TSB Recommendation A18-03

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)CAR subsection 602.11(2) establishes that the responsibility to ensure an ice-free surface lies with the operator and flight crew. 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.

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.

Transport Canada (TC) agrees with the recommendation.

As a commitment by the Minister of Transport to the TSB for its Recommendation A18-03 to increase compliance to CAR 602.11(2), Phase 1 of the Targeted Inspection (TI) campaign was initiated in February 2020. The primary purpose was to observe whether operators are implementing procedures documented in their manuals and in their response to the Minister’s Letter to Operators sent to them in May 2019. Unfortunately the campaign was cut short by the onset of the COVID-19 pandemic, so it was not possible to complete a representative sampling of air operators and airports during icing conditions. Therefore, insufficient data was collected to evaluate ground icing practices nationwide; however, when it is practicable to do so, TC intends to relaunch the TI campaign for the icing season of 2020/2021. An interim report of Phase I is being prepared and will be finalized in fall 2020.

TC also developed an education and awareness campaign and a status report on this campaign will be provided in the next update.

TC conducted a targeted communications campaign to raise awareness of the available documents and information related to airframe icing. As part of this campaign, TC created an “icing landing pageTransport Canada (2020), Aircraft icing for general aviation and others, at https://tc.canada.ca/en/aviation/publications/aviation-safety-letter/issue-3-2019/aircraft-icing-general-aviation-others (last accessed on 28 March 2023).” on its website ahead of the next winter season with links to these materials and promoted it to stakeholders through regular association meetings (e.g., NATA, ATAC, and the Canadian Business Aviation Association), by correspondence and through established distribution lists. A status report on these initiatives will also be provided in the next update.

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 last meeting was held on October 30 and 31, 2019 and the next one is planned in 2021.

TC plans to relaunch the TI campaign with Phase 1 in Winter 2020/21 and Phase 2 in Spring 2021, followed by analysis of collected data in Summer 2021 and development of a final report with recommendations in Fall 2021. The original Phase 1, which started in February 2020, was suspended in March 2020 due to pandemic restrictions and was therefore inconclusive as a result of insufficient data collection. A project charter is being prepared to relaunch the TI campaign, which will summarize what occurred in the original Phase 1 and explain the campaign re launch. Approval of the project charter is expected in December 2020.

In its response, Transport Canada (TC) indicated that it agrees with Recommendation A18-03.

The TSB is encouraged that TC has reached out to stakeholders, and that educational and awareness material have been made available regarding the hazards of aircraft taking off with contaminated critical surfaces. The COVID-19 pandemic has presented challenges to TC and prevented most of its planned targeted inspections aimed at increasing compliance with Canadian Aviation Regulations (CARs) subsection 602.11(2). Increased compliance with the regulation would reduce the likelihood of aircraft taking off with contaminated critical surfaces.

Until more robust actions are taken to increase compliance with CARs subsection 602.11(2), the risks associated with the safety deficiency identified in Recommendation A18-03 will continue to exist.

Therefore, the response to Recommendation A18-03 is assessed as Satisfactory Intent.

Transport Canada (TC) agrees with the recommendation.

Since the recommendation was issued in 2018, as an immediate measure, TC sent information to all operators and airport associations to remind them of recommended practices and proceduresTransport Canada (2020), TP 14052 – Guidelines for Aircraft Ground – Icing Operations, at https://tc.canada.ca/en/aviation/publications/guidelines-aircraft-ground-icing-operations-tp-14052 (last accessed on 28 March 2023). for de-icing, and provided links to the relevant TC guidance material. In 2019, TC conducted a targeted communications campaign to raise awareness of the available documents and information related to airframe icing and created an "Icing landing page"Transport Canada (2019), Aviation Safety Letter (TP185E – Issue 3/2019) – Aircraft icing for general aviation and others, at https://tc.canada.ca/en/aviation/publications/aviation-safety-letter/issue-3-2019/aircraft-icing-general-aviation-others (last accessed on 28 March 2023). on its website ahead of the winter season with links to those materials and promote it to stakeholders.

Following these immediate measures, the Department committed in September 2020 to:

• Relaunch the targeted inspection (TI) campaign (that was delayed due to the COVID-19 pandemic) with Phase 1 in Winter 2020/21 and Phase 2 in Spring 2021, followed by analysis of collected data in Summer 2021 and development of a final report with recommendations in Fall 2021; and,
• Evaluate the impact of these targeted campaigns, examine additional targeted inspection approaches and promotional measures based on the outcomes of the evaluation and develop a final report with recommendations.

