Presentation on Air Safety Issue Investigation A15H0001

November 2019
Kathy Fox, TSB Chair

Versions of this presentation were delivered throughout November 2019 to the Northern Air Transport Association (NATA), the Helicopter Association of Canada (HAC), and the Air Transport Association of Canada (ATAC).

Check against delivery.

Slide 1: Title

Slide 2: Outline

Slide 3: A declining accident rate
Overall, aviation in Canada has shown improved safety performance over the past 20 years. However, as you will see in the next slide, the air taxi sector continues to have more accidents, causing more fatalities, than all other sectors of commercial aviation in Canada—combined.

Slide 4: Which sector has the most accidents?
From 01 January 2000 to 31 December 2017, there were:

• 789 air-taxi accidents in Canada; and
• resulting in 240 fatalities.

This represents 55% of all commercial aviation accidents in Canada, and 62% of the fatalities in this period.
In contrast, for the same period, there were only:

• 93 airline accidents in Canada (6% of the total); and
• resulting in 15 fatalities (4% of the total).

But why? Why does this one sector of Canada’s aviation industry account for such a large proportion of accidents and fatalities? Let’s start to answer that question by painting a picture of what the sector looks like.

Slide 5: Context of air taxi operations in Canada

Canada’s aviation industry is as diverse and unique as the country itself, and nowhere is this better illustrated than in the commercial aviation sector known as “air taxi.” These smaller aircraft—carrying less than 10 passengers, by regulation—provide Canadians with a broad array of services: helicopters that transport injured or ill patients to hospitals; floatplanes to take commuters from harbour to harbour in coastal cities or to hunting or fishing camps; and aircraft to bring workers to remote areas, or deliver food, equipment, and passengers to small communities.

And although these vital air links have helped build Canada and sustain its population, air taxi operations are at higher risk than other sectors of the commercial aviation industry.

So again … why?

Well, partly because of the nature of the work. Air taxi operations take place in a very. different. context. from other sectors of commercial aviation—very unlike large scheduled airlines. Air-taxi services often have no set schedule and fly into remote areas in uncontrolled airspace with few or no aerodromes or navigation aids. Flights tend to be shorter, resulting in more takeoffs and landings. Access to basic weather information, or the latest aircraft technology, may be limited, especially when the aircraft themselves are sometimes decades old.

Slide 6: SII research questions

I n 2015, the TSB began a safety issue investigation—an exhaustive analysis of the sector as a whole, one that identifies the major risks faced by those who operate in this sector, as well as how those risks impact safety on every single flight.

Onscreen, you can see some of the questions we wanted to answer.

Slide 7: How the SII was conducted

In addition to the 17 previous studies that we looked at (which date back to 1990), we also sifted through a lot of TSB data, including:

• Qualitative analysis of TSB investigation report content (N=167)*
• Of these occurrences, 109 involved aeroplanes, 57 involved helicopters, and 1 involved both types
• Quantitative analysis using study-generated accident type categories (N=716)
• Qualitative analysis of summary transcripts (N=~300 hours of audio from 125 interviews with 32 operators) generating safety themes
• Qualitative analysis integrating accident type underlying factors and safety theme underlying factors to identify the best approach for raising the safety bar and improving the safety of air-taxi operations.

Slide 8: Industry consultations

I said on the previous slide that we conducted 125 interviews. That’s because we felt it was vital to hear from as much of the industry as possible. Here’s how that breaks down…

[Speak to slide]

Slide 9: Accident types

After sifting through all that data …

“Grounded theory” method was applied to create contextual accident types; i.e., types of accidents that described the circumstance of the accident as well as the outcome.

This yielded 14 aeroplane-related accident types and 9 helicopter-related accident types (23 in total).

Slide 10: 19 safety themes

We then identified 19 safety themes, illustrating the day-to-day challenges of operating in the air-taxi sector.

[Speak to slide as needed.]

But identifying those themes was only the start. Next, we mapped the themes onto the safe operating envelope model (which you’ll see on the next slide).

That model, which is applicable to socio-technical systems such as the air-taxi sector, was used to help illustrate the interactions between the safety issues and the context of the sector, and to help understand where safety improvements would be most effective.

What does all this look like on a day-to-day basis – in the real world? Well, there’s no such thing as a typical accident, but let me give you a scenario to illustrate some of what’s involved.

Slide 11: Safe operating envelope model

This diagram shows how the 19 safety themes were mapped onto the model of a “safe operating envelope.”

[Speak to slide]

Slide 12: Safe operating envelope model (continued)

Here’s a simplified version of that same model.

Like any business, air taxi operators face competing pressures—pressures that they have to manage in order to deliver a service, stay safe, and also stay economically viable.

As long as those competing pressures stay in relative balance, each flight should operate safely. But the problem is, those pressures don’t stay in balance on their own. They are always shifting, pushing the operation toward certain … boundaries.

Slide 13: Safe operating envelope model (continued)

Cross any of those boundaries and there are … consequences.

Slide 14: Safe operating envelope model (continued)

For instance, let’s say maintenance costs go up—way up.

Bankruptcy may be likely, unless costs can be reduced—for example, by delaying that maintenance work.

