Aviation Safety Issues Investigation Report SII A05-01

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Appendices

  1. Appendix A - Post-Impact Fire Accident Summary
  2. Appendix B - References
  3. Appendix C - Glossary

Appendix A - Post-Impact Fire Accident Summary

  Post-Impact Fire Accidents Involving Canadian-Registered Aircraft or Foreign-Registered Aircraft Under 5700 kg
from 01 January 1976 to 31 December 2002
  Type Certificate Amateur Built Basic Ultralights Advanced Ultralights Total
  No. % No. % No. % No. % No. %
Accidents 474   30   12   5   521  
Aircraft Involved w/ Post-Impact Fire 476   30   12   5   523  
Aeroplanes 382 80% 27 90% 12 100% 5 100% 426 81%
Helicopters 94 20% 2 7% n/a - n/a - 96 18%
Gyroplanes 0 0% 1 3% n/a - n/a - 1 0%
Fatalities 686   22   12   8   728  
FireFootnote 1 196 29% 4 18% 3 25% 2 25% 205 28%
ImpactFootnote 2 374 55% 14 64% 9 75% 4 50% 401 55%
Natural DeathFootnote 3 0 0% 1 5% 0 0% 0 0% 1 0%
Cause Undetermined 116 17% 3 14% 0 0% 2 25% 121 17%
Serious Injuries 223   7   0   1   231  
FireFootnote 4 73 33% 6 86% 0 - 1 100% 80 35%
Fire (minor)Footnote 5 4   0   0   0   4  
Fatal or Serious Injury Accidents 351   23   8   5   387  
Aircraft Involved 353   23   8   5   389  
Aeroplanes 287 81% 21 91% 8 100% 5 100% 321 83%
Fatalities 585   20   12   8   625  
  169 29% 4 20% 3 25% 2 25% 178 28%
  328 56% 12 60% 9 75% 4 50% 353 56%
  0 0% 1 5% 0 0% 0 0% 1 0%
Cause Undetermined 88 15% 3 15% 0 0% 2 25% 93 15%
Serious Injuries 175   7   0   1   183  
  55 31% 6 86% 0 - 1 100% 62 34%
  3   0   0   0   3  
Helicopters 66 19% 1 4% n/a - n/a - 67 17%
Fatalities 101   1   n/a   n/a   102  
FireFootnote 1 27 27% 0 0% n/a - n/a - 27 26%
ImpactFootnote 2 46 46% 1 100% n/a - n/a - 47 46%
Cause Undetermined 28 28% 0 0% n/a - n/a - 28 27%
Serious Injuries 48   0           48  
  18 38% 0 - n/a - n/a - 18 38%
Fire (minor)Footnote 5 1   0           1  
Gyrocopters 0 0% 1 4% n/a - n/a - 1 0%
Fatalities 0   1   n/a   n/a   1  
FireFootnote 1 0   0   n/a   n/a   0  
ImpactFootnote 2 0   1   n/a   n/a   1  
Cause Undetermined 0   0   n/a   n/a   0  
Serious Injuries 0   0   n/a   n/a   0  
  0   0   n/a   n/a   0  
Fire (minor)Footnote 5 0   0   n/a   n/a   0  

Appendix B - References

Bensyl, D.M., K. Moran, and G.A. Conway (2001), "Factors associated with pilot fatality in work-related aircraft crashes, Alaska, 1990-1999," American Journal of Epidemiology, 154(11), 1037-1042.

Federal Aviation Administration (1990a), 14 CFR Part 23, Airworthiness Standards: Crash-Resistant Fuel Systems, proposed rule, Federal Register, 55(40), February 28.

Federal Aviation Administration (1990b), 14 CFR Parts 27 and 29, Airworthiness Standards: Crash-Resistant Fuel Systems in Normal and Transport Category Rotorcraft, Notice of Proposed Rule Making, Federal Register, 55(194), October 5.