Since the previous update, TC has considered whether the TI campaign should be re-started in Winter 2020/21 but recommended to postpone the campaign until Winter 2021/22 when it is anticipated that on-site observation of de-icing/anti-icing practices can resume safely. The TI campaign is on track to be re-started for Winter 2021/2022 and will consist of two phases with the second phase continuing through the summer and the final report due before the end of 2022:

• Short term - Phase I (Winter 2021/2022): Observe de-icing/anti-icing events on-site and collect information.
• Medium term - Phase II (Spring/Summer 2022): Using the observed de-icing/anti-icing events as a starting point, review operator's Ground Icing Operations Program and procedures.
• Long term - (Fall/Winter 2022): Collect and analyze national data, draft final report with recommendations.

The education and awareness campaign related to this issue will resume with the re-start of the TI campaign as noted above. The final report for the Ground Icing Targeted Inspection is anticipated to be ready by December 2022.

In the meantime, a follow up article in an upcoming issue of the Aviation Safety Letter is planned to complement the one that was already published and is available on the TC websiteIbid..

As the 2021 Canadian Aviation Safety Collaboration Forum was cancelled, there was no opportunity to hold another breakout session on the topic. Another breakout is being considered for the 2022 event.

In its response, Transport Canada (TC) indicated that it agrees with Recommendation A18-03.

Due to the COVID-19 pandemic, TC postponed its planned relaunch for a two-phased targeted inspection (TI) campaign, which also delayed the resumption of its education and awareness campaign related to de-icing. According to updated information received from TC in January 2022, Phase I of the TI campaign is scheduled to be completed by 31 March 2022. The target completion date for Phase II is June 2022, and TC Regional Analysis, Occurrence, Planning and Reporting branches will conduct quality control and tracking of completed inspections. TC will evaluate the impact of this TI campaign, examine additional TI approaches and promotional measures based on the outcomes of the evaluation and develop a final report with recommendations. The final report for the Ground Icing Targeted Inspection is anticipated to be made available by December 2022.

The Board is pleased with the relaunch of TC’s TI campaign this winter, including the resumption of other related initiatives in 2022. The COVID-19 pandemic has presented challenges to TC, which delayed many of its planned actions aimed at increasing compliance with Canadian Aviation Regulations (CARs) subsection 602.11(2).

These actions, when implemented, have the potential to substantially reduce the risk associated with the safety deficiency identified in Recommendation A18-03 by raising awareness and increasing compliance with the regulation and thus reducing the likelihood of aircraft taking off with contaminated critical surfaces. However, until these actions are completed, the risks associated with the safety deficiency identified in Recommendation A18-03 remain.

Therefore, the response to Recommendation A18-03 is assessed as Satisfactory Intent.

Transport Canada (TC) agrees with the recommendation.All responses are those of the stakeholders to the TSB in written communications and are reproduced in full. The TSB corrects typographical errors and accessibility issues in the material it reproduces without indication but uses brackets [ ] to show other changes or to show that part of the response was omitted because it was not pertinent.

Since the recommendation was issued in 2018, as an immediate measure, TC sent information to all operators and airport associations to remind them of recommended practices and proceduresTransport Canada (2020), TP 14052 – Guidelines for Aircraft Ground – Icing Operations, at https://tc.canada.ca/en/aviation/publications/guidelines-aircraft-ground-icing-operations-tp-14052 (last accessed on 28 March 2023). for de-icing, and provided links to the relevant TC guidance material. In 2019, TC conducted a targeted communications campaign to raise awareness of the available documents and information related to airframe icing and created an "Icing landing page"Transport Canada (2019), Aviation Safety Letter (TP185E – Issue 3/2019) – Aircraft icing for general aviation and others, at https://tc.canada.ca/en/aviation/publications/aviation-safety-letter/issue-3-2019/aircraft-icing-general-aviation-others (last accessed on 28 March 2023). on its website ahead of the winter season with links to those materials and promote it to stakeholders.

Following these immediate measures, the Department committed in September 2021 to:

• Relaunch the targeted inspection (TI) campaign (that was delayed due to the COVID-19 pandemic) with Phase 1 in Winter 2021/22 and Phase 2 in Spring/Summer 2022, followed by analysis of collected data and development of a final report with recommendations in Fall/Winter 2022.
• Evaluate the impact of these targeted campaigns, examine additional targeted inspection approaches and promotional measures based on the outcomes of the evaluation and develop a final report with recommendations.

