New Recommendations 
A03-01 
Regulatory authorities quantify and mitigate the risks associated with in-service thermal acoustic insulating materials that have failed the Radiant Panel Test 

A03-02 
Regulatory authorities develop a test regime that will effectively prevent the certification of any thermal acoustic insulation material that, based on realistic ignition scenarios, would sustain or propagate fires. Interim Recommendation 

A99-08 
On an urgent basis, regulatory authorities validate all thermal acoustical insulation materials in use, or intended for use, in applicable aircraft, against test criteria that are more rigorous than those in Appendix F of FAR 25.853, and similar regulations, and that are representative of actual in-service system performance.

TC accepts that the Radiant Panel Test (RPT) is a significant step forward to improving safety over previous testing methods and will implement the RPT as the new standard for setting flammability criteria for thermal acoustic insulation materials as soon as possible. The RPT uses realistic ignition sources and has been validated against full-scale tests.

TC actively participated in developing the RPT and has now drafted Notices of Proposed Amendments (NPAs) that are scheduled to proceed through the formal Canadian regulatory process in the Fall of 2003. These proposed NPAs go beyond the scope of the TSB recommendation by incorporating criteria for thermal acoustic insulation to act as a barrier to the penetration of external fires into the cabin (burn through test). 

TC is also working with the FAA, through the auspices of the International Aircraft Materials Fire Test Working Group (IAMFTWG), to refine the RPT procedure criteria to include various elements such as hook and loop, tapes, adhesives, etc. 

TC has also proposed that the IAMFTWG be tasked to review of other materials identified by the TSB as a concern. 

The results of these activities will allow TC and other regulatory authorities to quantify and develop the necessary mitigation to address the risks associated with in-service insulating materials. 

Through our active participation in various working groups, both domestically and internationally, TC believes that the IAMFTWG is the best forum to address these issues effectively. The IAMFTWG consists of over one hundred internationally recognized specialists in the field, including TC representation.

Moreover, as the authority responsible for the certification of Bombardier products, TC also confirmed that Bombardier is not using MPET type products in their aircraft manufacture or design. 

During the period 2000-2002, worldwide regulatory authorities issued airworthiness directives (ADs) that requires the removal of MPET from affected aircraft. 

As further precautionary measure, TC has issued an airworthiness notice to the Canadian industry including manufacturing and maintenance organizations, design organizations and operators to reinforce that MPET not be used.

New Recommendation 
A03-03 
Regulatory authorities take action to ensure the accurate and consistent interpretation of the regulations governing material flammability requirement for aircraft materials so as to prevent the use of any material with inappropriate flammability characteristics 

Interim Recommendation 
A01-02 
For the pressurized portion of the aircraft, flammability standards for material used in the manufacture of any aeronautical product be revised, based on realistic ignition scenarios, to prevent the use of any material that sustains or propagates fire.

In addition, TC is continuing to work in the IAMFTWG on the development of test methods for other materials in hidden areas. Significant progress is being made. For example, test criteria for wiring (single, in bundles, including clamps etc.) are expected to be completed in 2003 and the development of these test criteria into standards will commence shortly thereafter. Other work on materials such as clamps, ducting, foams, and seals is progressing.

These testing standards will take into consideration realistic ignition scenarios. 

The current IAMFTWG work to define suitable testing standards will become the basis for implementing improved standards and guidance material.

Through our active participation in various working groups, both domestically and internationally, TC believes that the IAMFTWG is the best forum to address these issues effectively. The IAMFTWG consists of over one hundred internationally recognized specialists in the field, including TC representation.

TC has participated, with the JAA and the FAA, in the development of an Enhanced Zonal Analysis Program (EZAP). EZAP adds inspection and maintenance actions for aircraft wiring and the wiring’s immediate environment to determine the necessity to inspect and clean the zone of contaminants or combustible material found in the zone. EZAP will require initial and on-going inspection and cleaning of aircraft zones with wiring. EZAP has been implemented for new aircraft and an implementation plan is being developed for in-service aircraft. 

