AQTA – Keynote address
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Chair, Transportation Safety Board of Canada
Ottawa, Ontario, 19 March 2015
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[Slide 1: title page]
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'd like to start by congratulating you—l'Association québécoise du transport aérien (AQTA)—on a milestone anniversary. 40 years! That's four decades of “promoting and developing the interests of your members and of your industry” in Quebec. To come this far takes a clear vision and mandate, commitment, perseverance, and teamwork. So, well done!
In 10 days, 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 over 550 recommendations.
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.
[Slide 2: Balancing competing priorities]
In any transport organization, operators need to balance competing goals and multiple priorities. These include: safety, customer service, productivity, technological innovation, cost-effectiveness and return on shareholder investment. I have first-hand experience with these challenges: From 1982 until 1992, I was co-owner and operator of an air taxi company and flight training school near Montreal. This was pre-CARsFootnote 1 In today's terms, it would have been described as a 702Footnote 2/703Footnote 3/ FTUFootnote 4 operator with an Approved Maintenance Organization.
Now, we all know that most organizations publicly assert, “Safety is our first priority”. However, there is convincing evidence that profitability is often their first priority. In part, that's because 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, it may be relatively easy to calculate the costs avoided by not investing in new safety initiatives—but it's very hard to calculate what that adds in terms of an increased level of risk. Take, for example, pop-out windows and doors for float-planes, which are not yet mandatory. Or take Terrain Awareness Warning Systems (TAWS) for other aircraft, which are mandatory. Yes, some pro-active companies choose to make changes without being required to do so. But I'm also sure others choose not to spend money unless forced to by new regulations.
One way to better quantify the benefits of 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 and be able to look closely at why it happened, and at what non-punitive corrective actions may be required to prevent it from happening again. This corrective action could include crew training, for instance, or revisions to Standard Operating Procedures or aircraft maintenance practices. This is closely tied to an organization's safety culture; for example, do employees actually feel safe to report incidents? Or do they feel they'll be “blamed” or “punished?”
Assuming a company's safety culture is indeed healthy, an on-board recorder can be of great assistance in identifying incidents, and the resultant flight-data monitoring can provide a more realistic picture of normal operations. For instance, data-monitoring 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.
[Slide 3: Recurring findings]
Even without on-board recorders, however, the TSB has identified a number of causal and contributing factors that have appeared over and over again, particularly in accidents involving 703 carriers. Some of these factors include: pilot inexperience and insufficient training; as well as deficiencies in pilot decision-making, especially in poor weather. There's also pressure from clients, adaptations from company SOPs, aircraft handling (particularly with respect to stalls and unstable approaches), and the issue of operational control.
And while there's no such thing as a “typical” 703 accident, certainly not one that captures all of these factors, there are cases that illustrate some of these quite clearly.
One good example is our investigation into the crash of a Eurocopter AS350-BA helicopter north of Sept-Îles, Quebec, in 2010.Footnote 5
[Slide 4: Sept-Iles, QC (A10Q0132)]
On 17 August, 2010, shortly after 11 am, the pilot and three passengers departed under visual flight rules (VFR) from Sept-Îles, heading for Poste Montagnais, Quebec, approximately 100 nautical miles north. Fifty minutes after takeoff, the company's flight-following system indicated that the helicopter was 22 nautical miles north of Sept-Îles and not moving. A search was conducted and the wreckage was found on a plateau. There was no fire, but the aircraft had been destroyed on impact, killing the pilot and the 3 passengers.
In the spring of 2010, the pilot had begun his first season as a commercial helicopter pilot with this operator. At the time of the occurrence, the pilot had logged about 235 hours of flight time, including 113 hours as pilot in command.
Hydro-Quebec had chartered the helicopter to fly 3 passengers and 300 pounds of baggage to Poste Montagnais, with additional equipment to be transported separately on another fixed wing aircraft. However, the passengers showed up with about 760 pounds of work tools which they insisted they wanted to bring with them on the helicopter. Therefore, the pilot reduced the fuel load from the planned 75% to 60%, or about 2 hours for the planned 1 hour and 15 minute flight. As a result, the helicopter took off almost 400 pounds overweight, and with reduced fuel to deal with any en route contingencies.
[Slide 5: Planned flightpath and deviation (A10Q0132)]
The departure was postponed several times by the operator due poor weather. When it finally took off, in marginal weather conditions of low ceilings and restricted visibility, the pilot planned to follow the power lines to the Moisie River valley, then follow the railway tracks in the Nipissis valley north to destination. For undetermined reasons, the pilot didn't follow the railway tracks, but continued to fly at low level over the Moisie River for another 8 minutes or so. The helicopter then turned northeastbound toward the mountains before doubling back to the river. Given the helicopter's dwindling fuel situation, and the pilot's desire to complete the mission successfully rather than return to base, the pilot probably chose to take a shortcut to the east in the hopes of rejoining the Nipissis valley. Clouds were shrouding the mountain tops but the pilot likely felt he could fly over the plateau at low level.
