Presentation to AQTA 2014
Member, Transportation Safety Board of Canada
Gatineau, Quebec, 20 March 2014
Check against delivery.
Slide 1: Title Page
Hello. I would like to thank the AQTA for inviting me to speak to you.
Slide 2: Outline
Today’s presentation will address a number of areas, including:
- the TSB
- safety management systems
- lightweight flight data recorders
- updated TSB regulations
Slide 3: TSB: Our mission
The TSB is an independent government agency. Our mandate is to advance safety by conducting independent investigations into four federally regulated modes of transportation: marine, pipeline, rail, and air.
To that end, we conduct independent investigations, identify safety deficiencies, identify causes and contributing factors, make recommendations, and make our reports public.
It is also important to note that it is not the function of the TSB to assign fault or determine civil or criminal liability.
Slide 4: TSB offices
Our head office is located in Gatineau, Quebec, and our Engineering Branch is in Ottawa. We have eight other regional offices across the country.
Slide 5: TSB Watchlist
In 2012, the TSB updated its initial safety Watchlist, which identifies the issues posing the greatest risk to Canada’s transportation system. In this new version of the Watchlist, we were able to remove issues where we’d had success. However, we also added some new issues.
Unfortunately, there was little change with respect to issues in aviation, where the problems areas are well known and include:
- Safety management systems
An updated edition of the Watchlist will come out later in 2014.
Slide 6: Safety Management Systems (SMS)
A successful SMS is systematic, explicit, and comprehensive. Reason says it “becomes part of an organization’s culture, and of the way people go about their work.”
Slide 7: Balancing competing priorities
Many organizations claim “safety is our first priority”. There is, however, convincing evidence that, for some, the top priority is really customer service, or return on shareholder investment. However, products and services still need to be “safe” if an organization wants to stay in business and maintain public confidence—while avoiding accidents and costly litigation.
Therefore, balancing competing priorities and managing risk is part of any manager’s decision-making process. And while some risks are easier to assess than others, it is very difficult to foresee what combination of circumstances might result in an accident. This is particularly challenging in a complex socio-technical organization with a very low accident rate—e.g., air traffic control, and flight operations.
Slide 8: SMS requires the following
Transport Canada's regulations detail the generally accepted components of a Safety Management System.
In essence, SMS requires:
- Proactive hazard identification
- Incident reporting and analysis
- Strong safety culture.
Slide 9: SMS: Key ideas
While SMS may not eliminate all accidents, a properly implemented safety management system can help reduce the risk. Over time, this should reduce the accident rate. Many lessons can be drawn from accident investigations and the experience of those operators who have implemented SMS.
It’s no longer about mere “operator error.” Rather, safety is about identifying the risks that inevitably crop up because we’re human, and then managing or minimizing them. Organizational drift, goal conflicts, competing priorities, local adaptations … We’ll never get rid of them entirely, so it’s how we deal with them that matters.
Returning to the best principles of very reliable organizations, SMS can help develop a “mindful infrastructure.”
Slide 10: Case study: A10Q0098
On June 23, 2010, a Beechcraft A100 King Air was making an instrument flight rules flight from Québec City to Sept-Îles, Quebec. The crew started its take-off run on Runway 30; 68 seconds later, the co-pilot informed the airport controller that there was a problem with the right engine and that they would be returning to land on Runway 30. Shortly thereafter, the co-pilot requested aircraft rescue and fire-fighting (ARFF) services and informed the tower that the aircraft could no longer climb.
Slide 11: A10Q0098
A few seconds later, the aircraft struck the ground 1.5 nautical miles from the end of Runway 30. The aircraft continued its travel for 115 feet before striking a berm. The aircraft broke up and caught fire. The 2 crew members and 5 passengers died in the accident.
Slide 12: Causes and contributing factors
The report stated that "Some of these organizational practices, which were known to management, were contrary to the company's written directives." The Board found that the company's poor safety culture contributed to the acceptance of unsafe practices. Among these was a requirement to take off with unapproved reduced power settings, to "save" wear and tear on the engines.
A company's safety culture is demonstrated by its procedures and processes, behaviours by management and employees, and safety-related values and beliefs. A frequently cited definition of an organization's "safety culture" is as follows:
"Shared values (what is important) and beliefs (how things work) that interact with an organization's structures and control systems to produce behavioural norms (the way we do things around here)." - Uttal (1983)."
Implemented properly, safety management systems (SMS) allow aviation companies on their own to identify hazards, manage risks, and develop and follow effective safety processes. Until SMS are more broadly implemented within the aviation industry, the TSB remains concerned regarding the risks to Canadians, and will continue to monitor progress in this area. I will leave you with a question: Can SMS work in an operation with a poor safety culture—and if not, what do we do about it?
Slide 13: Case study: A11W0048
Moving on to a new subject, on March 31, 2011 a turbine powered de Havilland DHC-3 Otter left Mayo to make a 94-statue mile day visual flight rules flight to the Rackla Airstrip (Yukon). Approximately 19 minutes later a 406 MHz emergency locator transmitter (ELT) alert was received by the Canadian Mission Control Centre. The aircraft wreckage was located on a hillside 38 nautical miles northeast of Mayo. The wheel-ski equipped aircraft had experienced a catastrophic in-flight breakup and the pilot, who was the sole occupant, sustained fatal injuries.
Slide 14: Findings from A11W0048
- The aircraft departed controlled flight for reasons which could not be determined, and broke up due to high speed.
- If cockpit or data recordings are not available to an investigation, the identification and communication of safety deficiencies to advance transportation safety may be precluded.
- If companies do not proactively monitor flight data, the identification and correction of safety deficiencies may be precluded.
Slide 15: Flight data recorders: recommendation
This accident was not the first time the TSB could not conclusively determine WHY an occurrence happened. In fact, we have discussed the issue of data recorders in the past. But this investigation served as a launching point for a Board recommendation calling for the installation of lightweight flight recorder systems by commercial operators using small aircraft.
Our recommendation? That TC work with industry to remove obstacles and develop recommended practices for the implementation of flight data monitoring and the installation of lightweight flight recording systems for commercial operators not required to carry these systems.
2013 status: “Satisfactory intent”
Slide 16: With more data, everybody wins
In too many investigations involving small aircraft, it was not possible to conclusively determine WHY an occurrence happened. Reliable data helps remove doubt in the mind of crews, families, operators, and others about what happened.
Flight data monitoring will give operators the tools to look carefully at individual flights (and ultimately at the operation of their fleets) over time, so they can figure out what needs to be fixed to prevent an accident.
The TSB believes that the information recorded on lightweight flight recording systems will also be useful in occurrence investigations. This will help investigators better understand the events that led up to the occurrence, and hopefully reduce the number of accidents.
Slide 17: TSB Regulations
These regulations were approved in 1992 and had not been updated since that time. In the past 22 years, there have been many changes in the transportation industry, and the updated regulations were needed to address this evolution. The updates are the result of consultations with over 225 stakeholders, such as Transport Canada, provincial governments, industry associations, transportation companies and interest groups
The changes mean the regulations are now simpler and organized more clearly. They also clarify some previously ambiguous provisions and will mean changes to what needs to be reported to the TSB in the event of an occurrence.
Slide 18: Regulations: Overview
As far as changes, some definitions have been updated. There are also fewer sections—just two, whereas before there were six.
Part I of the updated TSB Regulations will take effect on July 1, 2014. Part II is already in effect.
Slide 19: Information to be reported
Here are some specifics with respect to what information needs to be reported after an occurrence.
Any person providing air traffic services (ATS) having direct knowledge of the occurrence shall report aviation occurrences:
- Parts that have become detached
- Injury caused by propeller wash
- Incidents involving aircraft greater than 2250 kg (down from 5700 kg) and also Part VII of the CARs
In the old version, the conduct of interviews led to confusion.
The new regulatory requirements impact the interview process.
- The interview required before an investigator must be in camera. - In private
- Only the following persons may attend an interview:
- any person who is requested by the investigator to attend;
- All interviews must be recorded. This should be done by way of an audio recording. An investigator may decide to do a video recording.
On written request, a person making a statement must be provided with a copy of that statement.
I urge you to review the changes to our regulations, which are available on the TSB website.
Slide 21: Conclusions
Companies can benefit from implementing SMS whether or not there is a regulatory requirement.
FDRs: Operators can benefit from installing them now.
Industry can work with TC to remove obstacles for use of CVRs and image recorders, and promote use of FDRs for safety purposes.
Thank you for your time.
Slide 22: Questions?
Slide 23: Canada wordmark
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