TSB Recommendation A19-02

Eliminating the acceptance of unsafe practices

The Transportation Safety Board of Canada recommends that the Department of Transport collaborate with industry associations to develop strategies, education products, and tools to help air-taxi operators and their clients eliminate the acceptance of unsafe practices.

Air transportation safety investigation report
A15H0001
Date the recommendation was issued
Date of the latest response
December 2023
Date of the latest assessment
February 2024
Rating of the latest response
Satisfactory Intent
File status
Active

Recommendation A19-02 in PDF [276.05 KB]

Summary of the occurrence

In May 2015, the Transportation Safety Board of Canada (TSB) launched an in-depth Safety Issues Investigation (SII) into the risks that persist in air taxi operations across Canada. This SII reviewed 15 years of data to identify safety issues in Air Taxi Operations in Canada that have not been sufficiently mitigated. This SII examined air taxi operations as a whole and considered safety issues that are germane to the entire air taxi industry and not just to one specific segment of the industry.

The Board concluded its SII and released report A15H0001 on 07 November 2019.

Rationale for the recommendation

This SII highlights what types of unsafe practices have been happening for years and continue to happen: from flying overweight to flying in marginal weather, to flying with inadequate fuel reserves. Deviations from standard operating procedures, company policy, procedures, regulations, or safe practices can result in outcomes similar to those that have contributed to numerous accidents and incidents over the years.

At the same time, the safety margin built into these operations may allow an unsafe flight to be completed successfully. When operations are conducted successfully with a reduced safety margin, this may lead to an acceptance of unsafe practices and make it difficult to know how much of the safety margin has been eroded.

An important step in raising the bar on safety in air-taxi operations is getting clients, passengers, and operators not to accept unsafe practices even when there seems to be a sufficient safety margin, and to speak up to prevent them from happening. This requires strategies, promotion and education to change values, attitudes and behaviours, which will eventually result in a change of culture.

Safety culture is defined as the way safety is perceived, valued, and prioritized in an organization. Establishing a positive safety culture has many challenges; however, it is a necessary first step in creating the values, attitudes and behaviours required for operators to effectively manage the risks associated with their operations. In practical terms, a positive safety culture can in part be built or supported by proactive safety management.

The evidence of this change in culture will be an operation that supports and reinforces PDM/CRM practices through a strong company culture, including support for decision making by managers, supervisors, and peers. Supportive influences and actions from all stakeholders can help operators prioritize safety and manage risks to an acceptable level. But to do this, time and resources must be invested before the flight, and investments must be made as part of increasing safety pressures through training and education, company-wide safe decision making, the use and support of PDM/CRM practices, and safety management that includes a culture of operating safely. To be effective, all this must be done with the knowledge of the operating context of air-taxi operations and the hazards and risk factors specific to this sector.

The emphasis now needs to be on using a positive safety culture and proactive safety management to increase safety pressure that will eventually lead to a culture where unsafe practices are considered unacceptable.

Therefore, the Board recommended that

the Department of Transport collaborate with industry associations to develop strategies, education products, and tools to help air-taxi operators and their clients eliminate the acceptance of unsafe practices.

TSB Recommendation A19-02

Previous responses and assessments

January 2020: response from Transport Canada

TC agrees with the recommendation and is committed to working with its stakeholders to identify unsafe practices and support initiatives to improve safety.

To this end, TC has begun planning to implement a campaign focussed on safety in the air-taxi sector. TC will engage key stakeholders at the next Aviation Safety Forum to be held in January 2020 where key potential safety pillars of the initiative and the need for industry collaboration will be discussed with representatives of the air-taxi sector.

Provided there is industry support, the air-taxi safety campaign will be modelled on the ongoing successful General Aviation Safety Campaign (GASC) where TC partnered with the Canadian Owners and Pilots Association (COPA) and SmartPilot.ca to encourage safe practices within the general aviation community.

Based on knowledge, experience, and safety information gained from the GASC and its related safety initiatives, the air-taxi safety campaign will concentrate on eliminating the acceptance of unsafe practices as identified in the TSB’s investigative report A15H0001.

Examples of some topics that the air-taxi safety campaign could focus on are “pushing the weather” and “flying overweight”.

TC, in collaboration with stakeholders, will finalize the issues on which the Safety Campaign will focus in the spring of 2020 and begin the implementation of the campaign by the end of fall 2020.

