Air transportation safety recommendation A07-05

Reassessment of responses to TSB Recommendation A07-05

Landing distance considerations

Background

On 02 August 2005, 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. 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. 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. 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.

The Board concluded its investigation and released report A05H0002 on 12 December 2007.

TSB Recommendation A07-05 (December 2007)

The report established that the crew was not aware of the landing distance required to land safely on a contaminated runway. This was due in part to some ambiguities in the landing distance information provided to the crew and an absence of direction by Air France regarding the need for crews to determine landing distances required.

In the latter portions of the approach, the crew actions indicate a concern regarding landing distance when faced with landing on Runway 24L. There is no indication that they had calculated the landing distances required for the arrival, nor are there any direct and specific Air France procedures that would require such calculations by the crew.

This accident shows the need for pilots to know the landing distance required by their aircraft for the conditions to be encountered at the expected time of landing, and to compare this figure to the length of the runway assigned for the landing. It is essential that both figures be known to enable crews to calculate the margin of error available so that they are better prepared to make the correct decision when they encounter deteriorating conditions. In this occurrence, the crew members realized at some time during the landing sequence that the landing was going to be long. Had they known that the margin for error was slim, or indeed non-existent, the crew would likely have executed a go-around.

In the absence of knowledge of the required landing distance under varying performance conditions, crews will not be aware of rapidly developing overrun situations. Because of this, the Board found there is a high potential that crews will make inadequate go/no-go decisions, thereby increasing the risk of damage to persons, property, and the environment. Therefore, the Board recommended that

Transport Canada's response to Recommendation A07-05 (February 2008)

In its response to this recommendation, Transport Canada (TC) states that, subsequent to the 1992 Final Report of the Commission of Inquiry into the Air Ontario Crash at Dryden, Ontario, it 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.

TC is of the opinion that, once in force, the NPAs will accomplish the following:

1. There will be a new CAR Subpart 705 regulation, requiring 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
2. 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.
3. 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.

TSB assessment of Transport Canada's response to Recommendation A07-05 (September 2008)

The Board is confident that the proposed NPAs described above will, if approved, substantially reduce or eliminate the safety deficiency. However, to date, the action has not been sufficiently advanced to reduce the risks to transportation safety. The proposed NPA regulation work has been ongoing for a number of years, but it is unknown when these NPAs may be approved, or whether there may be significant changes before they come into force. The Board was looking for a more aggressive attention to this deficiency, as a number of recent runway overruns such as the one involving One-Two-Go flight 269 in Phuket, Thailand, on 16 September 2007, are a clear indication that runway overruns from contaminated runways will continue to recur, unless crews know exactly what their margin for error is.

Therefore, TC's response to Recommendation A07-05 is assessed as Satisfactory Intent.

Transport Canada's response to Recommendation A07-05 (February 2010)

TC's response states that the CARAC consultation process is complete. Meanwhile, TC continues to review this file while awaiting pre-publication in the Canada Gazette, Part I under Department of Justice, Regulatory Unit File #10000-396.

TSB reassessment of Transport Canada's response to Recommendation A07-05 (July 2010)

The issue of landing accidents and runway overruns is on the Board's Watchlist. The Board is disappointed by the lack of information contained in TC's latest response. Instead it reminds the Board that its NPAs, first proposed in 1999, remain under review by the Department of Justice. In its assessment of TC's 21 February 2008 response, the Board called for TC to take a more aggressive approach in order to mitigate the risks associated with this deficiency. Unfortunately, TC's latest response is silent on any short term solution to assist pilots to make better landing decisions in deteriorating weather conditions. The Board believes that unless TC develops a short term component to its action plan, to mitigate the risks associated with this deficiency, the potential for runway overruns in deteriorating weather will continue.

If adopted, the planned action may result in a course of action that would, in the long term, reduce or eliminate the deficiency identified in Board Recommendation A07-05.

Therefore, assessment of TC's response remains Satisfactory Intent.

Transport Canada's response to Recommendation A07-05 (January 2011)

TC advises that its CARAC consultation is complete and that the file containing TC's proposed regulatory changes associated with Recommendation A07-05 is currently under review with the Department of Justice (Regulatory Unit File #10000-396). Such a review of proposed amendments is always necessary to ensure they are sustainable for industry, meet the safety objectives and are still current especially when there is a lapse of time between consultation and drafting. Once the review is complete, the drafting of the rules will progress through the Canada Gazette stage.

