ISASI 39th Annual Seminar
Wendy Tadros

Transportation Safety Board of Canada
at the International Society of Air Safety Investigators (ISASI)
39th Annual Seminar
Advancing Aviation Safety
One Investigation at a Time
Halifax, Nova Scotia
September 9, 2008

Click here to see PowerPoint Presentation

Slide 1 (Introduction)

Good morning. Thank you for the kind introduction.

As Chair of the Transportation Safety Board of Canada, it is a pleasure for me to speak to the world's leading safety investigators. In my 12 years at the TSB, I have come to admire the work you do. I am impressed by both your dedication and your attention to detail.

Today, we have an opportunity to share our ideas and experiences. It is also a great opportunity to discuss the latest investigative techniques and to foster the strong working relationships that are absolutely essential to advancing transportation safety.

Slide 2

This year's ISASI theme is "Investigation: The Art and the Science". I want to talk to you about the SCIENCE behind some key TSB investigations and the contribution they have made to aviation safety worldwide. In particular, I want to talk to you about our Morningstar and Air Transat investigations which have resulted in positive change, thanks to solid investigative work and prompt action by regulators and industry in Canada and abroad.

I also want to practice the gentle art of persuasion and talk in more detail about MK Airlines, Air France and Swissair.

These are 3 investigations where we would like to see greater uptake of our recommendations - and - where with your support, together, we could make air travel even safer.

I want to start by telling you about some very positive international efforts on two fronts: firstly with Cessna 208 aircraft and secondly with inspections for composite materials.

Slide 3 (Loss of Control and Collision with Terrain)

In the early morning hours on October 6, 2005, a Cessna 208 cargo plane took off clean from Winnipeg with one pilot aboard. It climbed normally but within minutes, the performance of the aircraft diminished as ice built up on its critical surfaces. The situation quickly worsened and the aircraft crashed, killing the pilot.

Slide 4

The TSB did not wait until the investigation was complete to communicate with our international partners and make our safety recommendations.

In January of 2006, both the TSB and the NTSB made recommendations to advance safety for the more than 1600 Cessna 208s flying worldwide.

The actions taken by Transport Canada, the FAA, and the manufacturer on design, training and procedures are positive.

It is my hope they will mean no more in-flight icing accidents with Cessna 208s.

Slide 5 (Air Transat - Flight 861 - Loss of Rudder)

On March 6, 2005, an Airbus A310 took off from Varadero, Cuba. Seventeen minutes later, the crew heard a loud bang, followed by vibrations. Then the aircraft started to Dutch Roll. The crew managed to descend, stabilize the aircraft and return safely to Varadero.

Once on the ground, the problem quickly became obvious.

Slide 6

The Air Transat investigation is another stellar example of international cooperation resulting in positive and concrete action to advance aviation safety.

This occurrence did not garner a lot of attention with the public. After all, the aircraft landed safely and nobody died. But it certainly intrigued TSB investigators and they were determined to figure out what caused the rudder to fall off a modern aircraft.

Slide 7

What they learned in the initial days of the investigation, led to Airbus issuing an All Operators Telex calling for the inspection of all aircraft equipped with these composite rudders. Four hundred and eight Airbus wide-body aircraft were inspected worldwide.

These fleet checks suggested inspection programs may not always find defects in composite materials.

Slide 8

When we learned this, the Board urgently recommended that Transport Canada, the European Aviation Safety Agency (EASA) and industry come up with an inspection program to detect damage before it progresses. In the United States, the NTSB took similar action, reflecting the importance of international voices.

Transport Canada and EASA heard us. Transport Canada is working with the National Research Council of Canada on inspection techniques to detect failures in composite materials, and EASA is working with Airbus.

What followed was the development of early, consistent and reliable detection programs for composite materials. This absolutely could not have been accomplished without solid investigative work and international cooperation.

The implementation of the Morningstar and Air Transat recommendations are 2 of our successes.

Slide 9

Now, let's start by tackling a number of the hard issues in aviation safety today by talking about some areas that need more improvement. I would like to see greater uptake of the recommendations flowing from the MK Airlines, Air France and Swissair investigations.

These are not easy issues - if they were, they would have been fixed a long time ago. They are the tough issues and I would like to try to make the case for why I believe these recommendations are so important.

Perhaps if I can do that - if I can gain your support - we can get the ball rolling internationally and make aviation even safer.

Slide 10 (MK Airlines - Reduced Power at Take-off and Collision
with Terrain)

Let's look at the investigation of the MK Airlines crash on October 14, 2004 at the airport right here in Halifax.