Since the previous update, TC completed Phase 1 of the TI campaign over Winter 2021-22. Analysis of Phase 1 of the TI campaign was successful in identifying gaps in compliance. Results have led TC to re-examine the planned next steps. While the previously planned Phase 2 of the TI will move forward, additional activities are also being recommended. Recommendations on how to proceed are now being consulted and will be presented to TC senior management in Fall 2022. If approved, TCCA will:

• Short term (Fall 2022): Proceed with Phase 2 of the TI as planned to understand flight crew decision-making process and identify best practices.
• Medium term (Winter 2022/2023): Conduct ad-hoc ground icing inspections on an opportunity basis. Analyze results of completed Phase 2 inspections and produce report with recommendations.
• Long term (Spring 2023 and ongoing): Based on results of final report: project plan recommendations, develop new safety promotion material / campaign to raise awareness in the industry, and engage with industry associations to promote safe practices. Explore a possibility to develop a pilot project using remote surveillance technology to monitor activities at remote aerodromes.

A final report on the Ground Icing Targeted Inspection was originally planned for Winter 2022. A report following Phase 2 of the TI will still be developed but the campaign’s final report may be delayed to include results from the additional inspections being recommended over the upcoming winter. Confirmation to come following approval of Phase 1 report recommendations.

As an ongoing commitment, TC will conduct a targeted communications campaign to raise awareness of the available documents and information related to airframe icing by circulating another de-icing email to industry. This is planned for January 2023 and will contain information on available documents related to the topic. Plans for an icing landing page are underway.

TC will continue engaging with Canadian stakeholders by holding the next Standing Committee on Operations Under Icing Conditions (SCOUIC) meeting on October 4-5, 2022. TC also continues to participate at the Canadian Aviation Safety Collaboration Forum (CASCF) via work with the De-icing and Anti-icing at Remote Locations Working Group.

In its response, Transport Canada (TC) indicated that it agrees with Recommendation A18-03.

Since the last TSB assessment, TC completed Phase 1 of the targeted inspection (TI) campaign. The Board understands that Phase 1 of the TI campaign identified gaps in compliance and that the results have led TC to re-examine the planned next steps. Phase 2 of the TI campaign will now move forward; additional activities are also being recommended.

The final report for the Ground Icing Targeted Inspection, originally planned for release in Winter 2022, is now anticipated to be made available after Phase 2 of the TI campaign is completed. Subsequent to its October 2022 response, TC informed the TSB that all targeted inspections should be completed by 31 March 2023. Once the analysis of the results is completed, TC will share a final report with the TSB.

Additionally, although TC had planned to conduct a targeted communications campaign in January 2023 to raise industry awareness of the available documents related to the topic of de-icing, this has not occurred to date. However, cold weather operations and de-icing was featured in TC’s December 2022 Aviation Safety Letter (Issue 4/2022).

While some action has been taken by TC to assess and gather information, the Board is concerned with the protracted delays of its planned actions aimed at increasing compliance with Canadian Aviation Regulations (CARs) subsection 602.11(2).

The proposed actions, when implemented, have the potential to substantially reduce the risk associated with the safety deficiency identified in Recommendation A18-03 by raising awareness and increasing compliance with the regulation and, thus, reducing the likelihood of aircraft taking off with contaminated critical surfaces. However, until these actions are completed, the risks associated with the safety deficiency identified in Recommendation A18-03 remain.

Therefore, the Board considers the response to Recommendation A18-03 to show Satisfactory Intent.

Transport Canada (TC) agrees with the recommendation.

Since the recommendation was issued in 2018, as an immediate measure, TC sent information to all operators and airport associations to remind them of recommended practices and proceduresTransport Canada (2020). TP 14052 - Guidelines for Aircraft Ground - Icing Operations. Available at: https://tc.canada.ca/en/aviation/publications/guidelines-aircraft-ground-icing-operations-tp-14052 for de-icing and provided links to the relevant TC guidance material. In 2019, TC conducted a targeted communication campaign to raise awareness of the available documents and information related to airframe icing and created an "Icing landing page"Transport Canada (2019). Aviation Safety Letter (TP185E – Issue 3/2019) – Aircraft icing for general aviation and others. Available at: https://tc.canada.ca/en/aviation/publications/aviation-safety-letter/issue-3-2019/aircraft-icing-general-aviation-others on its website ahead of the winter season with links to those materials and promote it to stakeholders.

Following these immediate measures, the Department committed in September 2021 and October 2022 to:

• Launch a targeted inspection (TI) campaign with Phase 1 in Winter 2021/22 and Phase 2 in Spring 2023 followed by analysis of collected data and development of a final report with recommendations in Winter 2023.
• Evaluate the impact of these targeted campaigns, examine additional targeted inspection approaches and promotional measures based on the outcomes of the evaluation and develop a final report with recommendations.