On November 8, 2001, TC issued instructions to its maintenance inspectors to ensure that maintenance schedules for large transport category airplanes include approved procedures for the inspection of the thermal acoustic insulation during heavy maintenance checks to detect any contamination. 

TC is completing a formal risk assessment related to another on-board fire scenario that addresses the effects of contamination. The risk assessment team includes representatives from TC, the FAA, the TSB, the NTSB and the aircraft manufacturer. This assessment will establish the appropriate mitigation measures.

New Recommendation 
A03-04 
Regulatory authorities require that every system installed through the STC process, undergo a level of quantitative analysis to ensure that it is properly integrated with aircraft type-certified procedures, such as emergency load shedding. 

Safety Concern 
Role of the FAA Aircraft Evaluation Group

TC is involved at the beginning of the project by requiring that the applicant submit a plan. This enables TC to determine that all appropriate analyses will be conducted. TC also conducts detailed technical follow-up audits on selected projects to confirm the adequacy of the analyses and take appropriate corrective action, if required. 

In 2002, TC issued formal guidance material to enhance the consistent use of a certification plan as an important tool early in the certification process prior to any aircraft modifications.

New Recommendation 
A03-05 
Regulatory authorities establish the requirements and industry standard for circuit breaker resetting.

TC has reiterated the best practices regarding the resetting of tripped circuit breakers in a recent article published in TC’s Aviation Safety Letter.

• Material Flammability Test Requirements for Aircraft Wiring 
• Limitations of FAR 25.1353 Electrical Equipment and Installation 
• Potential Limitations of MIL-W-2275/16 Wire 

Interim Recommendation 
A01-03 
A certification test regime be mandated that evaluates aircraft electrical wire failure characteristics and against specified performance criteria, with the goal of mitigating the risk of ignition.

Zonal analysis, an assessment of how the various aircraft systems in a particular area interact, is a well-established part of the certification process.

TC, as part of its involvement in Aging Transport Systems Rulemaking Advisory Committee Working Group 9, has participated in the development of the Enhanced Zonal Analysis Program (EZAP), which adds inspection and maintenance actions for aircraft wiring and the wiring’s immediate environment. EZAP has been implemented for new aircraft and an implementation plan is being developed for in-service aircraft. Implementation will mitigate risk of exposure to ignition sources. 

In addition, TC recognizes that the creation of standards for separation for wiring is beyond the scope of ATSRAC’s tasking. However, the FAA is addressing this concern through a research contract and TC is confident that the results will form the basis for international harmonized standards. 

TC is monitoring ongoing FAA research associated with aircraft electrical wire failure characteristics including the effects of wire and insulation degradation and wiring separation and segregation standards. TC will participate in any harmonization activity related to the outcome of this research program.

• Arc Fault Circuit Breaker

• Certification Flight Crew Reading Light 

• Standby Instrumentation

• Advisory A010042-1 (Standby Instrumentation)

• TC acknowledges that the arc fault circuit breaker may not be suitable to address all ignition scenarios. However, this new device does represent a significant contribution to improving safety especially when considered in combination with other improvements already made or under development. The development of this technology is well advanced and arc fault circuit breakers are now being tested under operational conditions. The Canadian industry is participating in these trials. 
• TC has evaluated electrically powered fixtures on domestic aircraft certification programs to determine that this condition does not exist. TC continues to perform this evaluation on new domestic programs. Aviation regulatory authorities have been unable to validate that this condition exists on any aircraft type other than the MD-11. 
• TC recognizes that adequate redundancy in the power supply is an important requirement for standby instruments. Current Canadian standards require three independent electrical power sources, which sustain essential flight instrumentation for flight crews operating transport category aircraft. 
• TC has reviewed its pilot training standards for transport category aircraft. Current TC training standards stress training in the operation (normal, abnormal and emergency) of aircraft systems and equipment. This includes a requirement for pilot training with failures related to navigation and communication equipment. This does include standby instrument proficiency.

