The 2008 Flightscape Users Conference
Transportation Safety Board of Canada
at the 2008 Flightscape Users Conference
June 25, 2008
Good morning, everyone. I am pleased to be here as a Board Member of the Transportation Safety Board of Canada.
The TSB is Canada's independent agency responsible for investigating marine, rail, pipeline and aviation occurrences. Our goal is to investigate these transportation occurrences to find out what happened, why it happened and make recommendations to regulators, manufacturers and operators on what needs to be done to reduce the risks. As part of its mandate, the Board also reports publicly on the findings of its investigations in order for the federally-regulated transportation community and others to learn from those accidents.
Our strength lies in our people - a team of accident investigators with a wide variety of specialties, who not only use time-honoured investigative techniques but also seek to find or develop new ones. This is what happened when in 1986 TSB Engineering Branch staff started to develop software capability to analyze flight recorder data. At that time, no such tool was commercially available. As the software capabilities developed, other accident investigation agencies approached the TSB to use the software. By the year 2000, there were 14 international users. In 2001, the TSB decided to commercialize the software and Flightscape took over its development. Today we are proud to know there are many different users of this software, from accident investigators to aircraft manufacturers and operators, who use it to improve product and operational safety.
Today the TSB uses Insight software to analyze FDR data in aviation investigations to develop flight path animations. The animations are extensively used for correlating investigation information and for analyzing aircraft performance. For example, these animations were crucial in helping the Board's understanding of what happened during the August 2005 runway overrun of an Air France Airbus A340 aircraft at Toronto's Pearson airport. The more than 600 data parameters recovered from that FDR provided the TSB investigative team with a very detailed picture of exactly what the aircraft was doing during its final approach and landing phase. This precise information, coupled with other information, such as cockpit voice recordings and witness testimony to name a few, were crucial to the TSB's understanding of the causes and contributing factors in this accident. This, in turn, provided the TSB with the confidence to make seven strong recommendations aimed at mitigating the risk of large aircraft overrunning the world's runways.
After all, as I said before, our mandate is to make the transportation system safer. Using detailed and accurate FDR information to find out what happened is a critical part of that sequence, and is important to us in achieving our goals.
The TSB is now using similar simulation approaches in its investigations of occurrences in the marine and rail sectors. During our investigation into the sinking of the passenger ferry Queen of the North, TSB marine investigators were able to recover data from navigational systems on the bridge and play it back on a simulator to determine what happened. This investigation also led us to make a recommendation to mandate voyage data recorders on all of Canada's large passenger vessels. While the specific software packages are different, the principles are similar - and are enhancing our abilities to do a more comprehensive job of understanding the causes and contributing factors of transportation accidents.
When it's time to publicly release our investigation reports, flight path animations derived from FDR data become an important communications tool. These video images are extremely useful in helping us provide the public and the media a clear picture of the sequence of events leading to an accident, thus providing a better understanding of the causes as well as our recommendations so that similar accidents can be prevented in the future.
While these flight path animations are useful to investigators and the public, we must be aware that these animations are reproductions of what the FDR parameters show. Therefore, animations do not explain why the machine was doing what it was doing at the time. Human factor elements will always be part of an accident as long as there are humans at the controls. When looking at FDR data and flight path or other FDR-derived animations, we must be careful not to jump to conclusions to answer the why questions or apply hindsight bias. We must look at the context in which the humans at the controls acted; why it made sense to them at the time , whether they were factors pertaining to the individuals themselves, such as what information they had at the time, behavioural patterns or medical issues, or whether organizational factors were at play, such as training standards, operating procedures or conflicting management goals. As such the TSB dedicates a great deal of time to understand the role these human and organizational factors play in each accident investigation.
In closing, the analysis of flight recorder data is one important element of a thorough accident investigation. Detailed flight recorder data gives us a good understanding of what the machine was doing leading up to an accident and flight path animations derived from FDR data are valuable in illustrating the sequence of events when we release our investigation reports. I hope the knowledge and experiences you will share during this conference will lead to a greater understanding of how best to use flight data analysis to advance aviation safety.
Thank you for your attention and enjoy the conference.
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