Speeches

Opening Remarks at Air 2009, Accident Investigator Recorders Meeting

by Wendy A. Tadros
Chair
Transportation Safety Board of Canada
22 September 2009

Good Morning and Welcome!

The Transportation Safety Board of Canada is pleased to host the world's leading specialists in flight data gathering and analysis. Now in its sixth year, this is an important venue to share information on the successes and challenges you face in your day-to-day work.

It also gives you an opportunity to develop a stronger network of contacts within your specialty. The fact that this group continues to grow with each passing year demonstrates your understanding of the importance of international cooperation and partnership. It is by sharing information - that together, you will find new avenues for improving data gathering, preservation and analysis.

Sharing information is important but so too is thinking "outside the box" and having the persistence to see your ideas through. This is part of what I want to talk to you about today - sharing your expertise, ingenuity and being persistent. I also want touch on where the Canadian Board is going with respect to recorders. Last but not least, I want to talk about the importance of the work you do.

During my tenure at the TSB, I continue to be impressed by creativity and persistence. The invention of the flight recorder itself is the perfect example of creativity and persistence. Dr. David Warren, an Australian fuels chemist, was part of a team investigating the crashes of deHavilland Comets in 1954, during the dawn of the jet age.

At that time, Dr. Warren envisioned installing a portable audio recorder aboard aircraft to capture the final conversations of the crew and other ambient sounds. There was little interest from the investigative team at that time, but Dr. Warren continued developing his idea, telling others about it, building a prototype and flight testing it. When he presented his prototype for official evaluation, Australian aviation authorities dismissed the idea.



It wasn't until a chance meeting - 4 YEARS LATER - with Sir Robert Hardingham, the Secretary of the United Kingdom Air Registration Board that things began to change. Hardingham was very enthusiastic about the potential of Dr. Warren's invention, so he invited him to the UK to further develop his idea.

This was the "tipping point" for the idea and Dr. Warren's idea later became the orange, crash-resistant "black box" that we know today. Aviation authorities in the UK began to require the installation of flight recorders aboard their aircraft and other jurisdictions soon followed suit. Because Dr. Warren never gave up, today, recorders are mandatory aboard many aircraft��AND you all do what you do.

Creative thinking and perseverance really pays off when accident data is not available or destroyed, whether in aviation or other modes of transportation. This brings to mind the TSB's investigation of a 2006 train runaway and derailment near the Western Canadian town of Lillooet. The Locomotive Event Recorder - which is similar to an FDR, was destroyed.

Investigators learned the train was equipped with a device called a sense and braking unit or SBU. The SBU replaced the old cabooses and the SBU now delivers brake pressure information to the train crew. Investigators found the SBU is sometimes equipped with a GPS that could be configured to provide more information with which to monitor train movements.

However, the railway had not ordered this feature and to their knowledge, none of their SBU's was equipped with a GPS. Further they argued, even if there had been GPS functionality, the information would not have been saved.

But our investigators doggedly pursued this possibility and 18 months later, GPS data was successfully recovered from the SBU.



Thanks to the ingenuity and persistence of the investigative team, the valuable data was retrieved and it confirmed how the brakes were applied as the train descended the grade before losing control and derailing. Without this information, we would not have been able to clearly determine what caused the derailment and the safety lessons would have been lost.

So why am I telling you these stories - early on a Tuesday morning?

I am telling you this to remind you to never give up, no matter how "out there" or far-fetched others may think your ideas are. It is important to keep pursuing them. It is important that we find new accident data sources, that we improve existing data recorders and that we find solutions to prevent data loss.

The sad loss of Air France Flight 447 last June demonstrates the critical need to find solutions to ensure flight data is ALWAYS available for future investigations. The ideas you will be discussing in the next couple of days could turn out to be the solutions sought.

At the TSB, challenges with data recorders over the years have led to some positive changes. As you may recall, the flight recorders on Swissair Flight 111 stopped working 5 and a half minutes before impact. As such, the Board made eight recommendations dealing with on-board recorders. These recommendations included increasing recording capacity and making sure they continue recording in the event of electrical failures.

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.

But this progress would not have been made without international cooperation and dedication to aviation safety. We would like to see 2-hr CVRs and an independent power supply as the international standard.

One area I'm sure we'd all like to see progress on is image recorders. We recommended them during the Swissair investigation. The NTSB and the ATSB have made similar recommendations, and image recorders are on the NTSB's Most Wanted List.

We are encouraged that some manufacturers are developing image recorders and some operators are voluntarily installing them.

Given the technological advances we've seen in recent years, I am confident that installing them will become less expensive.



However, 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.

In Canada, these recordings can only be used for safety investigation purposes. We do not mention cockpit voice recorder data in our final reports unless it is absolutely necessary to support a safety finding. However, other countries treat recorder data differently. This is why the TSB's recommendation on image recorders was paired with a recommendation for internationally harmonized rules to protect these recordings for investigative purposes.

We must ensure that recordings - including video recordings - - will not be released and will only be used to advance transportation safety. This is where international regulatory co-operation is vital and where you can add your voices.

Given the aviation industry's global nature, one player alone cannot bring about widespread change.

We saw this with Dr. Warren's story and with our Swissair recommendations. It takes co-operation at all levels: technical and regulatory. Meetings such as this are important, not only for sharing technical know-how but also for developing strong networks - so that you can draw on the expertise of others the next time you run into a data recorder problem or find other data sources during an investigation.

In closing, your presence here in Ottawa today demonstrates your commitment to furthering international co-operation in investigative flight data retrieval and analysis. By working together, you can take advantage of new data sources, look for ways to better preserve data and make the case for improvements such as image recordings.

And- perhaps in time we can find ways to ensure some sort of recorders make their way onto smaller aircraft. For that would truly be a break through. A break through that would allow us to learn more about all of the safety deficiencies in aviation. Ultimately, we need this information to make compelling arguments for change�. to make aviation safer still.

Our success really depends on supporting each others work but it also depends on your creativity and your persistence.

And on that note, I wish you a good and productive meeting.

Thank you.