TSB Report on 2015 Air Canada Airbus Collision

A Message from Your Union
On March 29, 2015, Air Canada flight 624 was involved in a collision with terrain at the Halifax Stanfield International Airport.  The accident occurred after Air Canada received an exemption under the Canadian Aviation Regulations (CARs) to operate its Airbus 320 aircraft under the revised 1:50 ratio.
The TSB report does not say anything about whether the evacuation of the aircraft or passenger safety would have been enhanced had Air Canada not adopted the 1:50 ratio on this flight.  However, the facts presented in the report show that the implementation of the new cabin crew ratio was rushed.  They also support CUPE’s ongoing concern about Transport Canada’s ability to ensure that airline procedures are properly amended so that all aircraft can be safely operated under when new regulations are introduced.
We are very lucky that this incident ended as it did.  We commend the actions and efforts of the cabin safety personnel involved in the accident who, even without the required training, ensured the safety of all passengers onboard the aircraft.
Below, we have highlighted and commented on the sections of the report that pertain to cabin personnel.  If you would like to read the TSB’s full investigation report, you can access the document online by clicking on the following link:
https://www.bst-tsb.gc.ca/eng/rapports-reports/aviation/2015/a15h0002/a15h0002.pdf.
Background
On May 18, 2017, the Transportation Safety Board of Canada (TSB) released its report on the collision involving Air Canada flight 624 that occurred on March 29, 2015.  The aircraft involved in the collision was an Airbus A320-211.  It was on a scheduled flight from Toronto, Ontario (Lester B. Pearson International Airport) to Halifax, Nova Scotia (Stanfield International Airport).
While approaching the runway in Halifax, the aircraft severed power lines, struck the snow-covered ground before the runway threshold, continued airborne through the localizer antenna, struck the ground two more times, slid along the runway, and then came to a rest beyond the runway threshold.
There were 133 passengers and 5 crew members (2 pilots, 1 service director, and 2 flight attendants) on board.  Twenty-three passengers sustained minor injuries.  Three crew members sustained minor (2) and serious injuries (1).
The service director had 10 years of experience with Air Canada, while the two flight attendants each had 5 and 2 years of experience.
Cabin Crew Issues & Findings
Cabin Crew Responds Quickly to Collision to Protect the Safety of Passengers
The report notes that all passengers evacuated the aircraft within five minutes after it came to a stop.  The cabin crew acted quickly to open the cabin doors to help passengers exit the aircraft safely.
The 1:50 Ratio & Passenger Safety
In August 2014, Transport Canada (TC) granted Air Canada an exemption under the Canadian Aviation Regulations (CARs) to operate its Airbus 320 aircraft under the revised 1:50 ratio.  Under this exemption, Air Canada was required to train its flight attendants on how to open both exits and to manage passenger flow at more than 1 exit if they would be responsible for doing so (i.e., dual-exit drills).
The report notes that, “Air Canada began operating with the 1:50 ratio before incorporating the dual-exit drill into its ART as of April 2015.  At the time of the accident, neither the service director nor the flight attendants had received the dual-exit drill training, nor were they aware of the requirement for such training in order for Air Canada to operate with the exemption allowing 1 flight attendant for each unit of 50 passengers.”  Air Canada did not incorporate practical training on 2-door operations into its flight attendant training until after the accident.
This finding is consistent with CUPE’s assertion that TC and Air Canada failed to meet their obligation to properly introduce relevant procedures necessary to ensure that emergency situations could be effectively dealt with by crew members as required under the new 1:50 ratio.
Seatbelt Testing: Protecting the Safety of All Flight & Crew Members
The captain of flight 624 suffered a minor head injury after hitting the glare shield during the collision.  He was wearing his seatbelt during the accident.  The captain’s head hit the glare shield because, “there were insufficient acceleration forces to lock the shoulder harness and prevent movement of his upper body.”
The first officer (FO) suffered a head injury as well as a serious injury to their right eye.  The FO was wearing their seatbelt during the accident.  However, the automatic locking feature of the inertia reel of the FO’s right shoulder harness was found to be unserviceable, which allowed their upper body to move and twist to the left upon impact.
The crew restraint system consists of a shoulder harness and lap belt.  At the time of the accident, Air Canada did not have a copy of the maintenance manual for the restraint system, which details how the system is expected to perform and be tested.  Air Canada’s standard operating procedures do not require crew members to perform the pull test that is used to verify that the “shoulder harness is airworthy and capable of restraining the seat occupant when subjected to a sudden acceleration force.”  The company’s restraint system maintenance schedule “does not specify that a shoulder harness pull test be carried out as part of the inspection.”  And, the maintenance instructions provided by the manufacturer of the FO’s seat did not include the proper instructions on how to perform the pull test.  No discrepancies in the restraint system were noted following an inspection two weeks prior to the accident.
