"I can say with some degree of certainty that if we don’t do something to change the system, accidents like this runway overrun occurrence will needlessly happen again," said Nick Stoss, the TSB’s director of air investigations.
At least 10 other large aircraft have slid off runways in inclement weather worldwide since the crash took place. Investigators said another accident likely will occur in Canada unless clear guidelines and training are introduced to improve landing during stormy weather.
Transport Minister Lawrence Cannon said Wednesday his government "fully supports the intent of the recommendations."
The Airbus A300 left Paris carrying 297 passengers, reaching Toronto in the midst of a thunderstorm. Control tower personnel informed the crew about the poor visibility and warned that two planes that landed minutes before the Air France flight experienced braking problems on the rain-slicked runway.
As the plane made its final approach, there were numerous lightning strikes at the end of the runway along with heavy rain and gusts of wind.
Nonetheless, the pilot proceeded with the landing.
"The flight crew members became overwhelmed by the severe weather conditions and became task saturated, making a normal landing difficult," the report states. "The pilots, who were by this time both focusing primarily outside the aircraft, were not aware that wind shift was also occurring."
A tailwind caused the plane to land 1,158 metres down the 2,743-metre runway, nearly 855 metres farther along than normal.
"It came in too high and too fast," said Wendy Tadros, TSB chairwoman. "It simply ran out of room."
Despite the pilot’s errors, officials said they should not be blamed. "This crew was as qualified and as competent as any other crew and it would serve no purpose in hindsight to start pointing fingers," said Real Levasseur, the TSB’s lead investigator. The runway used by Air France had a 60 metre safety strip past its end, which complies with current standards. However, the plane needed far more room to stop, coming to rest in a ravine more than 300 metres from the runway.
This is the second time a plane has overshot a runway at Pearson causing serious injury.
A similar incident occurred in 1978 when a plane overshot following an aborted take-off, causing two deaths and 47 serious injuries.
A coroner’s jury at the time recommended the runway be extended but no action was taken.
The TSB has recommended all runways for heavy aircraft have safety zones of 300 metres or other tools to stop aircraft.
Scott Armstong, a spokesman for the Greater Toronto Airport Authority said his organization, which operates Pearson, is considering the recommendations and will follow the government’s lead in implementing them.