Flight gets a look inside the TSB


By Adam Hunt


Yves Jolicoeur

COPA Flight 8's meeting in November featured a presentation by Yves Jolicoeur, an accident investigator with the Transportation Safety Board of Canada (TSB).


Jolicoeur started his presentation by giving information on his own background. He learned to fly in 1979 in Gatineau, flew fire patrols on Cessna 172s and 182s, charters on Cessna 310s and Piper Navajos and then moved into airline flying.


He flew for First Air, Nationair and Air Club on aircraft as diverse as the Hawker Siddley HS 748, Airbus A310 and Boeing 727, 737 and 747. When he joined the TSB in 2003 Jolicoeur started in standards performance and later became an investigator.


Jolicoeur next moved on to explain the TSB, how it is organized and how it works. The TSB is based in Gatineau and has a total of eight offices around the country, investigating air, marine, rail and pipeline accidents. The organization is relatively small, with 240 employees to deal with about 4,000 reported occurrences each year. Their role is to find out what happened, why and how it happened and then communicate to help avoid future occurrences.


Due to the high number of reported occurrences the TSB can't investigate them all so they focus on the ones that they think will result in the most lessons learned.


Flight 8 members were interested in why the TSB investigates so few general aviation accidents. Jolicoeur said the Board has a detailed policy http://www.tsb.gc.ca/eng/normes-standards/evenements-occurrences.asp to help decide which are investigated and which are just recorded.


Ultimately it comes down to asking what we can learn from the accident. He also emphasized that the TSB does not assign blame and that its reports cannot be used in court cases. Their role is strictly preventing future accidents through learning about the ones that have already occurred; he added that "there are no new accidents."


The TSB scales its investigations to the size of the accident. In the case of small investigations, the TSB might just assign an operations investigator and a technical investigator, plus any specialists needed. They would travel to the scene, examine the physical evidence, interview eyewitnesses and send samples to the TSB lab in Ottawa if required to carry out such tasks as analyzing aircraft instrument needle impact marks.


Once the field and post-field investigations are complete they will write a report, which the TSB aims to publish in both official languages within a year of the original accident.


Larger accidents are handled similarly to small ones, but may involve larger teams of TSB staff. Jolicoeur used the example of the 2004 crash of a Boeing 747 that ran off the end of the runway on take-off in Halifax.


This investigation involved many dozens of TSB staff in many specialized areas. From the operations side they have specialists in air traffic services, airports, rescue and fire-fighting, performance, human factors, dealing with witnesses and cabin safety. From the technical staff they may make use of specialists in structures, systems, including cockpit voice recorders and flight data recorders, power-plants, maintenance and site management. There is also administrative and support staff to keep the large investigation running smoothly.


For the last part of his presentation Jolicoeur focused on four general aviation accidents and one incident that highlighted a risk that is common in the fall and winter - continued VFR flight into deteriorating weather and resulting collision with objects and terrain.


He provided photographs and narratives about a Cessna 150 collision with a large tower in fog, a Cessna U206 on floats that crashed in a valley while flying in low cloud and low visibility, a Bell 206B Jet Ranger that crashed into a frozen lake in white-out conditions and a Eurocopter EC120B helicopter that crashed in heavy rain after its windshield fogged up at very low altitude.


Jolicoeur's final tale was of a very low-time Cessna 172 pilot flying from Gatineau to Val d'Or, Quebec, who made very bad weather decisions and ended up on top of 6,000 feet of cloud, but who, through "superior use of luck" alone managed to survive his flight to fly another day.