March 2020: TSB assessment of the response (Satisfactory Intent)

In its response, Transport Canada (TC) indicated that it agrees with Recommendation A19-02 and will be taking the following approach to address the safety deficiency identified in the recommendation:

  • Develop a safety campaign for the air-taxi sector to help eliminate the acceptance of unsafe practices. The campaign will be modelled on the ongoing General Aviation Safety Campaign (GASC).
  • Engage key stakeholders at the Aviation Safety Forum in January 2020 to gather input and support.

The issues that will be the focus of the safety campaign are expected to be finalized in the spring of 2020. The air-taxi safety campaign is expected to be launched by the end of the fall of 2020.

The Board is encouraged by TC’s planned actions to address the safety issues associated with the acceptance of unsafe practices in the air-taxi sector. These actions, when fully implemented, have the potential to substantially mitigate the risk associated with the safety deficiency identified in Recommendation A19-02.

Therefore, the response to Recommendation A19-02 is assessed as Satisfactory Intent.

December 2020: response from Transport Canada

Transport Canada (TC) agrees with the recommendation.

In TC’s initial response of January 2020, TC committed to engage with key stakeholders to plan the implementation of an Air Taxi Safety Campaign by the end of Fall 2020.

Similar to the General Aviation Safety Campaign, the Air Taxi Safety Campaign will help eliminate the acceptance of unsafe practice in the sector. Due to the ongoing situation with the global pandemic, the campaign has been delayed. When industry is able to be fully engaged to receive messaging and safety information on the subject, TC will be sending a letter announcing the launch of the Campaign inviting industry to participate.

Activities planned in this campaign will include the review and update of exiting literature and communication products to promote safety in the Air Taxi sector (human factors handbook, Crew Resource Management package), the development of new safety promotion products targeting specific unsafe practices determined by the working groups and a broader outreach to Air Taxi passengers.

Depending on the progression of the global pandemic, any alternative tools for communicating and engaging with stakeholder will be considered.

March 2021: TSB assessment of the response (Satisfactory Intent)

In its response, Transport Canada (TC) indicated that it agrees with Recommendation A19-02 and will undertake a campaign to address the safety deficiency identified in the recommendation.

Echoing its initial response from early 2020, TC continues to plan a similar strategy that was employed with its General Aviation Safety Campaign. The Air Taxi Safety Campaign will aim at helping to eliminate the acceptance of unsafe practices in the sector.

TC indicated that as part of its planned campaign, the following activities would take place:

  • Review and update of existing literature and communication products to promote safety in the air-taxi sector;
  • Development of new safety promotion products targeting specific unsafe practices; and
  • Broader outreach to air-taxi passengers.

TC indicated that, due to the ongoing global pandemic, the campaign has been delayed from the original launch in the fall of 2020. TC indicated that, once the air-taxi sector has resumed operations and is able to be fully engaged to receive messaging and safety information on the subject, TC will then announce the launch of the campaign, inviting the air-taxi industry to participate. TC is currently planning for early 2021 as a possible timeframe to start. Due to the uncertainty regarding the progression of the pandemic, TC also indicated it was considering the use of alternative methods for communicating and engaging with stakeholders in the air-taxi sector.

The Board is encouraged by TC’s planned actions to address the safety issues associated with the acceptance of unsafe practices in the air-taxi sector. These actions, when fully implemented, have the potential to substantially mitigate the risks associated with the safety deficiency identified in Recommendation A19-02.  

Therefore, the response to Recommendation A19-02 is assessed as Satisfactory Intent.

December 2021: response from Transport Canada

Transport Canada (TC) agrees with the recommendation.

Since the recommendation was issued in December 2019, TC committed to work with its stakeholders to identify unsafe practices and support initiatives that will improve safety. TC discussed this recommendation with its partners during the Aviation Safety Collaboration Forum in January 2020 and obtained their support for TC to set up an Air Taxi Safety Campaign (ATSC), which will look at eliminating the acceptance of unsafe practices by promoting a positive safety culture in the air taxi sector.

In our last update in December 2020, the Department mentioned that due to the ongoing situation with the global pandemic, the campaign has been delayed.

Since then, TC has completed some background work in preparation of the launch of the ATSC:

  • A communications plan and key messages related to the campaign objectives to collaborate with stakeholders during the first year.
  • Three pillars grouping the areas to be addressed as per the TSB recommendation (Safety, Operational and Sector pressures) have been sorted and defined in order to develop strategies, education products, and tools to help air-taxi operators and their clients eliminate the acceptance of unsafe practices.
  • A project plan addressing the road map for the next 4 years of the campaign has also been structured and, as a campaign teaser, a web page for the air taxi that has been created.Footnote 1
  • Other activities in preparation include the review and earmarking of existing literature and communication products for updates; and branding discussions for the look and feel of the campaign.
  • Contact information for potential stakeholder participants from industry who could be contacted during the campaign for collaboration initiatives is being gathered and verified.

