Helicopter Association of Canada fall meeting 2012

Wendy Tadros, Chair
Transportation Safety Board of Canada
HAC Fall Meeting 2012
05 November 2012

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Good morning.

It's nice to see all of you today. Thanks for the invitation.

I'd like to start by acknowledging the very difficult job that helicopter pilots and AMEs do.

So frequently, you operate close to the ground, or near obstacles and over terrain that is … challenging.

You operate in remote parts of the country, where there may be little (or no) infrastructure, in conditions that can be … austere. And the type of work you do often places your aircraft near its power and performance limits.

And AMEs work in harsh conditions, often at night, outside, with no hangar facilities, in all kinds of weather—to keep these complex machines running … and ready to go.

And yet despite all this, despite this very difficult work that you do, when we look at the statistics, we see that the accident rate for helicopters is coming down in North America.

According to last year's figures from the International Helicopter Safety Team (IHST), the world rate was at 6.5 accidents per 100,000 hours. That's a decrease of roughly a third from a decade ago. In North America, we're even lower, at 5.2 per hundred thousand. But what I find truly impressive is the IHST's goal: they want to reduce the accident rate by 80 per cent. That's thinking big.

Why has the number of accidents gone down? Lots of reasons, really, no small part of which is the excellent work of organizations like the HAC. You do your job well, promoting flight safety and educating your members, government, and the general public about important issues. You also get the word out to your members by exchanging maintenance practices and putting common issues on the table. Plus, I think as an industry—both helicopters and aviation as a whole—you are doing a better job of prioritizing safety, and of learning from one another.

But no matter how well we've done, the reality is we need to bring that rate down even lower.

Speaking of a statistic, I'd like to focus on one right now, one that has our attention at the Transportation Safety Board: 91 percent. That's the percentage of commercial aircraft accidents that involve smaller operators, such as those doing aerial work or which provide air taxi or commuter services. I'm talking about the 702s and 703s, mostly, though also the 704s (albeit to a smaller extent).

Let me repeat, because I think that number doesn't always sink in: 91 percent of commercial aircraft accidents in Canada in the last 10 years involved smaller operators. And together, they accounted for 93 percent of commercial aviation fatalities.

A caveat: “commercial aircraft” is a broad category, and no, it's not only helicopters. There are an awful lot of small turboprop or piston airplanes in there … but that being said, 702 and 703 covers most commercial helicopters in this country, so we can't ignore that fact. Medevacs, forestry work, law enforcement, and—as we here in Alberta are well aware—the oil and gas industry. Helicopters are crucial to these operations.

And, if you don't want to be “behind the aircraft,” as they say, you are going to have to think of ways to get ahead of that safety curve.

I will say up front that waiting for the regulators to take us there … waiting for the regulators to tell us what the best practice is … that's not going to get you ahead of the curve. Regulators seem to be regulating less, and that means that you can't be satisfied with only meeting what's required by regulation. Not if you want to fly the safest helicopters.

Bill Voss is the president and CEO of Flight Safety Foundation, and he made a similar point in an article in AeroSafety World earlier this summer. “The gap between what is legal and what is safe,” he wrote, “is already large, and it will get bigger.”

In other words, we can't wait for regulation. We need to be proactive.

And you know, your customers are demanding exactly that. They're voting with their wallets, as it were, and any operators that are holding out, insisting that only the regulator can force them to adapt and require improvements … Well, in this day and age of litigation, and in an environment where helicopters work more and more on dedicated contracts for big companies … well, those operators are finding out that clients have expectations, and that those expectations include not just on-time delivery, or equipment that is up to the task, but also safety. And that's just as true in the oil fields off Newfoundland and Labrador, as it is for someone flying into Fort Mac, or in the Arctic. It's almost … Darwinian. “Survival of the fittest” becomes survival of “the company with the best safety and efficiency record.” Because if your company's safety record is found wanting … well—to be blunt—you can probably kiss that contract good-bye.

OK, change is coming. There doesn't seem to be a lot of doubt about that. And so the question becomes, how are you going to change? What are the ways in which you can “up your game” and be proactive?

Today I want to talk about several of them.

The first is in the area of best practices.

The HAC has done a lot of good work in this area, and I think it should be recognized. You've set out guidelines and best practices for heli-skiing, mountain flying, pilot competencies for helicopter wildfire operators, low visibility and flight confined area operations, to name a few. No one has forced you to do this, either.

There's a line I particularly like, and it's in the introduction to the heli-skiing guidelines. Despite concluding that heli-skiing compares favorably to the industry's average hourly accident rate, you write, “Nonetheless, no operation is ever safe enough.” And, “despite the absence of any justification for regulatory action,” the HAC “has therefore decided to publish the present … guidelines in the anticipation that sharing opinions and information about risk management … might further improve safety, especially when it comes to newcomers to the business.”