Neither the Air Canada maintenance task cards, nor the Airbus maintenance task cards they are based on, indicated that a pull test was required on the restraint system.   While Air Canada was nonetheless performing a pull test, the company was not performing the test properly.
When seat restraint systems due not perform properly, they cannot achieve their main objective: minimizing the risk of injury or death to crew members during an accident.  Had a proper pull test been performed to confirm that the seat restraint system was airworthy, the FO would have been properly restrained in their seat during the collision.
Since the accident, Airbus has revised its aircraft maintenance manual so that it now includes the necessary provisions on properly performing the necessary shoulder harness pull test.
Given the critical importance of the seat restraint systems for all crew members – both pilots and cabin safety personnel – at all airlines, including Air Canada, we recommend that all CUPE health and safety committees raise the issue of the seatbelt testing procedure and work with their employer to develop processes that will ensure that proper seatbelt testing procedures are introduced and followed.
Cabin Crew Instructions Regarding Passenger Evacuation & The Removal of Carry-On Baggage
Some passengers exited the aircraft with their carry-on baggage.  The cabin crew had instructed passengers that they were not to retrieve their carry-on baggage during an evacuation during the pre-departure safety briefing and after the aircraft had come to a stop.  On-board safety feature cards also reinforced this message.
When passengers insist on retrieving carry-on baggage in emergency evacuations it can delay timely evacuations, damage evacuation slides, and increase the risk of injury or death to themselves and others.  The issue is widespread and not specific to this collision.
To enhance current measures undertaken to mitigate the risks associated with retrieving carry-on baggage during an evacuation, the TSB recommended that, “The Department of Transport require that passenger safety briefings include clear direction to leave all carry-on baggage behind during an evacuation.”  This is important since current regulations allow airline operators to voluntarily determine whether they will include this safety information in passenger briefings.
In its response to the recommendation, Transport Canada (TC) stated that it believes the AC700-012 Passenger Safety Briefings are having the desired effect.  TC also implies that although not all major carriers have implemented AC700-102, an adequate number are doing so.  TC is also satisfied that allowing airlines to voluntarily determine whether they will provide this safety information to passengers will “reduce but not substantially reduce or eliminate the safety deficiency.”  No further action is planned on the part of TC in relation to the TSB recommendation.
We are disappointed that this important issue continues to go unchecked by TC given the urgent need to evacuate an aircraft in 90 seconds and the fact that this has been a recurring issue in many recent air accidents.  TC’s response to this issue demonstrates its ongoing failure to uphold its core mandate for the aviation sector: ensuring the safety of air travel in Canada.
The Aircraft Passenger Address (PA) System
The aircraft PA system can be operated from both the cockpit and flight attendant stations.  Because it does not have an independent power supply (battery or electrical), the PA system cannot be operated during emergencies.
This meant that the flight and cabin crews could not use the PA system after the collision to communicate evacuation orders and safety information to passengers.  When PA systems are rendered inoperable or when announcements become inaudible following an accident, evacuations can be delayed and both passenger and crew safety is placed at risk.
This situation is not unique to this collision.  There is a documented history of PA systems manufactured by different companies becoming inoperative in air accidents where the front end of the aircraft impacts the ground.  Given how important it is for crew members to be able to communicate with passengers during an emergency, especially on large aircraft, we believe that it is imperative that changes be made to rectify the problem.
Coffee Brewer Malfunction & Flight Attendant Injury During Collision
During the collision, one flight attendant sustained a shoulder injury after they were hit by the centre coffee brewer, which had come free of its mounting rails during impact.  The report indicates that the brewer’s movable lever, which is a component of its locking device, was bent, scratched, and failed to move into the locking position.  A slight movement of the lever or repeated jolting of the brewer was sufficient to cause the lever to release the locking mechanism.
The report further states that, “In 1992, the manufacturer of the brewer issued an optional service bulletin that provided information on modifying the brewer to incorporate a new locking lever. The new lever is retained in the locked position by means of a screw that is threaded into the housing. When the screw is in place, the lever cannot be opened. Air Canada did not incorporate this service bulletin, nor was it required to do so by regulation.”
Cabin Crew Instructions Around the Bracing Position
When the cabin crew does not expect an emergency, or have time to prepare for an emergency, such as in this occurrence, Air Canada’s procedures require the cabin crew to provide passengers with an oral command to “bend over, keep your head down.”  The report notes that, “The service director and off-duty Air Canada flight attendants who were in transit shouted to passengers to keep their heads down and to bend forward.”  It is clear that the cabin crew followed proper procedures in order to protect the safety of passengers during the collision.