Aviation Investigation Report A02P0261

How This Report Is Organized

This report was prepared in accordance with Transportation Safety Board (TSB) standards for investigation reports. In keeping with these standards, the report is organized into the following main parts:

  • Part 1, Factual Information: Provides objective information that is pertinent to the understanding of the circumstances surrounding the occurrence.
  • Part 2, Analysis: Discusses and evaluates the factual information presented in Part 1 that the Board considered when formulating its conclusions and safety actions.
  • Part 3, Conclusions: Based on the analyses of the factual information, presents three categories of findings: findings as to causes and contributing factors to the occurrence; findings that expose risks that have the potential to degrade aviation safety, but that could not be shown to have played a direct role in the occurrence; and "other" findings that have the potential to enhance safety, or clarify issues of unresolved ambiguity or controversy.
  • Part 4, Safety Action: Based on the findings of the investigation, recommends safety actions required to be taken to eliminate or mitigate safety deficiencies, and records the main actions already taken or being taken by the stakeholders involved.

Available Formats

The report can be viewed in the following formats:

  • Paper.
  • On the TSB web site at http://www.tsb.gc.ca.

To obtain additional copies of the report, please contact

TSB Communications Division
Place du Centre
200 Promenade du Portage
4th Floor
Gatineau, Quebec K1A 1K8
Canada
Telephone: (819) 994-3741
Fax: (819) 997-2239
E-mail: communications@bst-tsb.gc.ca

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