Since the previous updates, TC completed Phase 1 of the TI campaign over Winter 2021–22 and Phase 2 in April 2023. Analysis of Phase 1 of the TI campaign was successful in identifying gaps in compliance. Results led TC to re-examine the planned next steps. A final report on the Ground Icing Targeted Inspection was originally planned for Winter 2022. A report following Phase 2 of the TI will still be developed but the campaign’s final report may be delayed including results from the additional inspections being recommended over the upcoming Winter. Confirmation to come following approval of Phase 1 report recommendations.

Phase 2 of the TI campaign was completed in April 2023. The campaign revealed that all the air operators observed and inspected had a Ground Icing Program and that their respective programs are mostly compliant with the Regulations. However, the inability of some air operators to ensure that their de-icing/anti-icing service providers are qualified to serve their aircraft is an area at risk. In conclusion, the poor practices observed during Phase 1 may not be directly related to specific deficiencies in the air operators’ Ground Icing Program. This could indicate that the flight crew’s decision-making to proceed or not, with contaminated surfaces, is not likely driven by a lack of procedures in the Ground Icing Program of the air operator, but more likely by a disregard for those procedures.

As a result of the TI Campaign, three recommendations were made:

• To conduct ground icing operations compliance inspections at Northern, remote aerodromes when ground icing conditions are present. The objective is to enhance TCCA visibility and focus on this operational area.
• To add a ground icing operations compliance inspection to the yearly surveillance plan.
• To provide training to the TCCA operations inspectors on aircraft de-icing and anti-icing practices. The training should include the Regulations, the use of the Holdover Time (HOT) guidelines, and the de-icing/anti-icing fluid types.

As an ongoing commitment, TC continues to conduct targeted communication to meet the TSB Recommendation. Rather than a separate communication campaign for January 2023, TC decided to leverage the audience of the Air Taxi Safety Campaign, a multi-year engagement, to deliver key messages on increasing compliance while raising awareness for overall safety for that sector.

Annually, TC also conducts a social media blitz during the winter months through TC’s Communications Branch to raise awareness about the risks involved with taking off with contaminated surfaces.

Information collected during the first two phases of the TI campaigns will also be communicated through collaborative opportunities with industry, particularly during the Spring 2024 Canadian Aviation Safety Collaboration Forum (CASCF). Furthermore, the Aviation Safety Letter (ASL) remains a primary tool for the delivery of information to a wide readership.

Finally, TC will continue engaging with Canadian stakeholders on a biennial basis through participation in the Standing Committee on Operations Under Icing Conditions (SCOUIC) meetings and at the CASCF via work with the De-icing and Anti-icing at Remote Locations Working Group:

• At the October 2022 SCOUIC meeting, the Director General gave an update on the Targeted Inspections for ground icing operations and the conclusion of Phase 1 of the campaign. Participants were also made aware of connections to the CASCF and the integration of the compliance awareness initiative through the Air Taxi Safety Campaign. Updates were also given regarding advancements of the related working group.
• Stakeholders will again be invited to participate in the next CASCF scheduled for Spring 2024 to further discuss increasing compliance.
• TC plans to continue using both platforms to update stakeholders moving forward.

In its latest response, Transport Canada (TC) indicated that it agrees with Recommendation A18-03.

In April 2023, TC completed Phase 2 of the targeted inspection campaign; however, the final report has not yet been released. The campaign determined that, while all air operators inspected had a Ground Icing Program that mostly complied with the regulations, the risk associated with the safety deficiency underlying Recommendation A18-03 remains. The campaign concluded that the poor practices observed during Phase 1 may not be directly related to specific deficiencies in air operators’ Ground Icing Programs; they could be indicative of issues with flight crew decision making, which are more likely the result of disregarding existing procedures, rather than a lack of procedures.

As a result, TC plans to conduct ground icing operations compliance inspections at remote aerodromes when ground icing conditions are present and to include ground icing operations compliance inspections to its yearly surveillance plan. TC also plans to continue communicating to its stakeholders its campaign results and the risk associated with safety deficiency underlying Recommendation A18-03.

While some action has been taken by TC to assess and gather information, the Board is concerned with the continued protracted delays of its planned actions aimed at increasing compliance with subsection 602.11(2) of the Canadian Aviation Regulations (CARs), such as implementing ground icing operations compliance inspections at remote aerodromes when ground icing conditions are present. It is concerning that these gaps were identified in Phase 1 of the targeted inspection campaign, but the risk has not yet been mitigated.

The proposed actions, when implemented, have the potential to substantially reduce the risk associated with the safety deficiency identified in this recommendation by raising awareness and increasing compliance with the regulation, thereby reducing the likelihood of aircraft taking off with contaminated critical surfaces. However, until these actions are completed, the risks associated with the safety deficiency identified in Recommendation A18-03 remain.

Therefore, the Board considers the response to Recommendation A18-03 to show Satisfactory Intent.