“NO OPERATION IS EVER SAFE ENOUGH.” That's a beautiful phrase right there. And I want to thank you for that attitude. Because that attitude makes my job a whole lot easier. It means you've looked at the risks, and you've looked at what is required by regulation, and like Bill Voss you've seen the gap between those two, and you've said “we can do more.”

In other words, you are getting ahead of that safety curve.

So, thank you.

And that's not all. In the area of helmet use, the TSB is pleased to see that the HAC recommended to operators that they “promote the use of helmets for helicopter flight crew members under all operational circumstances which permit their use.”

And yet accidents continue to happen—will continue to happen, as I said earlier. That doesn't mean you shouldn't continue to develop best practices and improve practices and procedures. But it does mean that, maybe, we should look a little wider than we sometimes do—at least when it comes to the actions of an individual pilot or pilots as a whole.

Too often, we at the TSB see that people think accidents begin and end with the person or people in the cockpit. Certainly, “human factors” play a role in the vast majority of accidents. But those human factors don't start or stop in the cockpit. Because when you get right down to it, all accidents are ultimately organizational. And the reason is because it's the decision-makers of an organization—the supervisors, managers, presidents, owners—who set the goals and communicate the priorities for everyone else. These senior members of an organization have to be aware of risks. They're also the ones who determine the operating environment: by providing the tools and training, by allocating resources, and by setting the tone for culture—for how things “get done.”

Take, for example, the 2009 crash of Cougar Flight 91 off the coast of Newfoundland. There was no one cause. No single factor alone brought down the helicopter and killed 17 people that day. In fact, our investigation report was explicit. There was a “complex web” of variables at play, we said—sixteen different contributing factors. Take any one of them away, and it is entirely possible the result might have been different. Did a stud snap on the oil filter bowl? Yes. But there were organizational factors, too: such as maintenance procedures, pilot training (including CRM issues), emergency procedures, certification standards, and the carriage of supplemental underwater breathing apparatuses.

So, as I said: we need to be looking “wider.” But what does that mean?

In part, it means mining your own organizations for information. Because if you don't know what's going on in your organization … well, you can't fix it.

OK, so how do you find out?

A good place to start is SMS. Safety Management Systems.

SMS is all about looking at what you do, looking at your practices, and looking for risks. Hazard identification. And then taking steps to deal with those hazards, proactively.

Now I want to be clear. I'm not saying SMS is some sort of panacea, nor that having it is guaranteed to cut accident rates by a specific percentage … but … there is a reason why ICAO has led the charge and why Transport Canada has already required it for large commercial carriers. And the reason is because SMS works: it really does help companies find trouble before trouble finds them. It is also the reason why we at the TSB have put SMS on our “Watchlist”—our list of issues that pose the greatest risk to Canada's transportation system. Because we want all companies, large and small, to implement it.

An SMS, for instance, might point out as the IHST recently did, that too often, helicopter pilots may not accurately be assessing the risks of flights they feel are standard or low-risk. And an SMS might also suggest—again, as the IHST recently did—that we therefore need to be just as careful during the “expected” or “easy” missions.

And to be fair, Transport Canada (TC) appears to be moving toward making SMS mandatory for all regulated civil aviation organizations, but that's still several years in the future. What do we do in the interim? Sit around and wait to be told to use something that we already know works?

Not at all. In fact there are some small organizations that are already taking the plunge, in advance of regulatory requirements. And to them I say congratulations. You're now ahead of the safety curve. And that's going to pay off. In safety, yes, but also because that's something you can trumpet to your customers: Look at our track record. We're the ones you want to fly with.

The final way I'd like to see operators be proactive dovetails with SMS: data mining. And here I'm talking about flight data, but also about voice and video.

Earlier this summer, I was in Baltimore to speak at the ISASI conference. I made a similar point then about recordings, one that I think bears repeating.

As investigators, we want as much information as possible. Not just flight plans, and wreckage, or even interviews with survivors or witnesses. We want hard data—objective facts that tell us what was going on leading up to the accident. We want to know about the relationship between the crew, and between the crew and base: what they said, what they saw, what they did.

Not having the information we need makes it tougher to find out what happened; it may even preclude the identification and communication of safety deficiencies that can advance transportation safety. And even when we think we know what happened … not having the evidence to prove it means we have less ammunition when we're pushing for change.

Our large investigations have long demonstrated the value recorders bring to accident investigation. And the number of smaller investigations where the cause is undetermined, or we have barely been able to skim the surface in our findings, argues for wider use of recorders … because having this information will let us dig deeper, and find out why so many of our small carriers—the commuter operators, the air taxis—are having so many accidents.

