Aviation Recommendation A03-07
PDF [164 KB]
REASSESSMENT OF THE RESPONSES FROM TRANSPORT CANADA TO AVIATION SAFETY RECOMMENDATION A03–07
Quick Access Recorder Data
On 02 September 1998, Swissair Flight 111, a McDonnell Douglas MD–11 aircraft, departed John F. Kennedy Airport in New York, New York, en route to Geneva, Switzerland. Approximately one hour after take–off, the crew diverted the flight to Halifax, Nova Scotia, because of smoke in the cockpit. While the aircraft was manoeuvring in preparation for landing in Halifax, it struck the water near Peggy's Cove, Nova Scotia, fatally injuring all 229 occupants on board. The investigation revealed that the flight crew had lost control of the aircraft as a result of a fire in the aircraft's ceiling area, forward and aft of the cockpit bulkhead.
The Board concluded its investigation and released report A98H0003 on 27 March 2003.
Board Recommendation A03–07 (27 March 2003)
Quick access recorders (QARs) are voluntarily installed in many transport aircraft for operational purposes and routinely record far more data than the mandatory flight data recorder (FDR). The optional QAR installed on SR 111 recorded six times the amount of data recorded on the mandatory FDR. Unlike the FDR, QAR data sets can be changed by operators to accommodate their operational requirements. For example, many airlines have developed Flight Operational Quality Assurance (FOQA) or Flight Data Monitoring (FDM) programs that rely on the increased data sets recorded by QARs.
The TSB supports FOQA and FDM programs and believes that there is no technical reason why all data, voluntarily collected for any operational purpose, should not be available for accident investigation. To achieve this, regulatory authorities need to develop regulations that protect the core parameters required for all FDRs, while also allowing FDRs to be easily augmented with additional parameters, higher sample rates, and higher resolutions without requiring re certification of the FDR and without requiring validation/calibration of parameters that are not dedicated to the FDR.
The TSB believes that all FOQA/FDM data already being routinely collected should be available for safety investigations. Therefore, the TSB recommended that:
Regulatory authorities require, for all aircraft manufactured after 1 January 2007 which require an FDR, that in addition to the existing minimum mandatory parameter lists for FDRs, all optional flight data collected for non–mandatory programs such as FOQA/FDM, be recorded on the FDR.
Response to A03–07 (16 June 2003)
In its 16 June 2003 response to Recommendation A03–07, Transport Canada (TC) provided the following comments:
- TC does not support the inclusion of all FDM data on the FDR.
- TC will continue to work with other Civil Aviation Authorities and accident investigation agencies to enhance the required FDR parameters.
- TC is concerned that, due to the sensitivity of the information, allowing FDM data to be recorded on an FDR may jeopardize the entire FDM safety initiative.
Board Assessment of the Response to A03–07 (29 October 2003)
TC's response does not support the deficiency as described in Recommendation A03–07. Rather, it states that it will work with all concerned to enhance the FDR capability as requirements change. There is no indication in its response to suggest any technical objection to supplementing the current FDR parameters. TC has expressed a concern that any attempt to capture FDM data on FDRs would jeopardize the FDM safety initiative. However, it does not explain why requiring FDRs to be easily augmented with additional parameters and routinely and readily accessed without requiring re–certification would put the FDM program at risk. Consequently, the response is assessed as Unsatisfactory.
Next TSB Action (29 October 2003)
The TSB Air Branch will liaise with TC to determine its understanding of the issue and to ensure that the industry further explores and moves towards concepts that will mitigate the risks described in Recommendation A03–07.
Response to A03–07 (07 April 2004)
In response to discussions with the TSB, on 07 April 2004, TC provided the following comments:
- TC states that QARs capture data that are not recorded by the FDR and that these data are potentially useful to accident investigators.
- TC proposes that there are two ways to make these data available: the memory of the QAR could be designed to withstand crash scenarios or the FDR could capture these data.
- TC states that technology exists to support either option, but there are significant limitations to TC's ability to force the industry to adopt the TSB recommended measure.
- TC suggests that the TSB work together with other investigative authorities to identify improvements to the current parameter listing.
- TC will support efforts to record and protect flight data recorded to support safety programs such as FDM.
Board Reassessment of the Response to A03–07 (16 June 2004)
TC's initial response of 16 June 2003 expressed concern that any attempt to capture FDM data on FDRs would jeopardize the FDM safety initiative. In its recent 07 April 2004 letter, TC is supportive of the benefits of capturing QAR data to enhance accident investigation efforts. TC no longer feels that implementing Recommendation A03–07 would harm safety programs such as FDM. In addition, although TC agrees that there are no technical impediments to implementing Recommendation A03–07, it states that there are significant limitations in TC's ability to require industry to adopt the recommended measure. Instead, it suggests that the TSB needs to work with other investigative agencies to identify improvements to the current parameter listings. Additionally, TC is committed to supporting any TSB initiatives to record additional data such as QAR data in a crash–protected environment.
TSB's recommendation was drafted in the belief that the most efficient method of acquiring QAR–type data in a crash–protected environment was for regulatory authorities to initiate regulatory change. TC's response indicates that it concurs with the intent of Recommendation A03–07 and agrees that regulatory authorities have a role to play. However, the action TC proposes requires that investigative agencies better define their requirements through established channels before any regulatory action can be initiated. The course of action that TC proposes would, if successful, reduce the risks associated with this deficiency.
Therefore, the response is assessed as Satisfactory Intent.
Response to A03–07 (14 December 2005)
TC's update dated 14 December 2005 stated that future rulemaking activity will be contingent on internationally harmonized requirements.