TSB reassessment of Transport Canada's response to Recommendation A07-05 (March 2011)

The Board continues to be disappointed regarding the slow progress of implementation of the NPA action needed to assist pilots in making better landing decisions in deteriorating weather conditions. If adopted, the planned action will, in the long term, reduce or eliminate the deficiency identified in Board Recommendation A07-05.

Therefore, assessment of TC's response remains Satisfactory Intent.

Transport Canada response to Recommendation A07-05 (May and September 2011)

May 2011

To address infrastructure issues TC is:

• Actively participating in the ICAO Aerodrome Panel and Aerodrome Design Working Group.
• Revising TP 312. RESA requirements are being addressed within the context of this exercise.
• Nearing completion of drafting regulations specifying winter maintenance standards with the aim of publication in the Canada Gazette by September 2010 (sic).
• Risk assessment and cost benefit analysis activities have been imitated relating to Code 4 runways to compare 150 &300 metre RESA benefits.

To prevent landing and runway-overrun accidents, TC has:

• TC is an active participant in the ICAO International Runway Friction Task Force and is currently engaged in its fifth meeting to help establish and identify where friction standards can be improved.
• Requirements are in place since 2006 for landings in low visibility conditions
• Issued guidelines for pilots and developing a number of regulatory amendments to help pilots with decision-making when flying in poor weather
• Published an Advisory and an Aviation Safety Letter article targeting airline operators
• Continued active participation in the ICAO Air Navigation Commission where the requirements for additional regulations are analyzed in an international context. This work will ensure that Transport Canada's requirements are harmonized with international requirements.
• TC is drafting a working paper on “Runway Safety”, for the upcoming ICAO assembly. The paper will address both incursions and excursions.

Additional details and information relating to this recommendation may be found in a letter to the TSB Board Dated May 02, 2011 RDIMS # 6680356.

September 2011 update

NPAs associated with Recommendation A07-05 elevated to the Transport Canada list of regulatory priorities.

CARAC consultation is complete. File is currently with the Department of Justice (Regulatory Unit File #10000-396).

A cross reference is to be made on recommendations residing in CRM (A09-02, A07-01, A07-03, A00‑06).

TSB reassessment of Transport Canada's response to Recommendation A07-05 (March 2012)

The issue of landing accidents and runway overruns remains on the Board's Watchlist.

While useful, some of the TC activity does not specifically address Recommendation A07-05. The Board continues to be concerned about the length of time being taken regarding the proposed regulatory action designed to address the deficiency related to this recommendation.

The response is considered Satisfactory Intent.

Transport Canada's response to Recommendation A07-05 (December 2012)

TSB Recommendation A07-05 will not be addressed by the development of a contemporary CRM training standard.

TSB Recommendation A07-05 is being addressed by a series of NPAs (1999-236, 1999-237, 2005-034, 2005-035 and 2005-036). These NPAs will proceed to legal drafting in 2013.

TSB reassessment of Transport Canada's response to Recommendation A07-05 (March 2013)

The issue of landing accidents and runway overruns remains on the TSB Watchlist as one of the highest transportation risks facing Canadians.

Slow progress is being made, with legal drafting expected in 2013. However, given the elapsed time since these NPAs were drafted, the Board continues to be concerned by the protracted length of time required to enact these new regulations. Therefore, the risk to Canadians from this safety deficiency persists.

The response is considered Satisfactory Intent.

Transport Canada's response to Recommendation A07-05 (November 2013)

This item remains a regulatory Priority . Pre-publication of the proposed regulations in the Canada Gazette, Part 1 is anticipated for fall 2014.

TSB reassessment of Transport Canada's response to Recommendation A07-05 (April 2014)

The Board continues to be concerned by the protracted length of time required to put these new regulations in place.

The issue of landing accidents and runway overruns is on the 2012 TSB Watchlist because it remains one of the highest transportation risks facing Canadians. The risk to Canadians from the safety deficiency identified in Recommendation A07-05 persists.

The response is considered Satisfactory Intent.

Transport Canada's response to Recommendation A07-05 (March 2015)

Transport Canada (TC) agrees with the intent of the recommendation. Pre-publication of the proposed regulations in the Canada Gazette, Part 1 is anticipated for spring 2016 as part of the proposed regulations regarding wet/dry contaminated runways.