Slide 15: Safe operating envelope model (continued)

Or maybe a pilot gets sick, or is fatigued from long hours, and the flight cannot depart. So the company has to call in a second pilot.

But let’s say that pilot arrives to find the aircraft is loaded a little overweight and the weather isn’t optimal.

Slide 16: Safe operating envelope model (continued)

Now there’s pressure from the clients and the boss for that flight to depart.

That’s where the problem lies: as you approach those boundaries. Because these competing pressures can force air taxi operations into a space that isn’t safe.

Slide 17: Safe operating envelope model (continued)

That doesn’t mean the result is always an accident …

Slide 18: Safe operating envelope model (continued)

… but it almost always means a reduced margin of safety.

Slide 19: Safe operating envelope model (continued)

The fix is to improve the balance of those pressures, especially the safety pressure.

But how do you do that?

Currently, there are 22 active TSB recommendations that apply to the air-taxi sector and need to be addressed.

As a result of this study, the TSB is issuing 4 new recommendations. These recommendations are broader than the previous 22.

Think of them as the “glue” binding together the necessary safety action.

Let’s take a closer look.

Slide 20: Boiling it down: 2 key underlying factors

When you boil it down, it turns out that air-taxi accidents that occurred during the study period fell into two broad areas:

First, a slow, incremental drift toward accepting unsafe practices. And I’m not talking about flagrant rule violations; I’m talking about a gradual drift that occurs over time with every successful (though not necessarily safe) flight. For instance: flying overweight, flying into marginal weather or forecasted icing, or flying with minimal fuel reserves.

These unsafe practices, however, which operators may not see as “unsafe” because they’re viewed as part of getting the job done … are compounded by factor number two: inadequate management of operational hazards. Here I mean things like sub-optimal crew pairing, dispatching a flight with a different pilot after a first pilot has refused, or not having scales available so that aircraft aren’t flown overweight.

Slide 21: TSB Recommendation A19-02

Hydro workers will always need to get to transmission sites … safely. People in remote communities will always need to get to a hospital … safely. Commuters. Tourism … The need for air taxi operations is not going away. But at the same time, air taxi flight crews and their passengers should not have to accept a reduced level of safety compared to those who fly on scheduled airlines.
And so things need to change. That will mean getting clients, passengers, crews, and operators to stop accepting unsafe practices—even unwittingly—and to speak up to prevent them from happening. And it will mean proactive safety management … all aimed at creating a culture of operating safely.

That’s what the first recommendation is all about: raising the bar on safety.

[Speak to slide.]

Slide 22: TSB Recommendation A19-03

The second recommendation is about how to promote proactive safety management processes and a positive safety culture. This where you come in.

In recent years, many industry organizations have promoted initiatives that go beyond current regulations, setting higher standards for members. A roadmap, as it were, toward best practices and safer flights.

Many operators belong to a variety of associations, such as:

• the Air Transport Association of Canada (ATAC)
• the Helicopter Association of Canada (HAC)
• the Association Québécoise du Transport Aérien (AQTA)
• the Floatplane Operators Association (FOA), and
• the Northern Air Transport Association (NATA)

Such associations are well positioned to influence safety within the sector and can provide a venue for sharing best practices, tools, and safety data specific to air-taxi operations. They can also provide assistance and training in implementing proactive safety management that incorporates a positive safety culture.

[Speak to slide.]

Slide 23: TSB Recommendation A19-04

Some operators interviewed for this SII identified gaps in the existing regulations and standards, and some operators recommended practices that go beyond the current regulatory requirements or that include concepts that are not yet addressed by regulations.

What do we mean by “gaps”? Well, for example, some operators have found that there’s a safer way to do things, a way that includes going above and beyond the regulatory minimum. They carry out all flights under instrument flight rules, for example. Or they use 2 pilots for all operations. Or they establish their own minimum requirements for pilot flight experience and training.

However, in the face of competing pressures, other operators may choose to simply comply with the existing regulations, even though going beyond the regulations would increase safety pressure. These operators, for example, may limit training expenses by providing only the training required by regulation, even when specialized mountain or survivability training (for instance) would mitigate risks associated with the operation.

As long as these gaps exist in the regulatory framework, there will be an uneven level of safety in the air-taxi sector.

[Speak to slide.]

Slide 24: TSB Recommendation A19-05

The fourth recommendation is about evaluating the impact of these safety actions—specifically, activity data such as hours-flown or movements.

Currently, hours-flown and movement data for commercial aviation in Canada are not broken down by sector or aircraft type when collected by the government. As a result we know how many accidents and fatalities occur in the air taxi sector each year, but we cannot calculate the accident rate per hour flown. This is critical, because if there’s a change in the number of accidents, we have no way of knowing whether it’s because there were fewer flights, or because of something else. And stakeholders need this data to determine if their actions are actually working.

[Speak to slide.]

Slide 25: Going forward

If Transport Canada and industry take action on today’s four new recommendations – as well as the previous 22 recommendations aimed at this sector – that will go a long way to raising the bar on safety for the air taxi industry in Canada.

Slide 26: Conclusions

[Speak to slide.]

Slide 27: Questions?

Slide 28: Contact us