"Effective Oversight Vital to Aviation Safety," says the TSB

GATINEAU, QC, Nov. 10 /CNW Telbec/ - Citing ineffective oversight by the Canadian Business Aviation Association (CBAA), the Transportation Safety Board of Canada (TSB) has released its final report into the 2007 landing accident in Fox Harbour, Nova Scotia. The accident injured 10 people when the private jet skidded off the runway, stopping 1000 feet from its initial touchdown point, close to neighbouring homes.

In its investigation (A07A0134), the TSB reported that private operators regulated by the CBAA were not held to the same standard that Transport Canada (TC) implemented for commercial operators. TC regulations require commercial airline companies to implement safety management systems (SMS) in stages, on a fixed timeline, while the CBAA was free to implement SMS for its operators on its own terms with no fixed timeframe.

In 2003, TC transferred regulatory responsibility for some aviation operators to the CBAA but prior to this accident failed to exercise effective oversight of the CBAA programs.

"This is a serious problem," said Kathy Fox, Board Member for the TSB. "Safety can be compromised when SMS plans are vague, deadlines are flexible, and critical oversight is lacking. Without proper milestones or auditing," she added, "SMS cannot function properly and the risks increase."

In two key recommendations, the Board calls for the CBAA to set SMS implementation milestones for its certificate holders and for TC to ensure the CBAA has an effective quality assurance program in place to audit its certificate holders.

In the course of the investigation, the TSB also found that many pilots were not aware of the limitations of the visual guidance systems used to conduct safe approaches and landings. These guidance systems, known as visual glide slope indicators (VGSI), use ground-based light beams to show pilots when they are too high or too low on approach but many pilots don't realize that some VGSI should not be used when flying larger aircraft.

Information on the distance between the cockpit and the landing gear (eye-to-wheel height) is needed to know which VGSI to use but the Board revealed this information is not readily available to pilots.

To address these issues, the Board made two additional recommendations requiring TC to make eye-to-wheel height information available to pilots, and that better training also be provided to them on VGSI so they have the information they need to land safely.

"Although both TC and the CBAA have taken steps since the accident," added Board Member Fox, "raising the safety standard will take an ongoing commitment from TC, the CBAA and the operators. The recommendations we've made today are the next step in this direction."

The complete text of the four recommendations from the TSB report can be found on the attached backgrounder sheet.

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.

This news release, the photo gallery, the animation and the final report A07A0134 can be found on the TSB website at www.bst-tsb.gc.ca.


On 11 November 2007, the Bombardier Global 5000 (registration C-GXPR, serial number 9211), operated by Jetport Inc., departed Hamilton, Ontario, for Fox Harbour, Nova Scotia, with two crew members and eight passengers on board.

At approximately 1434 Atlantic standard time, the aircraft touched down seven feet short of Runway 33 at the Fox Harbour aerodrome. The main landing gear was damaged when it struck the edge of the runway, and directional control was lost when the right main landing gear collapsed. The aircraft departed the right side of the runway and came to a stop 1000 feet from the initial touchdown point. All occupants evacuated the aircraft. One crew member and one passenger suffered serious injuries while the other eight occupants suffered minor injuries. The aircraft sustained major structural damage.

The Transportation Safety Board of Canada (TSB) investigation led to four recommendations calling for increased availability of eye-to-wheel height information, improved training on visual glide slope indicator systems and enhanced safety of private operators certified by the Canadian Business Aviation Association.

    Board Recommendations

    The Department of Transport ensure that eye-to-wheel height information
    is readily available to pilots of aircraft exceeding 12 500 pounds.

    The Department of Transport require training on visual glide slope
    indicator (VGSI) systems so pilots can determine if the system in use is
    appropriate for their aircraft.

    The Canadian Business Aviation Association set safety management system
    implementation milestones for its certificate holders.

    The Department of Transport ensure that the Canadian Business Aviation
    Association implement an effective quality assurance program for auditing
    certificate holders.

This backgrounder, the news release, the photo gallery, the animation and final report A07A0134 are available on the TSB website at www.bst-tsb.gc.ca.

SOURCE Transportation Safety Board of Canada

For further information: For further information: Media Relations: Transportation Safety Board of Canada, (819) 994-8053

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