Presentation to CAC’s OSTA committee
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Board member, Transportation Safety Board of Canada
Ottawa, Ontario, 12 February 2015
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About the TSB
The Transportation Safety Board of Canada was formed in 1990 with the passing of the Canadian Transportation Accident Investigation and Safety Board Act. We have approximately 220 employees across the country, and the Board currently consists of 4 Board Members, including the Chair. Our mandate is to advance transportation safety in the air, marine, rail and pipeline modes of transportation. We do this by conducting independent, expert investigations of selected occurrences and then reporting our findings publically.
One of the key tools for us to advance safety has been the Watchlist, which identifies those issues posing the greatest risk to Canada's transportation system. We first issued it in 2010. We issued newer iterations in 2012 and 2014, as progress allowed old issues to be removed. This latest edition features some issues that have been expanded, as well as one new issue. There are also outstanding issues, where we have seen little or no progress.
Our goals for the Watchlist are simple:
- Raise public and media awareness about the safety risks
- Demonstrate how concrete action will advance transportation safety
- Deliver corporate messages about our mandate
- Build on existing credibility, stimulate dialogue and trigger action by change agents
I'd like to look now at the multi-modal issue, and the other air issues, in a little more detail.
Safety management and oversight
A Safety Management System—or SMS—is an excellent tool to help companies identify risks, and to deal with those risks before accidents occur. However, not all air and marine transportation companies are required to have formal safety processes in place to manage their risks. And for those air, marine AND rail transportation companies that are required to have a formal SMS, they don't always implement it effectively. Moreover, Transport Canada's oversight and intervention has not always proven effective.
The solution to this issue is threefold:
- First, Transport Canada must extend the regulations for formal safety management processes to include a wider range of operators.
- Second, those operators that do have an SMS must demonstrate that it is working—in other words, that hazards are being identified, and that effective mitigation measures are being implemented to deal with those hazards.
- Third, when companies are unable to effectively manage safety, Transport Canada must not only intervene, but do so in a way that succeeds in changing unsafe practices.
Collisions with land and water
As I mentioned, we have also removed one issue from the previous version of the Watchlist—collisions with land and water, or CFITs. That's because new regulations now require Terrain Awareness and Warning Systems (TAWS) aboard a wider range of aircraft, thereby reducing the risk. In addition, non-precision instrument approach procedures now provide pilots with guidance to make stabilized descents. So, over time, we expect to see this type of accident decrease.
This is an expanded Watchlist issue. Put simply, the problem is that approach-and-landing accidents continue to occur at Canadian airports.
Earlier this year, we released our final report into the tragic crash of a First Air flight in Resolute Bay, which revealed the catastrophic consequences of continuing an unstable approach. And I'll give you another example in a few minutes. We know that too many unstable approaches are continued to a landing, and that, across Canada, there are approximately150 approach-and-landing accidents each year.
That's why we're calling on Transport Canada and aviation operators to take action to reduce unstable approaches. We are also calling on Transport Canada to move ahead with regulatory changes to guide airports to develop tailored solutions to lengthen runway end safety areas or implement other engineered systems to stop planes that overrun.
Risk of collisions on runways
The problem is that there is an ongoing risk of aircraft colliding with vehicles or other aircraft on the ground at Canadian airports.
Case study 1: Sunwing maintenance van (A13O0045)
The image you see is a dramatization, created when we first put the issue on our Watchlist back in 2010: an unauthorized vehicle on the runway at the same time an aircraft was making its final approach.
And then it happened.
In 2013, on a dark and rainy night at Pearson International Airport, a Sunwing Airlines maintenance van was left unattended—in drive and with the engine running. It rolled toward the threshold of Runway 24R. Air traffic control noticed a target on the ground radar just as an Embraer EMB190-100 was on short final. Air traffic control twice instructed the Embraer to pull up and go around, but the flight crew did not respond. The first call was over-talked by internal air-control systems, and the second was assessed as not for them as the call sign was garbled and they saw nothing ahead of them. They continued to land, passing approximately 35 feet overhead of the van.
The TSB investigation found nine different causes and contributing factors, including:
- A driver leaving the van unattended and in gear;
- Insufficient monitoring of airport surface detection equipment at the tower controller's position;
- An alert system which only provided 2 seconds of aural warning; and
- Go-around instructions that went unheeded.
However, the greater issue is that occurrences like this one continue to happen all over Canada. In fact, in a 10-year period from 2004 through 2013, there were 4153 runway incursions in Canada. Given the millions of take-offs and landings each year, incursions are rare, but their consequences could be catastrophic.