Slide 11

A Boeing 747 cargo flight took off using speed and thrust settings that were too low for its weight. It hit a berm at the end of the runway, crashed into the forest, and burned. All seven crew members died.

Slide 12

Major air investigations are often global in scope, and this one was no exception. This accident involved an American-built aircraft, registered in Ghana, operated by a Ghanaian licensed crew working for a UK-based airline.

Equally international were the investigators. Investigators from the United Kingdom, Ghana and Iceland participated in this TSB investigation.

Slide 13

What's interesting about this investigation and the reason it's worth talking about, is it was not a "ONE OFF".

When you see one performance accident, the inclination is to say "Well, the pilot should have followed the SOPs."

When you see multiple accidents around the world where actual takeoff performance differed from expected performance, you come to the conclusion that additional defences are needed in the system.

Slide 14

That is why the TSB recommended Canadian and international regulatory authorities require a takeoff performance monitoring system to ensure that crews of large aircraft will be alerted in time when there is not enough power to take off safely.

Transport Canada committed to working with industry on the development of a takeoff performance monitoring system. This is a step in the right direction. The Board is hopeful that a solution can be found to eliminate this safety deficiency.

Slide 15 (Air France - Runway Overrun and Fire)

PLAY VIDEO - Side View

You are now watching an animation of Air France 358's flight path, which was generated using FDR data. This accident took place at Canada's busiest airport - beside Canada's busiest highway at rush hour. It would be an understatement to say the overrun of an Air France A340 at Toronto caught the world's attention.

On August 2, 2005, with 297 passengers and 12 crew on board, the aircraft approached Toronto in a severe and rapidly changing thunderstorm with shifting winds and limited visibility. It came in too high and too fast.

Touching down 3800 feet along the 9000 foot wet and slippery runway, it simply ran out of room. The aircraft came to a stop in a ravine and while the evacuation was not without its difficulties - everyone got out before fire destroyed the aircraft.

Slide 16

The TSB is grateful to the people from the BEA, EASA, Airbus, Air France, Transport Canada and many other organizations for providing information and invaluable assistance to our investigators. Thanks to your participation, we developed a comprehensive analysis of the causes and contributing factors that led to seven recommendations to make air travel safer.

Slide 17

So, what did we learn?

We learned this crew was not alone.

Since the Air France accident in Toronto, at least 10 large aircraft have gone off runways around the world in bad weather. This tells us that the potential for landing accidents in bad weather remains.

Slide 18

To make air travel safer, the TSB made seven recommendations. Five of them focus on crews and the need for mandatory standards, training and procedures, and two are aimed at reducing the risk of injury following an accident.

Slide 19

The Board made recommendations asking that Transport Canada and the world's regulatory bodies limit landings in thunderstorms and require enhanced pilot training.

Our investigation revealed that the Air France crew, like many others, did not calculate the landing distance required for the conditions at destination. That is why we recommended that regulators require these always be calculated, so crews will know their margin of error.

The NTSB made a similar recommendation following an accident in which a 737 left the runway at Chicago's Midway Airport.

Slide 20

We also made two recommendations aimed at reducing the risk of injury following an accident.

We took a good hard look at the terrain at the end of Canada's runways and found it can increase the risk of injuries to passengers and crews.

To address this risk, the TSB recommended that Transport Canada require 300 meter runway end safety areas or an alternate means of stopping aircraft. This will bring all of Canada's major airports in line with international benchmarks.

Slide 21

Lastly, we examined the evacuation. As you know, successful evacuations are measured in seconds. We found, despite directions to the contrary, many passengers stopped during the emergency to take their carry-on baggage with them.

To improve evacuations, the TSB asked Transport Canada to require that passenger safety briefings include clear direction to leave all carry-on baggage behind.

Slide 22

While the response to many of these recommendations has been positive, we are concerned about the response on our recommendation calling for RESAs or EMAS.

Let's not forget that in the past 25 years, at least one aircraft a month overran a runway somewhere in the world. It is my conviction that until this problem is faced SQUARELY; the trend is bound to continue. I believe this important issue deserves more attention from the world's regulators including Transport Canada.

Slide 23 (Swissair - In-flight fire leading to collision with water)

Here in Nova Scotia, the 2nd of September marked the 10th anniversary of the night Swissair 111 crashed off Peggy's Cove. It is only fitting that I end with this investigation.

Slide 24

On that evening in 1998, Swissair Flight 111, a McDonnell-Douglas MD-11 departed New York City on a scheduled flight to Geneva, Switzerland, with 215 passengers and 14 crew on board.

About 53 minutes later, while cruising at flight level 3-3-0, the crew smelled an abnormal odor in the cockpit. Their attention was drawn to the area behind and above them and they began to investigate the source - which they thought was the air conditioning system.