Once the air-taxi sector has resumed operations and can be fully engaged to receive messaging and safety information on the subject, TC will be sending a letter announcing the launch of the ATSC inviting industry to participate. The new tentative timeline of Spring 2022 for industry engagement is expected.

March 2022: TSB assessment of the response (Satisfactory Intent)

In its response, Transport Canada (TC) indicated that it agrees with Recommendation A19-02 and will undertake a campaign to address the safety deficiency identified in the recommendation. TC indicated that due to the ongoing situation with the global COVID-19 pandemic, the campaign has been delayed.

However, TC has completed some background work in preparation for the launch of the Air Taxi Safety Campaign, which includes:

  • developing a communications plan and key messages related to the campaign objectives to collaborate with stakeholders during the first year;
  • grouping the safety, operational and sector pressures into areas to be addressed per the TSB recommendation;
  • developing a 4-year project plan for the campaign, as well as creating a web page;
  • reviewing the existing literature and communication products of the campaign; and
  • identifying potential stakeholders from industry that TC may collaborate with during the campaign.

Due to the uncertainty regarding the progression of the COVID-19 pandemic, TC has indicated that its new tentative timeline for industry engagement is spring 2022.

The Board is pleased that TC is preparing to launch the Air Taxi Safety Campaign and is planning to engage industry stakeholders in the coming months. These actions, when fully implemented, have the potential to substantially mitigate the risk associated with the safety deficiency identified in Recommendation A19-02.

Therefore, the response to Recommendation A19-02 is assessed as Satisfactory Intent.

January 2023: response from Transport Canada

Transport Canada (TC) agrees with the recommendation.Footnote 2

Since the recommendation was issued in December 2019, TC has worked with its stakeholders to identify unsafe practices and support initiatives that will improve safety. TC discussed this recommendation with its partners during the Aviation Safety Collaboration Forum in January 2020 and obtained their support for TC to set up an Air Taxi Safety Campaign (ATSC) which will look at eliminating the acceptance of unsafe practices by promoting a positive safety culture in the air taxi sector.

In our last update in December 2021, the Department reported completing some background work in preparation of the launch of the ATSC that includes a project plan addressing the road map for the next 4 years of the campaign and, as a campaign teaser, a web page for the air taxi that has been created.

As mentioned in the previous updates, due to the ongoing global pandemic, the launch of the ATSC was delayed from the original planned launch in the fall of 2020. As a result, it was decided that once the air-taxi sector resumed operations and was able to be fully engaged to contributing and receiving messaging and safety information on the subject, TC would then announce the launch of the campaign, inviting the air-taxi industry to actively participate.

With the industry recovering, TC is now pleased to announce the soft launch phase of the ATSC and held a virtual launch meeting on January 17, 2023.

Additionally, a TC ATSC websiteFootnote 3 has been created and updated with new campaign details and links. The website will provide access to free safety material, tools to help air‐taxi operators and their clients reduce safety risks and promote a positive safety culture.

Further work and promotional activities have also recently taken place, including promotion of the ATSC through the departmental Twitter account. A short animation video was developed to promote the launch of the ATSC with emphasis on the elimination [of] the acceptance of unsafe practices. This video is planned to be released early in 2023. Additional activities completed in 2022 include the creation and distribution of promotion material which includes banners and promotional cards to promote safety in the air-taxi sector.

Finally looking ahead to 2023, TC in collaboration with industry associations, will finalize the topics and issues based on the feedback received from our first meeting. This will allow us to develop the ATSC seminar schedule, content for further focus groups, safety seminars, and future promotional material.

March 2023: TSB assessment of the response (Satisfactory Intent)

In its response, Transport Canada (TC) indicated that it agrees with Recommendation A19-02 and will undertake a campaign to address the safety deficiency identified in the recommendation. TC indicated that, due to the ongoing situation with the global COVID-19 pandemic, the campaign had been delayed from the original planned launch in the fall of 2020.

With the industry recovering, TC has taken the following actions since its December 2021 response:

  • held a soft launch of the Air Taxi Safety Campaign (ATSC), created a website that will provide access to free safety material and tools to help air taxi operators; and
  • created and implemented other promotional activities to raise awareness of the ATSC.