Since the TSB first placed this issue on its Watchlist in 2010, the number of these occurrences has remained too high: in 2010 there were 346, followed by 454 in 2011, 429 in 2012, and 381 in 2013. In other words, they continue to occur more than once a day.
Improved procedures and enhanced collision warning systems must be implemented at Canada's airports.
I'd like to add here that the TSB has started having a number of one-on-one meetings with various airport authorities. For example, our Chair met with Calgary in January, and the COO met with Regina the same day. These meetings are part of our Outreach activities, to have more specific discussions about airports' operations and initiatives.
Case study 2: Northern Thunderbird Air (A12P0034)
I said earlier when mentioning the accident at Resolute Bay that the consequences of continuing an unstable approach can be catastrophic. Although not fatal, this is another example.
In March 2012, a Beechcraft 1900C was flying from Vancouver to Blue River, B.C. Arriving in the Blue River valley, the captain commenced a straight-in approach just before noon. Immediately after touchdown on the snow-covered runway, the left main gear entered an area of deep snow. The aircraft veered into the snow bank, sustaining substantial damage. The crew and the passenger were not injured.
The TSB investigation found six different causes and contributing factors, including:
- Up-to-date weather and runway condition information was not provided to the crew, nor did they request it
- The pilot continued the approach below the visibility limits specified in the company's standard operating procedures.
- Deteriorating weather, as well as the lack of approach aids and runway markings, hampered the pilot's ability to establish the aircraft onto a stable final approach prior to crossing the threshold.
- The company's standard operating procedures for stabilized approaches were not followed, and an unstabilized approach was allowed to continue.
In this case, no one was injured, and the only damage was to the aircraft. However, as I mentioned with the issue of risks of collisions on runways, the greater issue is that too many unstable approaches are continued to a landing.
Research indicates that 3.5% to 4% of approaches are unstable. Of these, 97% are continued to a landing, with only 3% resulting in a go-around. And while millions of successful landings occur on Canadian runways each year, there is a risk that accidents resulting in loss of life, injury, and aircraft damage can occur during the landing phase of flight. These accidents include runway overruns, runway excursions, landings short of the runway, and tail strikes.
The Transportation Safety Board of Canada (TSB) administers a program called SECURITAS that enables you to report-in confidence-concerns you may have about safety in the marine, pipeline, rail and air modes of transportation. It's important to note that what is reported through SECURITAS is not always reported through other channels.
Contacting SECURITAS—whether by letter, fax, phone, or by e-mail—can help the TSB identify widespread safety issues. It can also lead to the TSB making formal recommendations to the minister, or we may issue safety letters to government or industry.
It's also confidential. Our Act (Section 31) and the TSB Regulations prohibit the release of any information that could reveal a confidential reporter's identity without the reporter's written consent.
Each year, the TSB's Air Branch receives about 30 to 40 e-mails and 70 to 75 voice-mails.
What to report?
Here are some examples of things you might report to SECURITAS:
- Chronic lack of repair of aircraft, poor maintenance practices
- Unsafe runway or aerodrome conditions
- Inadequate or poor air traffic services in a particular area
- Poor reception of navigation signals, weak radio coverage, inadequate weather services
Unsafe procedures and practices:
- Routinely descending below minimum en route altitude or approach in instrument meteorological conditions
- Non-compliance with airworthiness directives, minimum equipment list
- Pilots flying in excess of regulatory flight-time limits
- Shortcuts in following checklist procedures
Special Issues Investigation — Air Taxis
Last November, at the Air Transport Association of Canada's (ATAC) annual convention in Vancouver, TSB Chair Kathy Fox announced a special issues investigation (SII) into Air taxis. Our goal is to identify the underlying safety issues and find out why air taxis are responsible for a large share of commercial aviation accidents and fatalities.
Although the terms of reference are not yet finalized, I can tell you that we will be speaking with operators and industry associations to obtain input. Part of this is because we will be seeking examples of “best practices.” Eventually, we may make recommendations to address identified systemic deficiencies.
Now let's look at the statistics, because they are truly shocking.
From 2005-2014, Air Taxi operations were involved in approximately twice as many accidents than aerial work and 10 times the number of accidents compared to either the commuter or airliner categories. And by far, the greatest number of fatalities occurs in the Air Taxi sector.
Common risk factors
This may be shocking, and unfortunately it's not new. Air taxi operations have been on our radar for some time. And previous TSB investigations have revealed some common risk factors. These include: pilot inexperience, insufficient training, deficiencies in pilot decision-making, deficiencies in crew resource management, inadequate (if any) risk analysis of operations, crew adaptations from standard operating procedures, and deficiencies in operational control.
That's just what we know already. Hopefully, the SII will help us learn a lot more.