After further troubleshooting, they assessed there was definitely smoke and decided to divert to Halifax.

While the flight crew was preparing to land, they were unaware that a fire was spreading above the cockpit ceiling. Soon thereafter, the aircraft's FDR logged a rapid succession of system failures. The crew declared an emergency and an immediate need to land.

About one minute later, radio communications and radar contact were lost, and the flight recorders stopped functioning.

About five and a half minutes after that, the aircraft crashed into the ocean with the loss of all 229 souls on board.

The crew did what made sense to them at the time. Knowing what they knew, we pieced together the sequence of events. We ran a number of detailed scenarios and concluded that based on the time available before the fire disabled the aircraft, the crew could not have landed the plane safely.

Slide 25


The Swissair investigation took four and a half years. It was the largest and most complex safety investigation ever undertaken by the TSB.

I continue to be heartened by the way in which so many people - from so many places - helped provide this investigation with its strength and purpose. Coordinated national and international efforts and the contributions of many hardworking people like YOU were absolutely invaluable.

Slide 26

This investigation led to a comprehensive report with the potential to change the face of aviation safety. The TSB made 23 recommendations, 14 during the investigation and 9 in our final report.

These recommendations fall into five broad categories:

  • on-board recorders;
  • circuit breaker resetting procedures;
  • supplemental type certification process;
  • material flammability; and
  • in-flight firefighting.

We are pleased to see the Swissair investigation led to improvements that make flying safer. However, there are areas where we think there still needs to be more progress.

Let me talk to you about 3 of those:

Slide 27


The first material to ignite in Swissair was MPET. When we discovered this we advised regulators. In Canada, the United States and France they required the removal of MPET insulation from many aircraft.

The TSB learned that, at the time, the flammability test to approve insulation materials was not rigorous enough. We were pleased to see this test replaced by the Radiant Panel Test.

We would like it if MPET was removed from ALL aircraft or we would like to know HOW the FAA's Alternative Means of Compliance will ensure insulation materials will not propagate fires. We would also like to SEE more stringent testing for ALL existing insulation materials.

Slide 28

Since Swissair, crews routinely divert to land immediately at the first hint of fire or smoke in an aircraft; and IATA and the Flight Safety Foundation worked together to develop industry-wide guidance on more effective checklist procedures for smoke and fire. This in turn resulted in some aircraft manufacturers making improvements to their Aircraft Flight Manuals. These are positive steps.

Slide 29

What we would really like to see is international adoption of the Emergency Checklist template. We will also continue to focus attention on two areas: the need for designated fire zones and a systematic approach to in-flight fire fighting.

Slide 30

In the transportation world, aviation has led the way with requirements for FDRs and CVRs. With each investigation, we refine what data we need to figure out what happened. The Swissair recommendations are aimed at ensuring crucial data will be available to investigators.

The upshot is the FAA now requires that any single electrical failure not disable both CVR and FDR. By 2012, they will also require 2-hour CVRs and an independent power supply providing 10 more minutes of recording time. There has been progress for sure in this important area and the FAA is leading the way.

We would like to see 2-hr CVRs and an independent power supply as the international standard. We are looking to Transport Canada to harmonize these rules for all Canadian registered aircraft.

Slide 31

One other outstanding recommendation we feel strongly about is the installation of image recorders. These recorders will help investigators to better understand what went on in the cockpit and with the aircraft. The NTSB also made this recommendation.

That being said, the cockpit is a pilot's workplace and I understand why they would oppose greater surveillance. This resistance can only be overcome if the international community protects the confidentiality of all recordings. We must ensure they will not be released and will only be used to advance transportation safety.

Slide 32 (Conclusion)

Our success depends on supporting each others work. I invite you go to our website. There you can learn more about the recommendations we have made during the TSB's 18 years.

After taking a closer look at these reports, and where you find similar safety deficiencies, I urge you to carry the flag for aviation safety and adopt the TSB's recommendations as your own.

Earlier, I spoke to you about how the Morningstar and Air Transat investigations changed the face of aviation safety.

And we have looked at how, as a result of the MK Airlines, Air France and Swissair investigations, there has been much progress.

This would not have been possible without your cooperation and dedication to aviation safety.

And while many recommendations have been implemented, I would like to see the face of aviation safety changed even more dramatically.

I would like to see ALL of the recommendations from the MK Airlines, Air France and the Swissair investigations effectively implemented.

International cooperation and information sharing are critical to advancing transportation safety. Let's work together to make sure that happens.

Slide 33

Thank you for your attention.