Federal Aviation Administration (1994), 14 CFR Parts 27 and 29, Airworthiness Standards: Crash-Resistant Fuel Systems in Normal and Transport Category Rotorcraft, final rule, Federal Register, 59(190), October 3.

Federal Aviation Administration (1999), 14 CFR Part 23, Airworthiness Standards: Crash-Resistant Fuel Systems, Notice of Proposed Rule Making, withdrawal, Federal Register, 64(250), December 30.

Hayden, M.S., D.F. Shanahan, L-H. Chen, and S.P. Baker (2005), "Crash-resistant fuel system effectiveness in civil helicopter crashes," Aviation, Space, and Environmental Medicine, 76(8), 782-785.

Hurley, T.R. and J.M. Vandenburg (2002), Small Airplane Crashworthiness Design Guide, Simula Technologies, Inc., April 12.

Jennings, R.T. and S.R. Mohler (1988) "Potential crashworthiness benefits to general aviation from Indianapolis Motor Speedway technology," Aviation, Space, and Environmental Medicine, January, 67-73.

Li, G. and S.P. Baker (1993), "Crashes of commuter aircraft and air taxis: What determines pilot survival?," Journal of Occupational Medicine, 35(12), 1244-1249.

Li, G., S.P. Baker and R.S. Dodd (1996), "The epidemiology of aircraft fire in commuter and air taxi crashes," Aviation, Space, and Environmental Medicine, 67(5), 434-437.

Li, G. and S.P. Baker (1997), "Injury patterns in aviation-related fatalities, implications for preventive strategies," The American Journal of Forensic Medicine and Pathology, 18(3), 265-270.

Lindsey, R. and D.S. West (2003), A Review of the Process of Economic Analysis into Risk Control Options for Mitigation of Post-Impact Fire Risks for Aircraft with a Maximum Certified Take-off Weight of 5670 Kilograms or Less, paper prepared for the Transportation Safety Board of Canada, 14 March 2003.

Ludwig, B. Jr., R. Clarke, and R. Lawton (1987), Study of General Aviation Fire Accidents (1974-1983), report number DOT/FAA/CT-86/24, final report prepared for the U.S. Department of Transportation, Federal Aviation Administration, February.

National Transportation Safety Board (1980), special study, General Aviation Accidents: Postcrash Fires and How to Prevent or Control Them, NTSB-AAS-80-2, Washington, D.C.

Parsons, G.G. (1990), Motor Vehicle Fires in Traffic Crashes and the Effects of the Fuel System Integrity Standard, National Highway Traffic Safety Administration Report DOT HS 807 675, November.

Perrella, W.M. Jr. (1978), Tests of Crash-Resistant Fuel System for General Aviation Aircraft, report FAA-RD-78-28, interim report prepared for the U.S. Department of Transportation, Federal Aviation Administration.

Soltis, S. (1987), "General aviation aircraft/fuel system configuration study regarding fuel bladder cell installation," 66th Annual Meeting of the Transportation Research Board.

Transportation Safety Board of Canada (1996), Air Investigation Branch, Autopsy and Post-Mortem Examination Protocol, November.

Appendix C - Glossary

AGATE Advanced General Aviation Transport Experiments
ANPRM Advanced Notice of Proposed Rule Making
ARFF Aircraft Rescue and Fire Fighting
ASIS Aviation Safety Information System
avgas aviation gasoline
CARs Canadian Aviation Regulations
CBA cost-benefit analysis
CFR Code of Federal Regulations
CRFS crash-resistant fuel system
EASA European Aviation Safety Agency
ERS Emergency Rescue Services
FAA Federal Aviation Administration (United States)
FARs Federal Aviation Regulations
FMVSS Federal Motor Vehicle Safety Standard
GASP General Aviation Safety Panel
g load factor
kg kilograms
km kilometres
km/h kilometres per hour
mogas motor gasoline
NACA National Advisory Committee for Aeronautics
NASA National Aeronautics and Space Administration
NFPA National Fire Protection Association
NPRM Notice of Proposed Rule Making
NTSB National Transportation Safety Board (United States)
PIF post-impact fire
TSB Transportation Safety Board of Canada
U.S. United States
VFR visual flight rules
VSL value of statistical life
ºF degrees Fahrenheit

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1.   Subsection 101.01(1) of the Canadian Aviation Regulations (CARs) defines a small aircraft as an aeroplane having a maximum permissible take-off weight of 5700 kg (12 566 pounds) or less, or a helicopter having a maximum permissible take-off weight of 2730 kg (6018 pounds) or less.

