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AIR TRANSAT INCIDENT IN CUBA (A05F0047) - RECOMMENDATIONS

On 06 March 2005 at 06:45 a.m. (Greenwich mean time), Air Transat Flight 961, left Varadero, Cuba, for Québec, Quebec, and encountered stability problems 17 minutes after take-off. The aircraft, an Airbus A310, was cleared to a lower altitude and stabilized. Because the company had maintenance facilities in Varadero, the crew requested a return to that locale and successfully landed. Upon landing, it was observed that the rudder had separated from the aircraft. It had 262 passengers and 9 crew members on board.

On 27 March 2006, the Transportation Safety Board of Canada (TSB) made two recommendations with respect to inspection programs that would ensure early and consistent detection of damage to the rudder assembly on specific aircraft.

The Board recommended that:

The Department of Transport, in coordination with other involved regulatory authorities and industry, urgently develop and implement an inspection program that will allow early and consistent detection of damage to the rudder assembly of aircraft equipped with part number A55471500 series rudders.

(A06-05)

The European Aviation Safety Agency, in coordination with other involved regulatory authorities and industry, urgently develop and implement an inspection program that will allow early and consistent detection of damage to the rudder assembly of aircraft equipped with part number A55471500 series rudders.

(A06-06)

The damage found during the post-occurrence fleet inspections suggested that the inspection program for this model of composite rudder was not adequate to provide for the timely detection of defects. The fact that delamination could grow undetected suggested that more attention is warranted to mitigate the risk of rudder structural failures. These recommendations, if acted on, will address these risks.

During the course of its investigation, the Board issued four safety advisories to Transport Canada. A safety advisory suggests remedial action to reduce risks to safety. The safety advisories were related to the following:

  • The need for the cockpit voice recorder to record sounds for longer periods of time to capture the initiating events of aviation accidents.
  • The requirement to capture unfiltered data to better estimate the probable rudder position history.
  • The need for higher sampling rates to more effectively determine the sequence of events in an accurate and timely manner.
  • The need to review the adequacy of published procedures to ensure that pilots have the required knowledge to safely recover from a Dutch roll situation.

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The public report, A05F0047 and communiqué are also available on this site.