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TSB critices Transport Canada on slow implementation of safety recommendation
11 April 2011

A TSB investiation into a cabin smoke and passenger evacuation incident revealed that Transport Canada had not yet implemented an actual regulatory change after accepting a safety recommendation dated December 2007. The recommendation called for passenger safety briefings to include clear direction to leave all carry-on baggage behind during an evacuation.

On March 23, 2010 an Air Canada Airbus A320-211 (registration C-FTJO), operating as flight AC433, departed Montréal/Pierre Elliot Trudeau International Airport, Québec, for Toronto/Lester B. Pearson International Airport, Ontario, with 98 passengers and 6 crew members on board.
In cruise, 1 of the 3 hydraulic systems failed. The flight continued toward destination where the flight made an uneventful landing. While stopped on the runway awaiting a tow, smoke entered the cabin and an evacuation was ordered. Two crew members and 2 passengers received minor injuries during the evacuation.

The TSB concluded that:

  1. A leak from the number 1 yaw damper caused fluid to be ingested into the auxiliary power unit and sent through the air conditioning system, resulting in smoke entering the cabin.
  2. When the crew ordered the evacuation as a result of the smoke, several persons received minor injuries while exiting the aircraft via the emergency slides.

It appeared that many passengers deplaned with their carry-on luggage. It could not be determined whether this was due to the fact that they were not aware of the instructions given by the flight attendants and included in the safety card, or if they were aware, but chose to disregard them. Passengers would have been more aware of this restriction if information was included during the pre-takeoff and pre-landing passenger briefings, as per TSB recommendation A07-07.

The few injuries that did occur may have been aggravated by the fact that the slides were wet from the rain, and the resultant speed of the exiting persons was higher than normal. While the baggage did cause some minor injuries and delays at the bottom of the slides, it did not appreciably increase the evacuation time. Were this a higher level of threat or emergency, however, even a slight delay could have resulted in more serious consequences.

Transport Canada agreed with the Board’s recommendation (A07-07) that called for passenger safety briefings to include clear direction to leave all carry-on baggage behind during an evacuation. However, to date, no regulatory change has been implemented. Due to the extensive delay between TC’s acceptance of this recommendation and the implementation of actual regulatory change, identified safety dificiencies continue to persist.

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