2.   See Glossary at Appendix C for all abbreviations and acronyms.

3.   An otherwise survivable accident is one in which the impact forces are within the limits of occupant tolerance, the aircraft structure preserves the required survival space, and the occupant restraint is adequate.

4.   A Safety Issues Investigation reviews multiple occurrences that the Board deems to be indicative of significant unsafe situations or conditions.

5.   Examples of wording in cause of death statements that indicated that a death was related to fire are "smoke inhalation and burns due to or as a consequence of fire," "inhalation of products of combustion and thermal injury," "immolation," "inhalation of hot gases," "shock due to or as a consequence of burns," and "multiple corporal trauma due to incineration." Examples of wording in cause of death statements that indicated that a death was related to impact are "multiple injuries," "multiple blunt force and deceleration injuries," "laceration right ventricle of heart," "lacerated aorta," "blunt force injury of head, trunk, and extremities," and "massive multiple injuries due to or as a consequence of blunt trauma."

6.   For all reported occurrences, initial determination of the facts is made to assist in deciding if an investigation is warranted. An investigation will be conducted if it is determined that there is potential to advance transportation safety. If an investigation is not warranted, the occurrence is classified as Class 5. The Board gathers and retains data for statistical and trend analysis, but no public report is prepared.

7.   A chronology of PIF occurrences that are typical of the 128 accidents in which fire contributed to serious injury or fatality can be found in Document 3.

8.   For the purpose of this report, type-certificated aircraft will be referred to as production aircraft or production helicopters.

9.   The National Fire Protection Association (NFPA) is an international, non-profit international standards development agency based in the United States dedicated to fire prevention and other safety issues. Two NFPA technical manuals based on accepted scientific principles and research, NFPA 422 (Guide for Aircraft Accident Response) and NFPA 921 (Guide for Fire and Explosion Investigations) provide excellent guidance to air safety investigators for fire investigation.

10.   705 traffic refers to aeroplanes operated by a Canadian air operator for air transport service that have a maximum certified take-off weight of more than 8618 kg, or for which a Canadian type certificate has been issued authorizing the transport of 20 or more passengers, or to helicopters that have a seating configuration, excluding pilot seats, of 20 or more.

11.   Jet B fuel is a relatively uncommon fuel type that is being phased out voluntarily by the oil refining industry.

12.   Wheels-up landing and gear-up landing are used interchangeably in this report.

13.   A research article by Mark S. Hayden et al. concluded that "The results of this study suggest a better performance, in terms of post-crash fire prevention, of CRFS-equipped civil helicopters as compared with those without CRFS. More widespread use of CRFS in civil helicopters would undoubtedly prevent some thermal fatalities and serious injuries."

14.   An unsafe condition is defined as a situation or condition that has the potential to initiate, exacerbate, or otherwise facilitate an undesirable event.

15.   File documents allowed up to three probable ignition sources to be selected for each occurrence.

16.   The use of a helmet is voluntary and associated with certain air operations such as firefighting and crop dusting.

Footnotes

Footnote 1

Fire or inhalation of smoke was identified as either partly or solely the cause of death.

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Footnote 2

Cause of death was due to impact forces.

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Footnote 3

Natural death occurring before the crash, due to aortic valve disease.

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Footnote 4

Fire-related injury might not necessarily be the cause of the serious injury.

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Footnote 5

The number of serious injuries accompanied by a minor fire-related injury.

Return to first footnote 5 referrer