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TSB urges Transport Canada to update cockpit voice recorder regulations


May 31, 2017   by Canadian Underwriter


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Transport Canada needs to update its regulations on flight recorders, Transportation Safety Board of Canada suggested Monday.

The federal government’s response to a recommendation from a 1993 accident that killed seven is “still unsatisfactory,” TSB argued Monday in a tweet.

TSB recommended more than 20 years ago that Transport Canada “streamline its processes to facilitate the timely Canadian implementation of updated flight recorder requirements.” Then in 1999, TSB recommended there be a mandatory two-hour recording capacity on cockpit voice recorders.

TSB is a separate organization from Transport Canada. TSB made its recommendation in an investigation report into the controlled flight into terrain of an Air Manitoba Hawker Siddeley 748 twin-engine turboprop. In that accident, TSB said the cockpit voice recorder “was installed so that only the cockpit area microphone (CAM) recorded to the CVR tape,” adding that the other three channels “did not record because of inadequacies in the installation of the recorder.”

In an update published in March, 2017, TSB noted that proposed regulatory amendments “designed to mitigate the risks associated” with the CVR component of its recommendation from the 1993 accident, “is anticipated to be pre-published” in the summer of 2017 in the Canada Gazette.

“Since 2011, this milestone has been revised three times,” TSB said earlier. “Progress toward mitigation of the risks associated with this recommendation has been slow.”

Shortly after 6:00 p.m. on Nov. 10, 1993, the Air Manitoba HS 748 took off from Sandy Point, Ont., entered a right turn, descended into trees and crashed, killing all seven occupants.

“Either the pilot flying was following an erroneous horizon indicator, or he was flying without adequate reference to the available flight instruments,” TSB said in its report into the accident, released in 1995. Although the flight recorders were recovered in a serviceable condition, “no data was recorded with respect to the occurrence flight,” TSB added at the time.

Four years later, TSB recommended that by 2005, the Canadian government should mandate a two-hour recording capacity on cockpit voice recorders for all aircraft required to have both flight data recorders and cockpit voice recorders. That recommendation was made in a report into a fatal crash in September, 1998 off the coast of Nova Scotia of an MD-11.

The MD-11 (essentially a modified version of the DC-10), operated by Swiss Air, was attempting to make an emergency landing Sept. 2, 1998 at Halifax Stanfield airport. The plane never made it to Halifax and all 229 aboard died.

“The aircraft continued to fly for about six minutes with no on-board information being recorded,” TSB said in its report released in 1999. “This lack of recorded information hampered the accident investigation.”

In December, 2005, TSB noted that Transport Canada stated it intended to introduce a Notice of Proposed Amendment (NPA) into its Canadian Aviation Regulation Advisory Council (CARAC) process. Then in March, 2011, TSB said the NPA had yet to be tabled at a CARAC Technical committee meeting.

Four years later, TSB reported that Transport Canada indicated it planned to pre-publish new CVR regulations in the spring of 2016. This past January, TSB reported it anticipates that “proposed regulations” that address the two-hour recording capacity of CVRs “will be pre-published in the Canada Gazette, Part I, in summer 2017.”

In its report into the Swiss Air tragedy, TSB noted that the mandated cockpit voice recording time was “insufficient to allow for the capture of additional, potentially useful information.”

Swiss Air Flight 111 took off from New York City’s John F. Kennedy Airport shortly after midnight Sept. 2, 1998. The intended destination was Geneva. Shortly after 1:00 a.m., the crew noticed an unusual smell in the cockpit and requested a precautionary landing in Boston. They accepted a recommendation from Moncton, N.B.-based air traffic controllers to land at Halifax.

At about 1:10 a.m., the Swiss Air pilots decided they needed to dump fuel. They were off the coast about 25 nautical miles from Halifax but needed to lose height. At 1:24 a.m. they declared an emergency, reporting they were starting to dump fuel and had to land immediately. The last communication was a minute later. At 1:31 a.m. the MD-11 hit the water.

A fire on the MD-11 likely started above the ceiling near the cockpit rear wall, TSB concluded. TSB concluded the “likely” source was arced electrical cable associated with the in-flight entertainment network. That arcing “ignited the flammable cover material on metallized polyethylene terephthalate (MPET) covering on the thermal acoustic insulation blankets,” TSB said in the report.

After the accident, the U.S. Federal Aviation Administration issued an “Airworthiness Directive (AD) requiring inspections to determine whether wiring discrepancies exist that could cause electrical arcing, TSB said at the time.

The last passenger flight of the MD-11 landed in October, 2014 in Amsterdam, KLM Royal Dutch Airlines reported at the time.