We know, however, that the minute we bring this up—and I know that right here, today, will be no exception—cost gets factored into the equation. Fair enough. Now, though, technology is taking leaps forward. There are smaller, lighter, lower-cost options—recorders that can capture facts critical to the investigation—including actual weather, ambient sound, pilot actions and aircraft response. In other words, the business case is changing, and the time may now be approaching where we consider—where we reconsider—their feasibility. And I can tell you, that debate is taking place right now at the Transportation Safety Board of Canada.

We're not alone on this, either. The IHST already has a list of “Top 10 ways You Can Prevent Helicopter Accidents,” And number one on that list?

Install cockpit recording devices.

Alright … you may be thinking. Let's say we do recommend that our members spend the money, and we make it a suggested best practice to install these recorders. That helps you do your job, but as we all know, the TSB is usually involved only after something's gone wrong. What about us? What about operators? What about pilots, and passengers? How does a recorder help prevent accidents before they occur?

Thanks for asking. My response is four letters: F-O-Q-A.

Flight Operations Quality Assurance. You can also call it “flight data monitoring” or “FDA, for flight data analysis” if you prefer—that's fine. The point is that with recorders … you have access to more data. And not just any data. I'm talking about objective, quantitative data—information that can provide a true picture of normal operations.

I like FOQA because it lets you be proactive. It lets operators know how close they're coming to the brink, as well as the severity of any problems, and whether those problems are internal or external. And the applications aren't limited solely to safety and efficiency. There is also the potential for improved aircraft maintenance, and for the training of personnel.

Other people like FOQA because it gives you the kind of data that lets you make informed choices. Without the data, you're just guessing at what needs to change. And I don't need to tell you that, for a small helicopter company—or even a big one—an accident with a death can be devastating: not just in terms of its effect on families and loved ones of those involved, or even on company morale, but on the bottom line: litigation is expensive. And reputations can be ruined. Suddenly, you may no longer be able to attract the best crew, and your “brand equity” takes a hit. So in that sense … there's a business case for this, too, a return on investment above and beyond the competitive edge in terms of safety.

Oh, and shareholders care about it too. Because statistically, good safety performance correlates very closely with things like quality and productivity—which as you know are intimately tied to profitability.

This kind of monitoring has been implemented in many countries, and it's widely recognized as a cost-effective tool for improving safety. In the United States and Europe—thanks to ICAO—many carriers have had the program for years. Some helicopter operators have it already, and the FAA has recommended it.

But … is it mandatory? No.

However, as I said earlier, there are a lot of good ideas that aren't mandatory. Your own “best practices” aren't mandatory; yet they are hugely valuable.

The same goes for data analysis. When you mine this data and then feed it back through your SMS … when it's systemic, and properly analyzed and—again—proactive … it can be a powerful tool in your toolkit, and a strong defence against accidents.

We're entering some new territory with all of this. And so I want to talk about voice and video recordings—where there is a lack of legal clarity and where, if the government can make things clear, we will all have a real opportunity to make things safer.

If you want to put voice and video recorders on your helicopters there are two things you and your crews need to know. First you need to know that they cannot be used in your SMS. The law as it currently stands forbids that. And it needs to be fixed … fixed so you have an incentive to spend money on these new tools … fixed so you will see a payback.

Second, your crews need to know that voice and video recordings in the cockpit will continue to be put only to non-punitive use. At the time it was passed, the intent of the CTAISB Act—the Act that governs the TSB—was for all voice and video recordings to be sacred. They were to be protected by law and not released or distributed outside the TSB, and definitely not to discipline or prosecute individuals – regardless of whether there was an accident or not.

However, this is being called into question—with some in government and the transportation industries contending that these protections only apply if there is an accident. This needs to be clarified. It needs to be made crystal clear. Because if we really want this to work … if you really want your people to go along with this idea … they can't be worried that with video and voice recorders on board, that their jobs will suddenly be on the line.

So that's where we are. As the cost of newer and smaller recorders comes down … and as more operators realize that understanding human factors is critical if they are to prevent accidents … As these things converge, we could be approaching a real watershed moment, one where we have a chance to really bring that accident rate down, significantly.

But it's still going to take you and your companies, to show real leadership and lead the way on this issue.

Ten years from now—sooner, even: five years from now—it's my hope that we'll be able to look back on this, and say this … this was where we really began to make progress. This was where we demonstrated—not just to the helicopter industry, but to the entire country, to the entire transportation industry—what kind of leaders we are.

And that's why I'm here today. Because the people in this room … all of you … have already demonstrated that you are forward looking, that you are willing to go beyond doing “only” what is regulated, and that you are willing to think big. Even if that means thinking different.

Well, this is different. Very. And it's big.

Now let's see what happens.