A05H0002 - Approaches into Convective Weather – Pilot Decision Making – Landing Distance Considerations – Runway End Safety Area Requirements – Carry-on Baggage
Runway Overrun And Fire - Air France
Airbus A340-313 F-GLZQ
Toronto/Lester B. Pearson International Airport, Ontario
02 August 2005
Link to TSB Rec Report A07-01-03-05-06-07 ( http://www.tsb.gc.ca/eng/medias-media/fiches-facts/A05H0002/info_a05h0002.asp )
Link to TSB final report A05H0002 ( http://www.tsb.gc.ca/eng/rapports-reports/aviation/2005/a05h0002/a05h0002.asp )
Synopsis
The Air France Airbus A340-313 aircraft (registration F-GLZQ, serial number 0289) departed Paris, France, at 1153 Coordinated Universal Time (UTC) as Air France Flight 358 on a scheduled flight to Toronto, Ontario, with 297 passengers and 12 crew members on board. Before departure, the flight crew members obtained their arrival weather forecast, which included the possibility of thunderstorms. While approaching Toronto, the flight crew members were advised of weather-related delays. On final approach, they were advised that the crew of an aircraft landing ahead of them had reported poor braking action, and Air France Flight 358.s aircraft weather radar was displaying heavy precipitation encroaching on the runway from the northwest. At about 200 feet above the runway threshold, while on the instrument landing system approach to Runway 24L with autopilot and autothrust disconnected, the aircraft deviated above the glideslope and the groundspeed began to increase. The aircraft crossed the runway threshold about 40 feet above the glideslope.
During the flare, the aircraft travelled through an area of heavy rain, and visual contact with the runway environment was significantly reduced. There were numerous lightning strikes occurring, particularly at the far end of the runway. The aircraft touched down about 3800 feet down the runway, reverse thrust was selected about 12.8 seconds after landing, and full reverse was selected 16.4 seconds after touchdown. The aircraft was not able to stop on the 9000-foot runway and departed the far end at a groundspeed of about 80 knots. 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.
Recommendations
Transport Canada Response to Aviation Safety Recommendations A07-01, A07-03, A07-05, A07-06, and A07-07 issued by the Transportation Safety Board of Canada (TSB)
Transportation Safety Board of Canada Recommendation A07-01
Approaches into Convective Weather
“The Board recommends that the Department of Transport establish clear standards limiting approaches and landings in convective weather for all air transport operators at Canadian airports.”
Transport Canada Response to Recommendation A07-01
Transport Canada will consider this recommendation in consultation with other international aviation authorities with a view to harmonizing any regulatory initiatives that may result from this recommendation. In addition, Transport Canada is preparing an Issue Paper on this subject, to be presented at the next International Civil Aviation Organization (ICAO) Standard and Recommended Procedures working group meeting in Montreal, scheduled for summer 2008.
In the short term, Transport Canada will consider issuing an Advisory Circular (AC) that will discuss the hazards associated with flight operations in or near convective weather conditions. This AC would recommend that Canadian air operators include specific procedures in their company operations manual that would guide flight crewmembers in alerting the crew of the current weather and associated hazards, as well as to provide guidance in decision-making when faced with flight through or landing in such weather conditions.
Transportation Safety Board of Canada Recommendation A07-03
Pilot Decision Making
“The Board recommends that the Department of Transport mandate training for all pilots involved in Canadian air transport operations to better enable them to make landing decisions in deteriorating weather.”
Transport Canada Response to Recommendation A07-03
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 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.
Transportation Safety Board of Canada Recommendation A07-05
Landing Distance Considerations
“The Board recommends that the Department of Transport and other civil aviation authorities require crews to establish the margin of error between landing distance available and landing distance required before conducting an approach into deteriorating weather.”
Transport Canada Response to Recommendation A07-05
In response to the Commission of Inquiry into the Air Ontario Crash at Dryden, Ontario Final Report, 1992 recommendations MCR 43, 44, 45, and 46, Transport Canada conducted extensive research and testing on winter runway surfaces. Through the Civil Aviation Regulation Advisory Council (CARAC), three working groups were convened and six Notices of Proposed Amendment (NPAs) regarding aeroplane performance on wet and contaminated runways were approved. None of the proposed amendments have come into force as of yet, as they continue to undergo regulatory review with the Department of Justice.