Safety Concerns: 

• Flight Recorder Duration & Power Supply
• Underwater Locator Beacon 
• Non-Volatile Memory 

New Recommendations 
A03-06 
Regulatory authorities, in concert with the Civil Aviation industry, take measures to enhance the quality and intelligibility of CVR recordings. 

A03-07 
Regulatory authorities require for all aircraft manufactured after January 1, 2007, which require a flight data recorder, that in addition to the existing minimum mandatory parameter lists for FDRs, all optional flight data collected for non-mandatory programs such as FOQA/FDM, be recorded in the FDR.

A03-08
Regulatory authorities develop harmonized requirements to fit aircraft with image recording systems that would include imaging within the cockpit.

However, TC has already taken action to help improve access to valuable information. TC has proposed regulations that were published in Part I of the Canada Gazette on February 15, 2003, requiring a recording capacity of at least two hours for new aircraft. TC expects that the regulation will come into force in the Fall of 2003. Furthermore, an NPA is under development to retrofit existing aircraft with two-hour CVRs. This draft regulatory proposal will follow the normal consultative rule making process.

In addition to improving access, TC is also committed to maintaining the quality of recordings. To accomplish this, TC requires annual intelligibility tests under operational conditions to maintain the quality of CVR recordings. 

TC already requires the use of separate power supplies for aircraft required to have two flight recorders. TC is developing an NPA to strengthen the electrical power requirements. However, TC continues to work with foreign authorities and participate with international committees involved in the development of new standards for independent power supply. 

In relation to the underwater locator beacon, the international European Organization for Civil Aviation Equipment (EUROCAE) working group 50, a body of internationally recognized experts in the field including TC officials, has defined an international standard and recently confirmed that it is adequate.

Interim Recommendations 
A99-01 
As of January 1, 2003, any CVR installed on an aircraft as a condition of that aircraft receiving an original certificate of airworthiness be required to have a recording capacity of at least two hours

A99-02
As of January 1, 2005, all aircraft that require both an FDR and a CVR be required to be fitted with a CVR having a recording capacity of at least two hours.

A99-03 As of January 1, 2005, for all aircraft equipped with CVRs having a recording capacity of at least two hours, a dedicated independent power supply be required to be installed adjacent or integral to the CVR, to power the CVR and the cockpit area microphone for a period of 10 minutes whenever normal aircraft power sources to the CVR are interrupted. 

A99-04
Aircraft required to have two flight recorders be required to have those recorders powered from separate generator buses.

New Recommendation 
A03-09 
Regulatory authorities harmonize international rules and procedures for the protection of cockpit voice and image recordings used for safety investigations.

Safety Concern 
In-flight firefighting measures

Interim Recommendations 
A00-16 
Appropriate regulatory authorities, in conjunction with the aviation community, review the adequacy of in-flight firefighting as a whole, to ensure that aircraft crews are provided with a system whose elements are complementary and optimized to provide the maximum probability of detecting and suppressing any in-flight fire. 

A00-17
Appropriate regulatory authorities, together with the aviation community, review the methodology for establishing designated fire zones within the pressurized portion of the aircraft, with a view to providing improved detection and suppression capability. 

A00-20
Appropriate regulatory authorities, review current in-flight firefighting standards including procedures, training, equipment, and accessibility to spaces such as attic areas to ensure that aircraft crews are prepared to respond immediately, effectively and in a coordinated manner to any in-flight fire.

TC agrees that it is a reasonable objective that all crewmembers be capable of coordinating emergency response. TC already has in place comprehensive training standards for flight crews and flight attendants, which meet and, in some cases, exceed international norms. 

The Flight Attendant Training Standard requires that cabin crew conduct firefighting drills every year. The firefighting drills must include simulated fires in the following locations: cabin (e.g. under seat, overhead bin, closet); galley (e.g. garbage bin, upper electrical panel, oven); confined (e.g. waste bin, lavatory); and hidden areas (e.g. behind panels). In addition, Canadian standards require that cabin crew demonstrate, once every three years, proficiency with required onboard firefighting equipment by extinguishing an actual fire. 

