SMS and Air Taxi Operations: Lessons and Opportunities”
Presentation to ATAC 2011
Kathy Fox, Member
Transportation Safety Board of Canada
Montreal, QC
November 14, 2011

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Slide 1: Title Page

Slide 2: Balancing Competing Priorities

To stay in business in safety–critical industries such as aviation, companies must constantly manage competing priorities such as service, return on investment, timeliness, efficiency and safety.

Slide 3: Why Do "Safe Systems" Fail?

But as we all know systems that are built with safety in mind sometimes fail. This is best captured by Sidney Dekker’s concept of “drift into failure”.

Drift into failure is the result of the normal process of reconciling the different pressures an organization faces against a background of uncertain technology and imperfect knowledge.

What this means is that while you balance all the competing priorities in your day to day work, it’s difficult to think of all the ways something can go wrong. You might get away with it a number of times, but sooner or later that new part of a work process that you designed to save a little time or money might cause a failure in your system, leading to an accident.

Slide 4: Challenges faced by Air Taxi Operators

In Canada, Air Taxi operators face some unique challenges when compared to Commuter or Airline operations.

Air Taxi companies face more challenging flying conditions in their day–to–day operations. They fly into smaller aerodromes with shorter, possibly unimproved runways and little to no other infrastructure.

They fly smaller, older aircraft with less sophisticated avionics and navigation systems. This often means that crews might have higher workloads then those flying more modern aircraft. Also, because the aircraft are smaller, they often have to fly lower over challenging terrain and might thus be exposed to more challenging weather conditions for flight.

Flight crews generally have less flying experience than those in 704 and 705 operations, and there generally is a lack of mentorship available to inexperienced crews.

And quite often, many pilots see Air Taxi as a “stepping stone” in their careers, staying only long enough to gain the experience needed to fly in Commuter or Airline operations. As such there is a lot of staff turnover in 703 operations.

Slide 5: Accidents: 703s vs. Other Categories

Looking at the accident statistics, Air Taxi operations were involved in 7 to 8 times the number of accidents vs. the other commercial operation categories. And by far, the greatest number of fatalities occurs in the Air Taxi sector.

Slide 6: Why Change?

So the question is, what can Air Taxi operators do to reduce accidents?

Aviation regulators around the world have been asking the same questions about the entire aviation industry. Generally, the industry has an excellent safety record, but the traditional approach to managing safety, that is, enforcing compliance with regulations, responding reactively to change things following accidents and the “blame/punish/retrain” philosophy when it comes to crews who make mistakes, is insufficient to further reduce accident rates. In fact, some elements of this approach are a hindrance to safety, since crews are reluctant to share information about minor occurrences or near–accidents for fear of reprisals.

Slide 7: Safety Management System (SMS)

The world’s aviation regulators are moving towards implementing Safety Management Systems, or SMS. The best definition comes from James Reason, which you see on the screen.

Transport Canada began implementing SMS in aviation in 200?  Air Taxi operations are required to implement SMS by 2015.

Slide 8: Desirable Characteristics of Organizations Effectively Managing Safety

So what are some of the elements of an organization that effectively and proactively manages safety?

On the screen you see safety management expert Ron Westrum’s list of desirable organizational characteristics. Beside those, you will see what Transport Canada requires from air operators when they implement SMS.

Slide 9: Elements of SMS

But in essence, SMS requires the following:

Proactive hazard identification:

Incident reporting and analysis:

Strong safety culture:

Slide 10: TSB Reports

In a number of TSB accident reports, investigators have found examples of organizational issues which contributed to accidents.
These include:

  • Inadequate risk analysis
  • Employee adaptations
  • Goal conflicts
  • Failure to heed “weak signals”

I will now go over some examples from TSB investigation reports.

Slide 11: Loss of Control and Collision with Terrain (TSB Investigation Report A07Q0213)

In this accident, a Beech King Air 100 was flying an approach to Chibougamau/Chapais airport in Quebec in IFR conditions with two pilots aboard. They did one approach and decided to go around and attempt a second approach. On the second approach, the aircraft was left of runway centreline. The crew made right turn and then a steep left turn. After the left turn, the aircraft struck the runway about 500 feet from the threshold. A severe post–impact fire ensued, which killed the crew and destroyed the aircraft.

Slide 12: Loss of Control and Collision with Terrain (Continued)

In this case, we see examples of inadequate risk assessments and goal conflicts.

The crew was qualified for making the flight and received CRM training. However, they both had limited experience flying in instrument meteorological conditions and working in a multi-crew environment. A robust hazard identification system would have identified this risk and helped make a more appropriate crew pairing decision for the flight conditions.

We also see here a conflict between the goals of providing a service and ensuring maximum safety. Was a pilot with more IFR experience available to complete the flight which could be paired with one of the pilots with less experience?

Since this accident, the operator began providing its crews with additional simulator training, to review CRM principles as well as IFR procedures, uncontrolled airspace procedures and company SOPs.