TC indicated that delays are sometimes inevitable when higher Priority  tasks take up resources in the regulatory program. The defined criteria for assigning Priority  to regulatory initiatives are presented in the following table.

Note that the TSB Watchlist initiatives and other TSB initiatives are assigned Priority 2 and 3 respectively. These high ratings were assigned because the department takes TSB safety action very seriously. Occasionally, however, even important regulatory initiatives are shifted due to higher Priority  issues. The Board should be aware, however, that once Civil Aviation commits to regulatory action, timing may change, but the department will proceed with the initiative until is completed.

TSB reassessment of Transport Canada's response to Recommendation A07-05 (March 2015)

As mentioned in the 02 April 2014 reassessment, the Board continues to be concerned by the protracted length of time required to put these new regulations in place. In its 26 November 2013 response, TC mentioned it anticipated the fall 2014 for pre-publication of the proposed regulations in the Canada Gazette, Part 1. TC now anticipates pre-publication of the proposed regulations in the Canada Gazette, Part 1 in spring 2016.

The issue of landing accidents and runway overruns is on the 2014 TSB Watchlist because it remains one of the highest transportation safety risks facing Canadians. The risk to Canadians from the safety deficiency identified in Recommendation A07-05 persists. While TC's proposed actions are reasonable, the protracted delay is not. TC's continuing delay in completing the proposed action now warrants a change in the assessment rating of the response.

Therefore, the response is assessed as Unsatisfactory.

Transport Canada's response to Recommendation A07-05 (November 2015)

Transport Canada agrees with the intent of the recommendation.

Pre-publication of the proposed regulations in the Canada Gazette, Part I is anticipated for 2016 as part of the proposed regulations regarding wet or contaminated runways.

TSB reassessment of Transport Canada's response to Recommendation A07-05 (March 2016)

Transport Canada's latest update anticipates that its proposed regulatory amendments, designed to mitigate the risks highlighted by Recommendation A07-05, will be pre-published in the Canada Gazette, Part I sometime in 2016. The Board remains concerned that ongoing delays in this essential but lengthy consultation process prevents the implementation of these important regulatory amendments. Landing accidents and runway overrun occurrences remain on TSB's Watchlist and continue to expose Canadians to unnecessary risks until TC's proposed regulatory amendments are implemented.

Therefore, the response is assessed as Unsatisfactory.

Transport Canada's response to Recommendation A07-05 (January 2017)

Transport Canada agrees with the intent of this recommendation. Pre-publication of the proposed regulations in the Canada Gazette, Part I are anticipated for 2018 as part of the proposed regulations regarding wet or contaminated runways.

TSB reassessment of Transport Canada's response to Recommendation A07-05 (March 2017)

In November 2013, TC had advised the Board that this was a regulatory Priority  and that pre‑publication of the proposed regulations was anticipated in fall 2014. Since then, the date has continually slipped. In March 2015, TC anticipated pre-publication of the proposed regulations in spring 2016. TC indicated that delays are sometimes inevitable when higher-Priority  tasks take up resources in the regulatory program.  In TC's latest update, it anticipates that its proposed regulatory amendments, designed to mitigate the risks identified by Recommendation A07-05, will be pre-published in the Canada Gazette, Part I, in 2018.

The Board is very concerned by these ongoing delays and has included runway excursions on its 2016 Watchlist. Runway overrun occurrences continue to happen and the lack of timely action exposes commercial air travellers in Canada to unnecessary risks until these regulatory amendments are in effect.

Therefore, the response to Recommendation A07-05 is assessed as Unsatisfactory.

Transport Canada's response to Recommendation A07-05 (August 2017)

TC agrees in principle with the recommendation.

It should be noted subsequent to the development of the Notice of Proposed Amendment (NPA) for this provision, there has been an important new safety initiative respecting accountability for wet and contaminated runway conditions: Takeoff and Landing Performance Assessment (TALPA)/ Global Reporting Format (GRF). TC is actively involved in the implementation of TALPA/GRF and will strive to ensure that the TALPA/GRF concepts are included in the new regulations. Pre-publication of the proposed regulations in the Canada Gazette, Part I are anticipated for 2018 as part of the proposed regulations regarding wet or contaminated runways.