Board Reassessment of the Response to A03–07 (23 June 2006)
In TC's original response dated 16 June 2003, it did not support Recommendation A03–07. In a second response dated 07 April 2004, TC indicated that it concurred with the intent of Recommendation A03–07 and agreed that regulatory authorities have a role to play in bringing about the desired changes as defined by investigative agencies. In its update letter of 14 December 2005, TC has reverted to its original response that was assessed by the Board as Unsatisfactory. TC's present position states that future rulemaking activity will be contingent on internationally harmonized requirements.
It is the Board's understanding that TC remains committed to its 07 April 2004 response that, if fully implemented, will substantially reduce the risks associated with Recommendation A03–07.
Therefore, the assessment remains at Satisfactory Intent.
Next TSB Action (23 June 2006)
TSB staff will liaise with TC to clarify its position with respect to the deficiency identified by Recommendation A03–07.
Response to A03–07 (07 February 2007)
TC's response reviews its previously stated position that it does not support Recommendation A03–07. While its response reiterates that any future rule–making activity will be contingent on internationally harmonized requirements, it does not provide details of any relevant harmonization activities in support of the intent of Recommendation A03–07.
Board Reassessment of the Response to A03–07 (24 July 2007)
TC has reverted to its position as originally stated in its response dated 16 June 2003. Although TC states in its most recent response that it will continue to participate in rule–making harmonization activities with other Civil Aviation Authorities, it does not indicate whether or not any of its harmonization activities are relevant to the intent of Recommendation A03–07. TC's response does not provide any new information that would suggest that TC, or any other regulator, is actively advocating strategies to address the deficiency identified in Recommendation A03–07.
As TC's action will not reduce or eliminate the deficiency, the assessment is changed to Unsatisfactory.
Next TSB Action (03 October 2007)
TSB staff will follow up with TC as to options that could further mitigate the risks associated with the deficiency identified in Recommendation A03–07.
Response to A03–07 (11 March 2008)
TC's response states that it does not support the inclusion of all FDM data on the FDR.
However, TC will continue to participate with other civil aviation authorities and accident investigation boards in the harmonized activities, which may lead to practical enhancement in the required FDR parameters listing. Future rulemaking activity will be contingent on internationally harmonized requirements.
On 10 March 2008, the FAA announced Final Rules in regards to Revisions to Cockpit Voice Recorder and Digital Flight Data Recorder Regulations.
TC considers this recommendation closed because:
- of the applicability and feasibility of the recommendation given the current situation; and
- any further changes in this area will take place only as a result of international regulation harmonization.
Board Reassessment of the Response to A03–07 (13 August 2008)
TC's response does not provide any new information that would suggest that TC, or any other regulator, is actively advocating strategies to address the deficiency identified in Recommendation A03–07.
TC's action will not reduce or eliminate the deficiency; therefore, the assessment remains as Unsatisfactory.
Next TSB Action (13 August 2008)
TSB staff will continue to monitor occurrences reflecting similar type deficiencies upon which Recommendation A03–07 is based.
Review of A03–07 Deficiency File Status (23 September 2009)
In its latest response to Recommendation A03–07 TC states that it considers the recommendation closed and that future rulemaking activity will be contingent on internationally harmonized requirements.
Therefore, the assessment remains at Satisfactory–in–Part
Based on these statements, the Board concludes that no further action is planned to be taken by TC. Additionally, that any mitigation strategy to deal with the deficiency identified in Recommendation A03–07 will be the responsibility of third parties outside the direct influence of TC.
Next TSB Action (23 September 2009)
TSB Air Branch staff will not actively monitor TC's activities to require all optional flight data collected for non–mandatory programs such as FOQA/FDM, be recorded on the FDR.
Transport Canada Response to A03–07 (30 September 2011)
"September 2011 update:
This recommendation is the next priority after Sept 2011 CARAC. This recommendation is under review."
On 28 March 2012, TC submitted an update stating the following:
Notices of Proposed Amendments addressing TSB recommendations concerning cockpit voice recorders were presented to the Canadian Aviation Regulation Advisory Council (CARAC) technical committee September 23, 2011.These proposed changes are harmonized with ICAO.
A follow–on NPA to update the requirements for Flight Data Recorders (FDRs) is planned for the 2012/2013 fiscal year. This process will examine harmonization of Canadian airworthiness regulations and standards with ICAO requirements and recommendations for FDRs.
Board Assessment of the Response to A03–07 (31 March 2012)
The Board is pleased that TC has decided to reactivate its review of the risks associated with Recommendation A03–07. The Board is hopeful that TC will conduct its review and share its findings with the TSB in a timely manner.
The proposed action may reduce the safety deficiency identified in Recommendation A03–07.
The response is considered Satisfactory Intent.
Next TSB Action (31 March 2012)
The TSB will monitor the progress of the planned review and will reassess the deficiency on an annual basis or when otherwise warranted.
The deficiency file is assigned an Active status.
Transport Canada's response to A03-07 (04 December 2012)
In 2013, TC plans to establish a focus group to determine how to address the changes to the international standards of ICAO Annex 6, Parts I, II, and III relating to FDRss.
Board assessment of the response to A03-07 (06 March 2013)
The Board is satisfied with TC's decision to create a focus group that will assist in the development of an implementation plan of the recently published FDRs-related changes to ICAO Annex 6, Parts I, II, and III.
TSB is looking forward to timely completion of this review and, as it has in the past, the Board is willing to provide briefings or information to assist the focus group.
The proposed action may reduce the safety deficiency identified in Recommendation A03-07.
The response is considered Satisfactory Intent.
Next TSB action (06 March 2013)
The TSB will monitor the progress of the planned focus group and assess the deficiency on an annual basis or when otherwise warranted.
The deficiency file is assigned an Active status.
- Date modified: