Keynote address to Air Transport Association of Canada
Chair, Transportation Safety Board of Canada
November 18, 2014
Check against delivery.
Thank you very much for that kind introduction and for the invitation to speak to you today. It is a real pleasure to be here. I have been a Member of the Transportation Safety Board for just over 7 years, and it is an honour to have been appointed as the new Chair of the TSB, almost exactly 3 months ago. While I am very excited to take on this new challenge, I'm also very mindful of the great responsibility it brings.
I'd like to start by congratulating you—the Air Transport Association of Canada—on a milestone anniversary. 80 years! 80 years is a long time. That's eight decades of “promoting safe, reliable, efficient and affordable air transportation.” To come this far takes a clear vision and mandate, commitment, perseverance, and teamwork. So, well done!
Next March, the Transportation Safety Board of Canada turns 25. Our mandate is also very clear and focused—to advance transportation safety by conducting thorough, independent investigations, making public our findings as to causal and contributing factors, identifying safety deficiencies and making recommendations to address them. Since its creation in 1990, the TSB has conducted well over 1000 investigations in the air, rail, marine and pipeline modes of transportation, from coast to coast to coast, and issued 559 recommendations. But more on that later.
Overall, we have a very safe air transportation system in Canada. But our job at the TSB is to identify ongoing safety risks in the system, so that action can be taken to make air transportation even safer. That's what the Canadian public expects, even demands, us to do.
In any transport organization, operators are required to manage competing goals and multiple priorities including safety, customer service, productivity, technological innovation, cost-effectiveness and return on shareholder investment. Most of these organizations publically assert, “Safety is our first priority”. However, there is convincing evidence that profitability is often their first priority. Yet companies generally recognize and accept that products and services must be ‘safe' if the company wants to remain in business, maintain customer and public confidence, avoid accidents and consequent costly litigation, and reduce the potential for overly prescriptive regulations or enforcement action.
From 1982 until 1992, I was co-owner and operator of an air taxi company and flight training school near Montreal. This was pre-CARs.Footnote 1 In today's terms, it would have been described as a 702Footnote 2/703Footnote 3/ FTUFootnote 4 operator with an Approved Maintenance Organization. So I have experienced first-hand and can certainly appreciate some of the challenges faced by smaller operators.
Safety initiatives often cost money, which isn't always easy to find for a small operator with thin margins. And while it's easy to quantify the cost of implementing new technology, or additional training, or hiring more staff—it's not always easy to quantify the safety benefits. Put another way, while you may be able to calculate the costs avoided by not investing in new safety initiatives, it's very hard to calculate what that adds in terms of an increased level of risk.
Let me give you an example. In 1995, the TSB recommended that “The Department of Transport require the installation of ground proximity warning systems on all turbine-powered, IFR-approved, commuter and airline aircraft capable of carrying 10 or more passengers”. It took until 2003 for the draft regulatory changes to clear CARAC,Footnote 5 and the final regulations were published in July 2012 with a two-year phase-in for existing aircraft affected by the new regulations. While it took almost 19 years for the regulations to take effect, we are nevertheless pleased that Transport Canada expanded the requirements beyond the scope of the original TSB recommendation.
I'm sure that many pro-active operators chose to implement the new technology, known as Terrain Awareness Warning Systems or TAWS, before they were required to do so. But I'm also sure that others may have waited to incur these costs, until the new regulations came into effect. Regardless, you now know how much that technology cost you to equip your fleet. What you don't yet know (or maybe some of you do) is the value of the resultant safety benefits.
One way you may be able to better quantify the benefits of such safety initiatives is through your internal, non-punitive incident-reporting systems. Provided your employees feel safe to report “near misses”, you may learn of an incident where your pilots received a warning that the aircraft was close to terrain, allowing them to take timely action and avoid a controlled flight into terrain (more commonly known as CFIT) accident. Furthermore, by identifying these types of occurrences, you can look more closely at why this happened in the first place, and what other non-punitive corrective actions may be required—such as crew training, or revisions to Standard Operating Procedures or aircraft maintenance practices.
An on-board recorder can be of great assistance in this kind of effort, and the resultant flight data monitoring can provide a more realistic picture of normal operations. For instance, it can let operators know how close, and how often, pilots are coming to the brink of safe operations, or raise questions about deviations from standard operating procedures such as “no-fault go-around” policies.
But back to CFITs. From 1995 until the end of 2013, there were 203 such accidents. TAWS can serve as an antidote to CFIT. So over time, we expect to see this type of accident decrease.
Unfortunately, we continue to see certain underlying causal and contributing factors over and over again in other accidents, particularly in the 703 operations. Some of these factors include: pilot inexperience and insufficient training; deficiencies in pilot decision-making and crew resource management, especially in poor weather. A good example is our investigation into the crash of a Piper Navajo Chieftain at North Spirit Lake, Ontario, in January 2012 (A12C0005) which killed the pilot and 3 passengers. The TSB found that the pilot's decision to conduct an approach to an aerodrome not serviced by an instrument flight rules approach in adverse weather conditions was likely the result of the pilot's inexperience, and may have been influenced by the pilot's desire to successfully complete the flight. And the pilot's decision to descend into cloud and continue in icing conditions was likely the result of inadequate awareness of the aircraft's performance in icing conditions and of its de-icing capabilities.
When we find these issues, we dig deeper to understand “why?” How, for example, did the operator manage its operational risks? What level of operational control and company oversight existed? In the North Spirit Lake investigation, we found that: the lack of procedures and tools to assist pilots in the decision to self-dispatch leaves them at increased risk of dispatching into conditions beyond the capability of the aircraft. Moreover, when management involvement in the dispatch process results in pilots feeling pressure to complete flights in challenging conditions, there is an increased risk that pilots may attempt flights beyond their competence.
And if a company isn't effectively managing its risks, we dig deeper still and look at whether the regulator had identified issues with the company. If not, why not? If yes, why wasn't the regulator's intervention successful in changing unsafe operating practices? An example of that was in the TSB investigation of the fatal crash of a Beech King Air departing Quebec City in June 2010 (A10Q0098) which killed the 2 pilots and all 5 passengers. There, the Board found that the significant measures taken by Transport Canada (TC) did not have the expected results to ensure compliance with the regulations, and consequently unsafe practices persisted.
Another big issue on the TSB radar and of concern to larger operators is the concept of crew resource management. CRM has been an area of investigation in several high-profile reports over the past few years. Last March, we released our investigation report into the tragic crash of First Air flight 6560, which struck a hillside one mile east of the airport in Resolute Bay in August 2011, killing 12 of the 15 people on board. That crash hit close to home for me. A frequent traveler to the North, I had flown into Resolute Bay a few days earlier on a chartered First Air B737 with over 95 passengers on board.
We spent a lot of time and effort trying to figure out why the crew members of Flight 6560 acted the way they did, and why they weren't able to reconcile their different perceptions of what was happening before it was too late. What we learned, among other things, is that the crew resource management training that is currently mandated by Transport Canada is outdated. Not only does it not include the most recent techniques and content, but there is no formal accreditation for instructors, nor fixed time parameters for course duration. And for the smaller operators, such as 703 air taxis and 704Footnote 6 commuter pilots, training is not mandated at all, as many of you may be aware—this despite a 2009 TSB recommendation calling explicitly for such training.
Now, in fairness, TC has begun to take action. In 2012, a focus group of TC and industry representatives submitted a report that proposed components of a contemporary CRM training standard for Part VII commercial operators. Later that year, the Civil Aviation Regulatory Committee (CARC) directed that a contemporary CRM training regulation and standard be developed for CAR Subparts 702, 703, 704, and 705.
As of this year, however, it is still not known how detailed TC's new training standard and guidance material will be compared to the existing standard, nor when that new standard might take effect. It is also not known how TC will ensure operators apply the new training standard so that flight crews acquire and maintain effective CRM skills. Therefore, the Board is concerned that, without a comprehensive and integrated approach to CRM by TC and aviation operators, flight crews may not routinely practice effective CRM.
Another area of Board concern is SMS: safety management systems.
I am well aware that SMS is not mandatory for all air operators. That being said, every transportation company has a responsibility to manage its safety risks, and SMS provides an excellent framework to achieve this. Implemented properly, it lets companies find trouble in advance … before trouble finds them.
However, the move toward an SMS regime must also be supported by appropriate regulatory oversight. This includes proactive auditing of companies' safety processes, as well as ongoing education and training, and traditional inspections to ensure compliance with existing regulations.
I'd like to turn now to the overall aviation accident record in Canada. As I said earlier, we generally have a very safe air transportation system in Canada. Prior to the tragic crash of First Air flight 6560, we had not had a fatal accident involving a Canadian Part 705 operation in the previous 10 years. Unfortunately, the record is not as good for the smaller carriers (show accident statistics slide). For the 10-year period ending December 2013, 57% of all commercial aviation accidents involved 703 operations, rising to 92% if you add in 702 and 704. 63% of the fatalities occurred in 703 operations, or 95% if we add in 702/704 operations.
Tomorrow, when I present to the Fixed Wing, Air Taxi and Flight Training Committee, I will be talking about some recurring findings in accidents involving 703 operations. I have already mentioned some issues, but other recurring issues are: inadequate (if any) risk analysis of operations, crew adaptations from standard operating procedures, and deficiencies in operational control, especially in self-dispatch operations. The TSB has decided to take a more in-depth look at these types of accidents.
Therefore, I am announcing today [pause] that the Transportation Safety Board of Canada will conduct a Safety Issues Investigation into risks associated with air taxi operations. A Safety Issues Investigation (also known as a Class 4 investigation or SII) is much broader in scope than our normal accident investigations. This involves looking at multiple occurrences in order to identify the underlying safety issues, and we may make recommendations to address identified systemic deficiencies. The TSB has conducted a number of such in-depth investigations in the past, notably into Survivability in Seaplane Accidents, VFR Flight into Adverse Weather, and Post-Impact Fires Resulting from Small Aircraft Accidents—to name a few. The terms of reference are not finalized yet. But I can assure you that we will be speaking with industry associations such as ATAC, as well as a sampling of operators, to obtain your input on the major safety issues you have identified, how they are being managed, and examples of “best practices”. We expect to start the study early in 2015.
You are probably wondering if I'm going to announce what is on the next TSB Watchlist today. For those who don't know, the TSB Watchlist was first launched in 2010 to highlight those safety issues that pose the greatest risk to Canadians. What I can say today is that we are currently updating our list and will be releasing the 2014 TSB Watchlist very, very soon!
In particular, we want to increase the uptake on long outstanding TSB recommendations. At this point, only 61% of the 253 air recommendations made by the TSB since 1990 have achieved the highest status of Fully Satisfactory. That's barely a passing grade on a pilot licensing exam…but that's another story! Much more needs to be done.
In conclusion, I feel a bit like someone invited to a birthday party who arrives and proceeds to make suggestions on how to renovate your house. But public confidence is absolutely crucial to a viable Canadian aviation industry. That's why the TSB will continue to push hard for changes that will advance transportation safety so that Canadians can have confidence when they board a commercial aircraft in this country, regardless of the size of airplane or operator. And we hope we can count on the active support of ATAC and its members to help move the safety bar higher.
Thank you for your kind attention. I'd be happy to take a few questions if we have time.