Air transportation safety recommendation A16-14

Assesssment of the response to Aviation Safety Recommendation A16-14

Oversight of commercial aviation in Canada: Policies, procedures and training

 Recommendation A16-14 in PDF [90 KB]


On 31 May 2013, at approximately 0011 Eastern Daylight Time, the Sikorsky S-76A helicopter (registration C-GIMY, serial number 760055), operated as Lifeflight 8, departed at night from Runway 06 at the Moosonee Airport, Ontario, on a visual flight rules flight to the Attawapiskat Airport, Ontario, with 2 pilots and 2 paramedics on board. As the helicopter climbed through 300 feet above the ground toward its planned cruising altitude of 1000 feet above sea level, the pilot flying commenced a left-hand turn toward the Attawapiskat Airport, approximately 119 nautical miles to the northwest of the Moosonee Airport. Twenty-three seconds later, the helicopter impacted trees and then struck the ground in an area of dense bush and swampy terrain. The aircraft was destroyed by impact forces and the ensuing post-crash fire. The helicopter's satellite tracking system reported a takeoff message and then went inactive. The search-and-rescue satellite system did not detect a signal from the emergency locator transmitter (ELT). At approximately 0543, a search-and-rescue aircraft located the crash site approximately 1 nautical mile northeast of Runway 06, and deployed search-and-rescue technicians. However, there were no survivors.

The Board concluded its investigation and released report A13H0001 on 15 June 2016.

TSB Recommendation A16-14 (June 2016)

This, and other investigations have highlighted the need for Transport Canada (TC) to adapt its approach to regulatory oversight to the competence of the operator. The documentation provided to TC inspectors evolved considerably in the time period covered by this investigation, and TC continues to provide new training to its inspectors as outlined in the Safety action taken section of the investigation report on this occurrence.

However, recent investigations have highlighted the fact that, when faced with an operator that is unable or unwilling to address identified safety deficiencies, TC has difficulty adapting its approach to ensure that deficiencies are effectively identified and that they are addressed in a timely manner.

TC's risk-based approach to surveillance planning resulted in the operators, which were all viewed as higher risk, being scheduled for more frequent surveillance. However, in A13W0120, unsafe conditions remained unidentified when the surveillance remained focused on processes. In other occurrences, unsafe conditions were allowed to persist for an extended period while TC relied heavily on a corrective action plan (CAP) process, in which the operators were ill-equipped to participate.

Therefore, to ensure that companies use their safety management system (SMS) effectively, and to ensure that companies continue operating in compliance with regulations, the Board recommended that

The Department of Transport enhance its oversight policies, procedures and training to ensure the frequency and focus of surveillance, as well as post-surveillance oversight activities, including enforcement, are commensurate with the capability of the operator to effectively manage risk.
Transportation Safety Recommendation A16-14

Transport Canada's response to Recommendation A16-14 (September 2016)

Transport Canada agrees that it must continually enhance its oversight policies, procedures and training. In fact, independent to this accident or this recommendation, TC committed in its National Oversight Plan for 2016/2017 to conduct an evaluation of its surveillance program.

Further to that commitment, in July 2016, TC launched a Civil Aviation Surveillance Program Evaluation and Update Project. The purpose of this project is to analyse opportunities for improvement identified via inspector feedback, analyse lessons-learned, and leverage business intelligence to update the surveillance program. The goal of the project is to ensure the surveillance program effectively verifies regulatory compliance at appropriate intervals and is effective in carrying out enforcement action, as required. While the project is scheduled to complete in December 2017, the department will not hesitate to implement enhancements sooner, if warranted.

The Board's recommendation A16-14 will be used as an input to this evaluation work.

Board assessment of Transport Canada's response to Recommendation A16-14 (December 2016)

In its response, TC indicated that it launched a Civil Aviation Surveillance Program Evaluation and Update Program that is scheduled to be completed in December 2017. The Board is encouraged that TC has committed to evaluating its surveillance program, and to considering opportunities for further improvements to ensure the effectiveness of its surveillance program.

In a recent briefing to the Board, TC provided a detailed update on the various program improvement initiatives undertaken since 2015-2016. The Board is pleased to note that TC has implemented some concrete actions such as: the establishment of a National Oversight Office, the implementation of an Oversight Advisory Board, the creation of a dedicated team working on surveillance policies and procedures, strengthened oversight planning, risk-based decision making, timely enforcement actions, and taking temporary measures that will permit an increase in the number of inspections on higher-risk areas while the program evaluation and update is being done.

The Board also acknowledges TC's efforts as it strives to find the right balance between planned and reactive oversight activities, as well as in the use of the various types of oversight tools available. Although TC has implemented numerous improvements, it is too early to assess whether or not TC's actions will adequately address the safety deficiency associated with this recommendation.

Therefore, the Board considers the response to the recommendation to indicate Satisfactory Intent.

Next TSB action

The TSB will monitor TC's ongoing actions related to the short-term and long-term enhancements to its oversight policies, procedures and training.

This deficiency file Active.

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