Source: http://www.bst.gc.ca/eng/recommandations-recommendations/aviation/2007/rec_a0703.asp
Timestamp: 2018-01-23 23:36:47
Document Index: 484153842

Matched Legal Cases: ['arts 703', 'arts 703', 'art 705', 'arts 704', 'arts 703', 'art 705', 'arts 702']

Recommendation A07-03 - Transportation Safety Board of Canada
Recommendation A07-03
During the flare, the aircraft travelled through an area of heavy rain, and visual contact with the runway environment was significantly reduced. The crew elected to continue with the landing. The aircraft touched down about 3800 feet down the 9000-foot runway; it was not able to stop on the runway and departed the far end at a groundspeed of about 80 knots (SSE). The aircraft stopped in a ravine at 2002 UTC (1602 eastern daylight time) and caught fire. All passengers and crew members were able to evacuate the aircraft before the fire reached the escape routes. A total of 2 crew members and 10 passengers were seriously injured during the crash and the ensuing evacuation.
Board Recommendation A07-03 (December 2007)
TSB Recommendation A07-03
Transport Canada's response to Recommendation A07-03 (February 2008)
In its response, Transport Canada indicates that, although the criticality of proper decision-making with respect to landing decisions in deteriorating weather cannot be discounted, there are other elements for which proper decision-making is equally critical. Transport Canada states it will include a training requirement for pilots operating under Subparts 703, 704 and 705 of the Canadian Aviation Regulations (CARs) to better enable them to make operational decisions when flying into or in the vicinity of deteriorating or challenging weather.
Board assessment of the response to Recommendation A07-03 (July 2008)
This response indicates that Transport Canada (TC) believes that a sound pilot decision-making process is critical to the safety of flight, not only when in the vicinity of thunderstorms, but also in other phases of flight. The Board does not disagree with this statement. Transport Canada states that it will include a decision-making training requirement for pilots operating under Subparts 703, 704 and 705 of the Canadian Aviation Regulations (CARs). This action should assist pilots in recognizing the dangers of conducting approaches in rapidly deteriorating weather conditions such as observed in the vicinity of thunderstorms. However, until such proposed action is actually implemented, the risk will remain unabated.
Transport Canada's response to Recommendation A07-03 (February 2010)
TC's latest response states that a draft NPA has been started for operations conducted under Subpart 705 of the CARs and that similar NPAs will be prepared for Subparts 704 and 703.
Board reassessment of the response to Recommendation A07-03 (July 2010)
Transport Canada's response to Recommendation A07-03 (January 2011)
Board reassessment of the response to Recommendation A07-03 (March 2011)
Transport Canada's response to Recommendation A07-03 (May and September 2011)
Since this issue is largely related to CRM, it will be addressed as part of Recommendation A09-02. Although Recommendation A09-02 only mandates commercial air operators operating under Subparts 703 and 704 to provide contemporary crew resource management (CRM) training, it is our intent to provide the same for commercial air operators operating under Subpart 705 as well. Training for decision making related to critical elements, such as “training for pilots to make landing decisions to deteriorating weather” seems to be a good fit to incorporate under Recommendation A09-02.
ToRs for the creation of a Working Group on CRM will be presented at the September 2011 CARAC Technical Committee meeting.
A cross reference is to be made on recommendations residing in CRM (A09-02, A07-01, A07-05, A00‑06).
Board reassessment of the response to Recommendation A07-03 (March 2012)
Transport Canada's response to Recommendation A07-03 (December 2012)
TSB Recommendation A07-03 will be addressed by the development of a contemporary CRM training standard, as documented in the CRM focus group report.
It was determined that a contemporary CRM training standard be developed to include the threat and error management (TEM) model to enhance flight crews' ability to assess conditions and make appropriate decisions in critical situations such as convective weather. TC will draft regulations and standards as appropriate, for inclusion in Subparts 702, 703, 704 and 705 of the CARs. Associated recommendations are A00-06 and A09-02.
Board reassessment of the response to Recommendation A07-03 (March 2013)
The issue of landing accidents and overruns remains on the TSB Watchlist. The Board continues to be concerned with the extremely slow pace of TC's activity related to the deficiency identified in Recommendation A07-03. However, the planned action, initiated in 2008 will, if and when fully implemented, substantially reduce or eliminate the safety deficiency.
The assessment remains Satisfactory Intent.
Transport Canada's response to Recommendation A07-03 (November 2013)
This item remains a regulatory priority and work to amend the Standard has begun. Recommendation A07-03 will be addressed in conjunction with the work being done on crew resource management (CRM) as described in Transport Canada's response to Recommendation A09-02. (TSB comment - the response to A09-02 is provided below)
Develop project plan and timelines for 702, 703, 704 and 705 CRM, including information to help determine whether a single rule set or keeping distinct requirements in individual parts is best;
Consolidate existing information into an Advisory Circular; and
Publish Advisory Circular following consultation with regional staff.
Advisory Circular 700-005 “Approach and Landing during convective weather conditions” provides material for air operators to include in the required training. Decision making skills (including enhancements associated with updating CRM training requirements) have been enhanced through use of this AC.
Board reassessment of the response to Recommendation A07-03 (April 2014)
Since the last time this recommendation was assessed, the TSB has released the final report into the crash of FAB6560 in Resolute Bay, Nunavut (A11H0002). That investigation identified ineffective crew interactions as a significant contributing factor to the accident. The crew's CRM training was abbreviated and based on the current, outdated TC standard. The Board issued a safety concern to the effect that without a comprehensive and integrated approach to CRM by TC and aviation operators, flight crews may not routinely practice effective CRM.
This recommendation was first issued in 2007. The project plan has been under development since December 2012. TC progress during the past 12 months in implementing TSB Recommendation A07-03 and proposed actions are preparatory in nature, and changes to regulations and standards are unlikely to occur in a timely manner. Given the number of accidents involving ineffective PDM and CRM (including A09A0016), the Board is concerned about the slow pace of action to address this recommendation.
The TSB will continue to monitor the progress of TC's proposed regulatory amendments to mitigate the risks associated with the safety deficiency identified in Recommendation A07-03, and will reassess the deficiency on an annual basis or when otherwise warranted.