Once in force, the NPAs will accomplish the following:
- A new CAR Subpart 705 regulation, which will require the Pilot-In-Command (PIC) to determine that sufficient landing distance is available prior to conducting an approach to land, taking into consideration the condition of the runway surface.
- CAR Subpart 725 standards will be amended to include:
- An information note concerning Aeroplane Flight Manual (AFM) landing performance on dry, wet and contaminated runways that states:
“Refer to guidance material on the determination of dry, wet and contaminated runway landing performance data. Achieving the Aeroplane Flight Manual landing distance on a dry runway is not likely attainable in operational service. Published landing distance data on wet or contaminated runways may need to be adjusted to account for operational variables”,
- the definition of “runway” as it pertains to this division,
- takeoff and landing performance on a dry runway,
- takeoff and landing performance on a damp runway,
- takeoff and landing performance on a wet runway, and
- landing performance on a contaminated runway.
4. CAR Section 705.61 Dispatch Limitations: Wet Runway - Turbo-jet-powered Aeroplanes, is currently meant to apply to paved, hard-surfaced runways (i.e. asphalt and concrete). This regulation will be amended to indicate that it applies to:
both wet and contaminated runways,
paved hard-surfaced runways (i.e. asphalt and concrete), and
all turbine powered (turbo-jet and turbo-prop) aeroplanes operated under CAR 705.
In summary, when these amendments to the CARs come into force, CAR 705 air operators and their flight crews will be required to determine that sufficient landing distance is available prior to conducting an approach to land, taking into consideration the condition of the runway surface (dry, damp, wet, or contaminated) resulting from deteriorating weather.
Transportation Safety Board of Canada Recommendation A07-06
Runway End Safety Area Requirements
“The Board recommends that the Department of Transport require all Code 4 runways to have a 300 m runway end safety area (RESA) or a means of stopping aircraft that provides an equivalent level of safety.”
Transport Canada Response to Recommendation A07-06
Transport Canada is currently working with industry experts to review airport certification standards.
The review of TP312 Aerodrome Standards and Recommended Practices has resulted in a recommendation to harmonize the Canadian standards with the current RESA standards beyond the runway strip end contained in Annex 14 – Aerodromes of ICAO.
The result of this review will be subject to the CARAC regulatory consultation process.
Transportation Safety Board of Canada Recommendation A07-07
Carry-On Baggage
“The Board recommends that the Department of Transport require that passenger safety briefings include clear direction to leave all carry-on baggage behind during an evacuation.”
Transport Canada Response to Recommendation A07-07
Transport Canada agrees with Recommendation A07-07 and will propose an amendment to the CARs to require that passenger safety briefings include direction to leave all carry-on baggage behind during an evacuation.
The proposed amendment will be subject to the normal CARAC regulatory consultation process.
A06P0010 - Single-Engine Propulsion System Reliability
Engine Power Loss . Forced Landing
Sonicblue Airways
Cessna 208B (Caravan) C-GRXZ
Port Alberni, British Columbia, 11 nm SSE
21 January 2006
Link to TSB Report A06P0010 (http://www.tsb.gc.ca/eng/rapports-reports/aviation/2006/a06p0010/a06p0010.asp)
Synopsis
The Cessna 208B aircraft (registration C-GRXZ, serial number 208B0469) was en route at 9000 feet above sea level, from Tofino, British Columbia, to Vancouver International Airport, British Columbia, when the engine failed. The pilot began a glide in the direction of the Port Alberni Regional Airport before attempting an emergency landing on a logging road. The aircraft struck trees during a steep right-hand turn and crashed. The accident occurred at about 1420 Pacific standard time, approximately 11 nm south-southeast of the Port Alberni Regional Airport. Five passengers survived with serious injuries; the pilot and the other two passengers were fatally injured.
Recommendations
Transportation Safety Board of Canada Recommendation A07-08
The Board recommended that, “The Department of Transport take into account all propulsion system failures when assessing the safety of single-engine commercial operations."
Transport Canada Response to Recommendation A07-08
To address this and other safety issues related to Canadian Single Engine Instrument Flight Rule (SEIFR) operations, the Department of Transport will undertake a complete review of commercial SEIFR related Canadian Aviation Regulations.
Should you require further information, please contact Aviation Safety Analysis at asi-rsa@tc.gc.ca