The Board is pleased that TC is planning to finalize the topics and issues to develop the ATSC seminar content and schedule for further focus groups, safety seminars, and future promotional material. These actions, when fully implemented, have the potential to substantially mitigate the risk associated with the safety deficiency identified in Recommendation A19-02.

Therefore, the Board considers the response to Recommendation A19-02 to show Satisfactory Intent.

Latest response and assessment

December 2023: response from Transport Canada

Transport Canada (TC) agrees with the recommendation.

Since the recommendation was issued in December 2019, TC has worked with its stakeholders to identify unsafe practices and support initiatives that will improve safety. TC discussed this recommendation with its partners during the Aviation Safety Collaboration Forum in January 2020 and obtained their support for TC to set up an Air Taxi Safety Campaign (ATSC) that will look at eliminating the acceptance of unsafe practices by promoting a positive safety culture in the air taxi sector.

In its December 2021 update, the Department reported completing some background work in preparation of the launch of the ATSC that includes a project plan addressing the road map for the next 4 years of the campaign and, as a campaign teaser, a webpage for the air taxi that has been created.

As mentioned in the previous updates, due to the ongoing global [COVID-19] pandemic, the launch of the ATSC was delayed from the original planned launch in the fall of 2020. As a result, it was decided that once the air‑taxi sector resumed operations and was able to be fully engaged to contributing and receiving messaging and safety information on the subject, TC would announce the launch of the campaign, inviting the air-taxi industry to actively participate. With the industry recovering, TC announced the soft launch phase of the ATSC and held a virtual launch meeting on January 17, 2023.

Additionally, a TC ATSC websiteFootnote 4 was created and updated with new campaign details and links. The website will provide access to free safety material, tools to help air‐taxi operators and their clients reduce safety risks and promote a positive safety culture.

Since its last update in January 2023, TC has developed promotional and educational products and materials as well as updates to the ATSC website to include new content for pilots, AMEs [aircraft maintenance engineers], operators, and their clients. These materials include a short, animated video to announce the campaign and its objectives (made available on TC’s website in Spring 2023) and printed products that will be distributed at events and conferences.

Additionally, since the previous update, TC participated in industry events such as [those organized by] Northern Air Transport Association (NATA) and Air Transport Association of Canada (ATAC), to promote the ATSC and invite participants to be part of future working groups. These working groups will convene based on the following safety themes: safety pressures, operating pressures, and sector pressures. The working groups are a way for TC to actively engage with this aviation community, support best practices, and reduce safety risks in the air-taxi sector.

Finally, looking ahead to 2024, TC in collaboration with industry associations, will create a focus group to help better understand the safety risks within the air-taxi industry and discuss how to increase safety mindset that will eventually lead to a culture where unsafe practices are considered unacceptable. The focus group will be responsible for refining, reviewing, and approving the ATSC survey that will be launched across the industry. The intent of this survey is to develop strategies, with industry stakeholders, that will lead to the reduction of accidents and incidents in the air-taxi industry. The focus group members will also identify safety deficiencies and share best practices, tools, and safety data specific to air-taxi operations.

Also, the ATSC will be a topic of discussion at the next planned virtual Aviation Safety Collaboration Forum (ASCF) that will take place in April 2024.

February 2024: TSB assessment of the response (Satisfactory Intent)

In its response, Transport Canada (TC) indicated that it agrees with Recommendation A19-02 and has been working to support initiatives that will improve safety.

TC has completed the following activities:

  • Created and updated the website for the Air Taxi Safety Campaign (ATSC).
  • Developed promotional and educational products.
  • Participated in industry events, promoting the ATSC.

The Board is pleased that TC is continuing to work on identifying safety deficiencies and improving safety, including:

  • planning working groups and a focus group to engage with stakeholders and to better understand and reduce the safety risks within the air-taxi industry;
  • assisting in creating a survey to develop strategies that will reduce accidents and incidents; and
  • discussing ATSC at an upcoming event.

These actions, when fully implemented, have the potential to substantially mitigate the risk associated with the safety deficiency identified in Recommendation A19-02.

Therefore, the Board considers the response to Recommendation A19-02 to show Satisfactory Intent.

File status

The TSB will continue to monitor the progress of TC’s actions to mitigate the risk associated with the safety deficiency identified in Recommendation A19-02, and it will reassess the response to the recommendation an annual basis or when otherwise warranted.

This deficiency file is Active.