TSB reassessment of Transport Canada's response to Recommendation A07-05 (March 2018)

TC has taken a number of actions to address the safety deficiency identified in Recommendation A07-05, with respect to aircraft landing distance considerations in deteriorating weather. These include the following:

• Since 1999, TC has issued 5 Notices of Proposed Amendment (NPAs) addressing aircraft performance on wet and contaminated runways. Proposed regulatory amendments would require aircrew to consider the condition of a dry, damp, wet or contaminated runway surface, and determine that sufficient landing distance is available before conducting an approach to land in deteriorating weather. However, TC has postponed the pre-publication of the proposed amendments in the Canada Gazette, Part I, several times, and now anticipates doing so in the spring of 2018; and
• TC is now involved in the implementation of Takeoff and Landing Performance Assessment (TALPA)/ Global Reporting Format (GRF), and intends to include TALPA/GRF concepts in its proposed regulations. The Board is encouraged by this initiative, given its potential to reduce the risk of runway overruns by means of evaluating and reporting runway conditions more effectively, and thus enabling pilots to calculate the required landing distance on a wet or contaminated runway more accurately.

The Board considers that the new regulations will, if adopted, substantially reduce the risk associated with the safety deficiency identified in Recommendation A07-05. However, the TSB continues to be concerned by the protracted length of time required to enact the proposed regulations.

Runway overruns are identified in the 2016 TSB Watchlist as a key safety issue that needs to be addressed to make Canada's transportation system safer. The TSB continues to find contributory factors and underlying risks in recent accident investigations that are similar to those that gave rise to Recommendation A07-05.

Therefore, the Board considers the response to Recommendation A07-05 to show Satisfactory Intent.

Transport Canada's response to Recommendation A07-05 (November 2018)

TC agrees in principle with the recommendation.

TC is in the process of developing a Notice of Proposed Amendment (NPA) to address this recommendation. The proposed amendments would require airline operators to put in place measures to help prevent overrun (landing long) by increasing calculated landing distance when runways are wet or contaminated (e.g., snow). The proposed regulations regarding wet or contaminated runways, are anticipated for pre-publication in the Canada Gazette, Part I, in the spring of 2020.

In addition, to take more immediate action, TC has published a Civil Aviation Safety Alert (CASA) Operation with Aeroplanes Utilizing TALPA-Based Performance Information to calculate landing distance. The purpose of this CASA is to alert Canadian pilots, flight dispatchers, air operators, foreign air operators, and private operators, of:

1. the important safety enhancements that are achieved by utilizing performance information that is based on Take-off and Landing Performance Assessment (TALPA) methods; and
2. the operational consequences, including possible delays, which may be associated with the use of TALPA-based performance information.

TC has also started working on two ACs on wet and contaminated runways - one to address take-offs and one to address landings that should be published in 2019/2020.

TSB reassessment of Transport Canada's response to Recommendation A07-05 (February 2019)

To date, the following actions have been taken by Transport Canada (TC) to address the safety deficiency identified in Recommendation A07-05, regarding aircraft landing distance considerations in deteriorating weather:

• Since 1999, TC has issued 5 Notices of Proposed Amendment addressing aircraft performance on wet and contaminated runways.
• In 2018, TC published Civil Aviation Safety Alert (CASA) No. 2018-08, Operation with Aeroplanes Utilizing Take-off and Landing Performance Assessment (TALPA)-Based Performance Information to Calculate Landing Distance. In the short term, this initiative should help raise the awareness of flight crews, flight dispatchers and air operators of hazards associated with operation on contaminated runways.

In addition to the above actions, TC plans to publish, in 2019/2020, two Advisory Circulars on wet and contaminated runways.

However, TC has postponed the pre-publication of the proposed regulatory amendments in the Canada Gazette, Part I, several times. It now anticipates publication in the spring of 2020. Even though the new regulations may, if adopted, reduce the risk associated with the safety deficiency identified in Recommendation A07-05, the Board is very concerned by the protracted delays to enact the proposed regulations.

Since 2010, runway overruns have been part of the TSB Watchlist, which identifies the key safety issues that need to be addressed to make Canada's transportation system even safer. Until the proposed regulatory amendments are in effect, commercial air travellers in Canada continue to be exposed to the risks that gave rise to Recommendation A07-05.

Therefore, the response to Recommendation A07-05 is assessed as Satisfactory Intent.

Next TSB action

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 A07-05, and will reassess the deficiency on an annual basis or when otherwise warranted.

This deficiency file is Active.