News release
Voluntary approach to address recommendation from the 2011 Resolute Bay air accident may not go far enough
Gatineau, Quebec, 2 September 2014 — The Transportation Safety Board of Canada (TSB) today released its assessment of Transport Canada’s response to
Recommendation A14-01, made following the release of the investigation report (A11H0002) into the 20 August 2011 controlled flight into terrain of a Boeing 737 in Resolute Bay, Nunavut. The aircraft was destroyed by impact forces and an ensuing post-crash fire. Eight passengers and all four crew members died, and three passengers were seriously injured.
In this accident, the aircraft arrived high and fast on final approach, was not configured for landing on a timely basis, had not intercepted the localizer, and was diverging to the right. This approach was not considered stabilized in accordance with the company’s stabilized approach criteria, and the situation required a go-around. Instead, the approach was continued. When the crew initiated a go-around, it was too late to avoid the impact with terrain. The Board recommended that Transport Canada require operators of large commercial aircraft (
Canadian Aviation Regulations [CARs] Subpart 705 operators) to monitor and reduce the incidence of unstable approaches that continue to a landing.
In response, Transport Canada issued a Civil Aviation Safety Alert (CASA) in which Subpart 705 operators are encouraged to use their safety management systems (SMS) to identify the incidence of unstable approaches and to develop mitigation measures for the risks they pose.
Additionally, the CASA referenced the voluntary use of flight data monitoring (FDM) in order to gain a greater understanding of unstable approaches and the causes. The CASA was also distributed to Subpart 703 and 704 operators (smaller air carriers) to encourage voluntary participation in mitigation activity. In June 2015, Transport Canada will commence follow-up surveillance activity with operators to see what measures have been put in place to mitigate the risk. Operators who indicate they do not have a problem will be asked to substantiate this
conclusion.
“Unstable approaches continue to be a high risk to safe flight operations in Canada and worldwide,” said Kathy Fox, Chair of the TSB. “Although TC’s Safety Alert is a positive step, it will be some time before the effectiveness of this voluntary approach can be validated.”
The Board noted that SMS has been in place for several years for Subpart 705 operators, yet the incidence of unstable approaches has not been effectively addressed. As well, if a flight data monitoring program is not required by the regulator, operators may not have the data to assess the risk to their operation posed by unstable approaches. Therefore, the Board has assessed the response to Recommendation A14-01 as
Satisfactory in Part and it will continue to monitor progress.
The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
For more information, contact:
Transportation Safety Board of Canada
Media Relations
819-994-8053