the department will explore the possibility of making the required regulatory changes.

TSB reassessment of Transport Canada's response to Recommendation A15-01 (March 2017)

In its response, TC indicates that it has met with industry organizations to discuss the acquisition of the information required by Recommendation A15-01. In addition, TC advises that the collection of that particular information is not covered by the Transportation Information Regulations. As such, in 2017-18, TC plans to explore possible regulatory changes to enable the collection of such information.

Although TC is proposing to explore regulatory changes to enable the collection of the data required by Recommendation A15-01, no details are provided as to how and when industry will be required to report this information.

Therefore, the response to Recommendation A15-01 is assessed as Satisfactory Intent.

Next TSB action

The TSB will continue to monitor TC's actions to mitigate the risks associated with the safety deficiency identified in Recommendation A15-01, and will reassess the deficiency on an annual basis or when otherwise warranted.

This deficiency file is Active.

Footnotes

Footnote 1

Transport Canada, Transportation in Canada 2013, TP 14816. Available at: https://www.tc.gc.ca/media/documents/policy/Transportation_in_Canada_2013_eng_ACCESS.pdf (last accessed 18 June 2015).

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Footnote 2

National Transportation Safety Board (2010). Safety Recommendations A-10-121 through -123.

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