The pilot continued the flight in conditions that were below visual flight rules (VFR) weather minima, thus increasing the risk of losing visual reference with the ground. While flying in marginal weather conditions, the pilot lost visual contact with the ground and then control of the aircraft, causing it to crash into terrain.
[Slide 6: Risk findings (A10Q0132)]
Again, this was just one accident, but it raises—and highlights—issues that are common for other 703 operators. (I'll note also that, although this was a helicopter accident, the issues are similar for fixed wing aircraft.) For instance:
- When the passengers of a large client show up with excess baggage, they exert implicit pressure that could lead the carrier and pilot to allow an overloaded flight.
- When baggage is not weighed, the take-off weight cannot be accurately calculated, and the helicopter may take off with weight in excess of the maximum allowable, thus increasing the risk of an accident due to overload.
- When inexperienced pilots face operational pressures alone without support from the company, they can be influenced to make decisions that place them and their passengers at risk.
When the TSB finds these kinds of 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?
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)—and here, I am talking about program validation inspections, or PVIs—did not have the expected results to ensure compliance with the regulations, and consequently unsafe practices persisted.
[Slide 7: Crew resource management (CRM)]
Another big issue on the TSB radar is the concept of crew resource management (CRM). The 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 any 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.
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.
[Slide 8: Safety management systems (SMS)]
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'll come back to this in a moment, but for now I'd like to turn to the overall aviation accident record in Canada. As I said earlier, we generally have a very safe air transportation system in Canada, especially for the larger carriers, which have had just one fatal accident in the previous 10 years.Footnote 7 [Slide 9: Accidents: 703 vs other categories] Unfortunately, the record is not as good for the smaller carriers. For the 10-year period ending December 2014, 57% of all commercial aviation accidents involved 703 operations, rising to 93% if you add in 702 and 704 operations. 63% of the fatalities occurred in 703 operations, or 95% if we add in 702 and 704 operations.
These are shocking numbers, and they are a key part of why I announced last November that the TSB will conduct a Safety Issues Investigation into risks associated with air taxi operations.
[Slide 10: Safety Issues Investigation (SII)]
A Safety Issues Investigation (also known as a Class 4 investigation or SII) is much broader in scope than our normal accident investigations. Starting this May, we will adopt a two-phase approach. Broadly speaking, the first phase will see us spend approximately six months analyzing data, accident reports, and studies by other groups and agencies from the past 15 years to identify the common themes and safety issues. The second phase, which is expected to take up to a year, will see us discuss these issues with operators, with the regulator, and with other stakeholders. We will be looking to analyze what we've found, to prepare an initial draft report, and then to report publicly on what we've learned. This may also include issuing recommendations if we feel they are required. Our team will consist of a number of investigators, along with experts in statistical analysis and human performance.
[Slide 11: TSB Watchlist]
But the SII was only one of the big announcements we made last November. The other was the unveiling of the TSB's Watchlist, a document that identifies those issues posing the greatest risk to Canada's transportation system. For those who don't know, the TSB Watchlist was first launched in 2010. A second iteration followed in 2012, to reflect progress in numerous areas. More progress allowed us to update the Watchlist again in 2014, but there are still areas where we have seen little or no progress, including: approach-and-landing accidents, the risk of collisions on runways, and the need for more companies to put in place measures to help them manage safety, and for the government to oversee these processes, and step in when they are not working properly.
I touched on this a moment ago when I mentioned SMS, but the issue is important enough that it bears repeating. Ideally, a government would implement regulations requiring all transportation companies to have formal safety management processes. And ideally, a government would oversee these processes in a balanced way, using a combination of inspections for compliance, and audits for effectiveness.
Again, I am a former owner/operator of small air taxi operation, so I understand that businesses don't always want more regulations or more government oversight. But regulations can be a very good way to ensure a level playing field in a highly competitive environment, especially because safety initiatives cost money. And sometimes a regulation may be the only way to ensure public safety.
And I also understand that small- to medium-sized companies may not have the financial resources to invest in sophisticated technology or more staff. But there's an old adage: “If you think safety is expensive, try having an accident!” And when you factor in those costs— the possible cost in human lives, the costs of repairs to equipment, of lost business, of ruined reputation—it's all the more reason to conduct a risk analysis of operations, and then put in place mitigation to reduce the chances, or the consequences, of an accident. That's what managing risk is all about.
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 l'AQTA and its members to help move the safety bar higher.
[Slide 12: Questions?]
Thank you for your kind attention. I'd be happy to take a few questions.
[Slide 13: Canada wordmark]