aie o Transportation Bureau de ta sécurité Safety Board —_des transports of Canada du Canada NEWS RELEASE NEWS RELEASE NEWS RELEASE NEWS RELEASE TSB calls for adequate aircraft de-icing equipment, greater compliance with de-icing regulations at remote northern airports Saskatoon, Saskatchewan, 14 December 2018 — Today, the Transportation Safety Board of Canada (TSB) is making two recommendations aimed at preventing flight crews operating in remote northern areas of Canada from taking off with ice, snow and frost contamination on aircraft. The recommendations stem from the TSB's ongoing investigation (A17C0146) into the December 2017 collision with terrain of the West Wind Aviation ATR-42 in Fond-du-Lac, Saskatchewan. Early in the investigation, it was determined that the crew took off from Fond-du-Lac with ice contamination on the aircraft's critical surfaces. The operator had some de-icing equipment in the terminal building, but it was not adequate for de-icing an ATR-42. Ice or snow on critical surfaces (such as wings, stabilizers and propellers) will result in aerodynamic degradation, which can lead to difficulty controlling an aircraft. To assess whether similar circumstances to this occurrence existed in the wider Canadian industry, the TSB sent out a questionnaire to pilots at 83 Canadian operators that fly out of, remote northem airports. Over 650 responses from pilots flying a wide variety of aircraft in all northern areas were received. Preliminary analysis of the data shows that pilots frequently take off with contaminated critical surfaces. Responses also indicate that aircraft de-icing equipment is often inadequate at remote northern airports. “Our questionnaire results are clear: the lack of adequate de-icing equipment at remote northern Canadian airports and the frequency of fights taking off with contaminated critical surfaces constitute a widespread, recurrent issue that exposes passengers and flight crews to unnecessary risk,” said Kathy Fox, Chair of the TSB. "Itis time that Transport Canada and the aviation industry give people the tools they need to adequately de-ice aircraft. There also needs to be better compliance with the regulations prohibiting takeoffs with ice, snow and frost contamination.” Many remote northern airports have an icing season of 10 months or more, and thousands of flights take off every year from these airports. The Board recommends that the Department of Transport collaborate with air operators and airport authorities to identify locations where there is inadequate de-icing and anti-icing equipment and take urgent action to ensure that the proper equipment is available to reduce the likelihood of aircraft taking off with contaminated critical surfaces. (TSB Recommendation A18-02) a+ CanadaOpening remarks Air transportation safety recommendations TSB investigation A17C0146 ~ Fond du Lac Saskatoon, Saskatchewan 14 December 2018 Check against delivery. Kathy Fox: Good morning On 13 December 2017, an ATR 42 aircraft operated by West Wind Aviation departed Fond-du-Lac Airport, Saskatchewan, with 3 crew members and 22 passengers on board. Seventeen seconds aiter takeoff the aircraft collided with trees and terrain. All 25 people aboard were injured, ten of them seriously. One of those, a passenger, subsequently died ‘The TSB’s investigation into the occurrence is ongoing. Today, based on what we've learned thus far, we are releasing two recommendations regarding flight crews that take off with frost, ice or snow contamination on aircraft, particularly at remote northern airports. First, we want Transport Canada, air operators, and airport authorities to make sure that adequate de-icing and anti-icing equipment is available for those who need to use it; and second, there must be greater compliance with regulations to reduce the likelihood that crews take off with contamination on “critical” aircraft surfaces—such as wings, propellers, stabilizers, or even some parts of the fuselage. ll talk more about both recommendations in a few minutes, but first I'l turn things over to the Investigator-in-charge, Mr. David Ross. He'll explain how the TSB came to. learn just how widespread this problem is. David Ross: Whenever the TSB begins an investigation, we look at a broad range of factors— mechanical issues, but also things like weather, operational policies and procedures, training, and human performance. The goal is to gather as much information as possible when establishing a sequence of events, and also because as an investigation evolves you never know what may turn out to be important later. A17C0146 Opening Remarks, December 2018 Page |1In this occurrence, we learned early on that the aircraft was not de-iced before takeoff, despite a pre-flight inspection by one of the pilots that revealed the presence of ice on critical aircraft surfaces. We also learned that there was some de-icing equipment in the terminal building at Fond-du-Lac, but that it was insufficient; for instance, neither of the two available ladders was tall enough to permit de-icing of the wings or horizontal stabilizer, nor did the hand-held spray systems have the capacity to clean the entire aircraft. According to the Canadian Aviation Regulations, "No person shall conduct or attempt to conduct a take-off in an aircraft that has frost, ice or snow adhering to any of its critical surfaces.” The reason is straightforward: snow or ice on critical surfaces will result in aerodynamic degradation, which can lead to difficulty controlling an aircraft. But when the equipment necessary to enable crews to follow this rule is not available well, not only does that needlessly increase the risk, it effectively removes a defence that was put in place to operate safely and save lives. So, last summer, the TSB sent out a questionnaire to pilots at 83 Canadian operators that fly out of many of Canada’s remote northern airports. We wanted to know whether the circumstances of the Fond- du-Lac occurrence existed in the wider Canadian industry. The results of this questionnaire, which was both voluntary and anonymous, were revealing We received over 650 completed responses from pilots flying many types of aircraft across a wide spectrum of commercial operations. Our preliminary analysis of the data indicates that at remote northern airports, aircraft frequently take off with contaminated critical surfaces. When I say aircraft, I mean the full range: transport jets and turboprops, commuter turboprops, and all types of air taxi aircraft. How often does this happen? ‘The short answer is: far too often. In fact almost 40% of participating pilots reported they are “rarely” or “never” able to have their aircraft effectively de-iced at remote airports. This is nota smalll problem. Respondents indicated a wide geographic distribution. And since many remote airports can have an icing season of 10 months or more, the risk, frankly, is substantial. ‘That's why we're here today, instead of waiting for the investigation to be completed. Because it’s already winter at these airports, and these recommendations need to be addressed now. A17C0146 Opening Remarks, December 2018 Page |2