The Flight Crew Training Standard requires emergency procedures training for pilots and includes training on fire in the air and on the ground as well as practical training on the use of fire extinguishers. The standard also calls for annual crew resource management training so that crew understand their responsibilities to minimize the time required to assess and gain control of emergency situations. Canadian standards require that pilot and flight attendants participate in joint training exercises to allow for a coordinated response to any possible in-flight emergency. 

To further minimize the risk of fires in inaccessible locations, TC has drafted NPAs, which are scheduled to proceed through the formal Canadian regulatory process in the Fall of 2003, for the new standard for enhanced flammability criteria for thermal acoustic insulation materials. TC will continue to work with the international community on aircraft design related initiatives, such as the improved electrical system protection.

In addition, TC is working with the FAA’s International Aircraft Systems Fire Protection Working Group (IASFPWG), to investigate the issues associated with fires in various hidden areas as well as the technical feasibility of fire detection and suppression systems for those areas.

Safety Concern 
Checklist Modifications 

Interim Recommendations 
A00-18 
Appropriate regulatory authorities take action to ensure that industry standards reflect a philosophy that when odour/smoke from an unknown source appears in an aircraft, the most appropriate course of action is to prepare to land the aircraft expeditiously. 

A00-19
Appropriate regulatory authorities ensure that emergency checklist procedures for the condition of odour/smoke of unknown origin be designed so as to be completed in a timeframe that will minimize the possibility of an in-flight fire being ignited or sustained.

Since 1987, TC has required that aircraft flight manuals for all transport category aircraft include an additional instruction that calls for an immediate landing at a suitable airport in the event of an in-flight fire, if there is any uncertainty of it being extinguished. Other authorities and foreign manufacturers have recognized the soundness of TC’s approach and are now adopting a similar approach. 

TC is also participating in international fora to develop a standardized philosophy for checklist design. 

In the short-term, TC is reviewing the relevant aircraft flight manual procedures for Canadian-designed aircraft with a view to reducing the time required to complete critical checklists. TC will be requesting the FAA and JAA to undertake the same review. TC will also propose to regulatory authorities that a joint working group be formed to develop guidance material for checklist development. 

TC incident statistical analysis indicates a heightened sensitivity to smoke in the cockpit and the increased frequency with which flight crews are landing immediately at the closest airport.

Interim Recommendation 
A01-04 
As a prerequisite to certification, all aircraft systems in the pressurized portion of an aircraft, including their sub-systems, components and connections be evaluated to ensure that those systems whose failure could exacerbate a fire in progress are designed to mitigate the risk of fire-induced fires.

Progress made in the area of material flammability is a key element in addressing this recommendation. This includes the significant progress made with the Radiant Panel Test (RPT) and the review of other materials by the IAMFTWG such as end caps, hook and loop, tapes, adhesives, etc.

Advisory A010020-1 
TSB suggested TC review controller training requirements. Consideration should be given to the need for additional training regarding aircraft emergency scenarios prior to the initial issuance of a licence to air traffic controllers under the Canadian Aviation Regulations (CARs). Specifically, further training may be warranted that provides the requisite knowledge and skills so that controllers are better able to provide safe and expeditious air traffic control (ATC) services to aircraft experiencing emergency or distress conditions. The need for regular continuation training and refresher exercises regarding emergency scenarios should also be considered.

TC will continue to audit training through its regulatory audit program.

Advisories 

• A980031-1 MD-11 Wiring Issues 
• A000008-1 Flight Crew Reading Light
• A000042-2 MD-11 Standby (Secondary) Instruments 

Info Letters 

• A000061-1 Flight Crew Reading Light
• A000062-1 & A000062-2 MD-11 Overheating Conditions in Overhead Aisle and Emergency Light Fixtures 

Alert 

• TSB Alert to Stakeholders on the In-Flight Entertainment Network/STC