Slide 13: Controlled Flight Into Terrain Thormanby Island, BC (TSB Investigation Report A08P0353)

In this accident in BC, a Grumman Goose amphibious aircraft with one pilot and seven passengers aboard departed from Vancouver on a flight to Powell River, in marginal VFR conditions. 19 minutes later, the aircraft crashed on South Thormanby Island in dense fog. The aircraft was destroyed in a post-impact fire and all but one passenger were killed.

Slide 14: Controlled Flight Into Terrain (Continued)

In this case, we found a number of safety issues that might have been mitigated by a functioning SMS. In fact this company had one in place since it also has a 705 operation, and was in the process of voluntarily adopting it throughout the organization.

In this case, we found some “weak signals” of risky situations that were not fully addressed:

The pilot was known for pushing the weather, and clients often requested this pilot, since he flew when others didn’t. The company discussed its concerns over his decision making three times. However, these were not documented, as required by the SMS.

As well, there was the goal conflict of service vs. safety, due to overt, passive or perceived pressure by clients to complete flights. Sometimes the client used other operators when this company would not fly.

Slide 15: Controlled Flight Into Terrain (Continued)

The investigation also found some shortcomings in risk assessment and mitigation:

  • More could have been done to train pilots in weather-related decision-making; and
  • Company procedures to better assist pilots in making weather-related decisions could have been implemented.

Since this accident, the company enhanced a number of procedures to prevent flight in marginal weather, provided PDM training for its VFR pilots and is conducting at least 3 line checks a year on its VFR pilots.

Related to its SMS, the company is conducting risk assessments of VFR routes and operations, accident investigation training and revised risk assessment procedures, and documenting circumstances when poor weather affects a flight so this data can be tracked to determine exposure to risks.

Slide 16: Collision at Takeoff—Muncho Lake, BC (TSB Investigation Report A07W0128)

In this occurrence, a Twin Otter was taking off from a short gravel strip at Muncho Lake, BC on a flight to Prince George, with two pilots and three passengers aboard. After becoming airborne, the airplane turned right, a part of the wing made contact with the highway at the end of the strip, struck other obstacles and finally crashed onto a rocky embankment. There was a severe post–impact fire. One passenger was killed, both pilots were seriously injured and the other two passengers suffered minor injuries.

Slide 17: Collision at Takeoff (Continued)

The investigation revealed a number of organizational challenges.

The operator was a small company that operated a few single engine land and sea airplanes.

The acquisition of the Twin Otter required some significant work to identify and mitigate all known risks associated with its operation, as well as additional record–keeping and administrative work.

There was also the additional workload associated with the approval to operate the Twin Otter as a 704 operator for IFR conditions. One challenge was finding and retaining a qualified Chief Pilot.

Slide 18: Collision at Takeoff (Continued)

We also found some examples of inadequate risk analysis and mitigation in this company:

Not enough was done to address all of the risks of taking off from this short airstrip.

Also, the two crew members came from corporate and airline operating environments and were new to working in a small, seasonal commercial air service. As such they did not have the operational support and more formalized procedures they would have in a larger operation.

Slide 19: Collision at Takeoff (Continued)

We also found examples of employee adaptations

Normally, takeoffs were only permitted out of this short airstrip with minimum fuel and only crew aboard. However on the accident flight, the aircraft carried passengers and a heavy fuel load.  Additionally, maximum performance STOL techniques were used for takeoff, for which the company did not approval to use.

Slide 20: Collision with Terrain—Sandy Bay, SK (TSB Investigation Report A07C0001)

On January 7, 2007, a Beech King Air was on a medevac flight to Sandy Bay, SK with two pilots and two emergency medical technicians aboard.

While in the landing flare on approach into Sandy Bay while in the dark, the crew decided to go around. The aircraft did not maintain a positive climb rate and crashed into the trees at the other end of the runway.  The captain was killed while the others survived with injuries.

Slide 21: Collision with Terrain (Continued)

This accident was an examples where “weak signals” about risky situations were not well-addressed.

By their nature, ‘weak signals’ may not be sufficient to attract the attention of busy managers, who often suffer from information overload while juggling many competing priorities under significant time pressures. 

The TSB investigation found that the crew of two pilots was unable to work effectively as a team to avoid, trap, or mitigate errors and safely manage the risks associated with the flight.

As our lead investigator at the time put it, “This crew did not employ basic strategies that could have helped prevent the chain of events leading to this accident.” This lack of coordination can be attributed in part to the fact that the crew had not received crew resource management (CRM) training.

Previously, there had been numerous “crew pairing issues” with respect to this particular crew. The company’s management knew about this, although they were unaware of the extent to which these factors could impair effective crew coordination.

As a result of this investigation, the Board issued a recommendation that 703 and 704 operations provide their pilots with CRM training.  Transport Canada is generally in agreement with this recommendation and is examining how to address it. As such the Board has rated TC’s actions as having Satisfactory Intent.

Slide 22: Lessons Learned

Slide 23: What Can Air Taxi Operators Do?

Slide 24: Conclusion

Slide 25: END