Annual Report to Parliament 2003-2004

AIR
Occurrence Statistics and Investigations

ANNUAL STATISTICS

Canadian-registered aircraft, other than ultralights, were involved in 296 reported accidents in 2003, an 8% increase from the 2002 total of 274. However, this is an 8% decrease from the 1998-2002 average of 323. Flying activity in 2003 is estimated to have increased by 3% from 2002 to 3,789,725 hours. This resulted in an accident rate of 7.8 accidents per 100,000 flying hours compared to the 2002 accident rate of 7.4 and the 1998-2002 average rate of 8.3. Canadian-registered aircraft, other than ultralights, were involved in 31 fatal occurrences in 2003, with 58 fatalities. This is slightly fewer than the 1998-2002 average of 33 fatal occurrences, with 66 fatalities. About half the fatal occurrences involved privately operated aircraft; 3 of the remaining 14 fatal occurrences involved helicopters.

The number of accidents involving ultralights increased from 36 in 2002 to 46 in 2003. However, the number of fatal accidents decreased from 9 accidents with 12 fatalities in 2002 to 7 accidents with 9 fatalities in 2003.

The number of foreign-registered aircraft involved in accidents in Canada increased from 13 in 2002 to 30 in 2003. Fatal accidents increased from 1 accident with 2 fatalities in 2002 to 6 accidents with 8 fatalities in 2003.

In 2003, a total of 834 incidents were reported in accordance with TSB mandatory reporting requirements. This represents a 4% decrease from the 2002 total of 865, but a 7% increase from the 1998-2002 average of 783.

Figure 8 - Air Occurrences and Fatalities

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AIR INVESTIGATIONS STARTED IN 2003-2004

The following information is preliminary. Final determination of events is subject to the TSB's full investigation.

AIR REPORTS RELEASED IN 2003-2004

ASSESSMENT OF RESPONSES TO AIR RECOMMENDATIONS ISSUED IN 2002-2003

OTHER AIR SAFETY ACTION TAKEN

• TC identified to NAV CANADA a safety deficiency concerning the degraded performance of anemometers due to ice accretion and has requested that NAV CANADA implement software changes that would suppress incorrect wind information under these conditions.
  
  
• NAV CANADA issued a station bulletin to all St. John's Flight Service Station personnel clarifying the procedure for reporting estimated winds in an aviation routine weather report. NAV CANADA also issued a bulletin to all units informing air traffic services units personnel to be vigilant during icing conditions and the actions to be taken if they suspect the anemometer is affected by ice accretion.
  
  
• Following an accident involving an input freewheel unit failure, TC published an article entitled "Freewheel Units" in Vortex, Issue 2/2002. The operator reduced the inspection interval for the component to 400 hours and the aircraft manufacturer issued a Safety Alert reminding operators of the maintenance manual's requirement for a specific inspection requirement for the part.
  
  
• Following an in-flight engine nose dome detachment, TC communicated with the FAA regarding a possible Airworthiness Directive to have all engine accessory supports replaced with modified accessory supports that have been strengthened.
  
  
• WestJet Airlines carried out a fleet-wide campaign to replace all engine accessory supports with modified accessory supports.
  
  
• TC is conducting a review of the applicable Bell 205A-1 instructions for continuing airworthiness to determine if action is necessary regarding the instructions for the installation of starters/generators and fuel lines.
  
  
• Following an accident involving fuel exhaustion followed by collision with terrain, TC conducted a post-accident regulatory audit and - at the request of the company -a systems safety review.
  
  
• Following a loss of separation occurrence, NAV CANADA Toronto ACC revised control procedures to include the requirement of matching radar targets to flight data strips as part of sector hand-over procedures.
  
  
• Following a collision with terrain accident, TC recommended that the company amend its standard operating procedures to state that after take-off, no turns will be performed below 1,000 feet above ground level unless instructed to do so by air traffic control.
  
  
• In response to a series of engine failures, the operator's Flight Operations Training Department amended the training program in areas specifically dealing with the recognition of turbine engine malfunctions, Extended Range Twin-Engined Aircraft Operations diversion procedures and in-flight communications. The engine manufacturer issued two Alert Service Bulletins to provide inspection procedures for specific engine parts.
  
  
• Following a double engine flame-out in the presence of ice on the lower engine nacelle cowl, the aircraft manufacturer issued a revised ground procedure training guide containing a more detailed description of the areas to be inspected and cleaned, and issued a Customer Special Installation on enlarging drain holes in the engine air inlet ducts. The operator incorporated the revised procedures into its training program.
  
  
• Following an aircraft window failure in flight, the operator issued a Quality Assurance Bulletin changing the inspection schedule from 1,200 hours to 200 hours. TC reviewed the operator's standard operating procedures to determine if improvements could be recommended.
  
  
• NAV CANADA issued an Operations Bulletin to personnel in the Edmonton Area Control Centre, drawing their attention to the necessity of following ATC MANOPS in matters pertaining to strip marking for aircraft operating at altitudes inappropriate for direction of flight. NAV CANADA also issued a Notice to Airmen and made permanent corrections to an en route pilotage chart which had depicted inaccurate information regarding an airway.
  
  
• Following a gear-up landing occurrence, the operator decided to require the fitting of a Ground Proximity Warning System on all fixed wing aircraft operated on their behalf by contracted carriers.
  
  
• TC proposed an amendment to the Canadian Aviation Regulations, which would require passenger-carrying aircraft of the class involved in the gear-up landing occurrence to be equipped with specific types of terrain avoidance warning systems.
  
  
• As a result of a loss of separation occurrence at Vancouver International Airport, NAV CANADA revised the Vancouver Tower Class C airspace procedures to require all arriving and departing aircraft operating under visual flight rules to obtain discreet transponder codes so that all aircraft tracked by radar might be correlated with flight number and flight plan information and be more conspicuous on the radar display.

APPENDIX A: GLOSSARY

Footnotes

¹ While the Board's operations are for the 2003-2004 fiscal year, occurrence statistics are for the 2003 calendar year. Comparisons are generally to the last 5 or 10 years. For definitions of terms such as accident, incident and occurrence, see Appendix A.

² In a live database, the occurrence data are constantly being updated. Although an occurrence may happen during a given fiscal year, the decision to undertake an investigation may be taken later as a result of a more thorough analysis of preliminary data.

³ Investigations are considered complete after the final report has been issued.

⁴ For definitions of terms such as recommendation, safety advisory and safety information letter, see Appendix A.

⁵ Also includes responses to recommendations issued in the previous fiscal year.

⁶ 10¹⁸ joules - a joule is a unit of work or energy equal to the work done by a force of one newton acting through a distance of one metre.

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