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Presentation to CBAA 2018

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Kathy Fox
Chair, Transportation Safety Board of Canada
Waterloo, Ontario
June 13, 2018

Check against delivery.

Slide 1: Title

Slide 2: Outline

Slide 3: About the TSB

Slide 4: How we communicate safety information

The TSB uses a variety of escalating products to communicate our safety messages, shown here pictorially.

Safety information letter: Safety information letters are generally concerned with safety deficiencies posing relatively low risks, and are used to inform regulatory or industry stakeholders of unsafe conditions that do not require immediate remedial action. Safety information letters are used to pass information for the purposes of safety promotion or to support or clarify issues that are being examined by a stakeholder.

Safety advisory letter: Safety advisory letters are concerned with safety deficiencies that pose low to medium risks, and are used to inform regulatory or industry stakeholders of unsafe conditions. A safety advisory letter suggests remedial action to reduce risks to safety.

Investigation report: The TSB conducts independent investigations into selected transportation occurrences in order to make findings as to their causes and contributing factors.

Safety concern: Provides a marker to the industry and the regulator that the Board has identified a safety deficiency for which it does not yet have sufficient information to make a recommendation. As more data and analysis becomes available, and if the safety deficiency is found to be systemic and not redressed, the safety concern may lead to a recommendation. Safety concerns are usually communicated in final investigation reports.

Board recommendation: The Board makes recommendations to address systemic safety deficiencies posing significant risks to the transportation system and, therefore, warranting the highest attention of regulators and industry. Under the CTAISB Act, federal ministers must formally respond to TSB recommendations within 90 days and explain how they have addressed or will address the safety deficiencies.

TSB Watchlist: The Watchlist identifies the key safety issues investigated by the TSB that pose the greatest risks to Canadians. Each issue identified on the list is supported by one or more of the safety communications described previously. In each case, actions taken to address these risks to date have been inadequate, and industry and the regulator must take concrete steps to eliminate them.

Slide 5: New! Class 4 Occurrence (Limited Scope Investigation)

The TSB recently reviewed and updated its policy on occurrence classification. We wanted to be more efficient, make better use of our resources, and be more transparent about how those resources are being invested. As part of these changes, the TSB has now started issuing a new class 4 short form report.

These are limited-scope factual investigations with reports that are significantly shorter, and I do mean short: typically a maximum of 6 pages. You'll be able to read the whole thing, front to back, in roughly the time it takes to drink a coffee.

The content will be mostly factual, and may contain limited analysis—but it will not include findings or recommendations. These types of reports should not only take fewer resources to produce, they should also take much less time, and the process will be much more streamlined than other reports.  We will still seek comments on the draft report from those directly involved; and the Board will still review and approve the final report.

In aviation, the TSB has already published four examples of this new type of short report as a pilot project, and they're available on our website:

Slide 6: Watchlist 2016

As some of you know, every two years, the TSB releases a new edition of its Watchlist, which identifies the key safety issues that must be addressed in order to make Canada's transportation system even safer. The first edition came out in 2010, with subsequent editions coming in 2012, 2014 and 2016.

There are currently 3 issues on the Watchlist that are directly related to aviation, plus two more that we consider “multi-modal.” The aviation issues are: unstable approaches that are continued to a landing, runway overruns, and the risk of collisions on runways. The multi-modal issues are safety management and oversight, and the slow progress by Transport Canada when it comes to addressing TSB recommendations.

I won't go into the details of the issues here, because we've already done so on a number of previous occasions. Plus, they are frequently addressed in detail in TSB investigation reports. What I would like to do is outline the process: how we decide which issues are the most pressing, and the way they make it onto – or, eventually off – the Watchlist.

Here's how it works currently: The directors of each investigation mode—Air, Marine, and Rail/Pipeline—start by reviewing our latest reassessments of the progress on our recommendations, and our most recent statistics. Secondly, they hold discussions with Transport Canada, with the aim of finding out what action has been, or is being, taken on a given issue. We ask questions like: Should new issues be added? Should other issues be removed? If so, which ones and why? This allows us to get a sense of what TC is thinking and planning.

We also plan to reach out informally to a few key stakeholders, specifically, those organizations and individuals who have reached out to us to express an opinion on a given issue.

Now, I need to stress: although we value such dialogue, it is not binding. The final say regarding what makes it onto—or off of—the Watchlist is the Board's. It's our decision, because the Watchlist is based on our investigations and on validated occurrence data.

So, after we've finished researching, we do an in-house assessment. Each of the modes submits to the Board a list of the issues they think should be included, and then the Board makes its decision. If issues are removed, as they sometimes are, it does not mean that the risk has been entirely eliminated – rather, that significant progress has been made toward reducing the risk. Conversely, just because an issue isn't on the Watchlist, doesn't mean the TSB feels it poses no risk at all – only that, at the moment, we do not possess sufficient data to support its inclusion on the Watchlist.

So that's the current process, which covers things up to the 2018 edition, which you can expect sometime this fall.

For the 2020 edition, we'll be making some modifications: specifically, we'll start a year early, in 2019. Our discussions with industry will also be both more widespread and more formal. Rather than wait for people to reach out to us, we're going to be proactive, and invite members of the aviation community to discuss what they see as the most important issues, and to discuss any progress, or barriers to that progress.

We expect this more formal process to accomplish two things: first, to maintain the momentum of the upcoming 2018 edition, and second, to inform the 2020 edition.

Slide 7: 5-year snapshot: 2013 - 2017

The outright number of incidents and accidents by CARs subpart possibly correlates with the amount of activity (movements, hours flown) in each subpart. However, we don't have activity data to confirm this.

For part 604 operations, there were 80 occurrences reported (77 incidents and 3 accidents) in the past 5 years.

Slide 8: Statistics 604 vs … everybody else

Here are those same numbers (77 and 3) broken down by type of event.

Slide 9: TSB Aviation investigation report A16P0186 (Kelowna)

I'd now like to talk about an accident that almost everyone here will be at least somewhat familiar with … and one frankly that I am quite eager to discuss with this particular audience.

On the evening of October 13, 2016, a privately operated Cessna Citation 500 took off from Kelowna, British Columbia, en route to Calgary, Alberta. On board were a pilot and three passengers.

Slide 10: A16P0186

Minutes after takeoff, the aircraft entered a steep descending turn and struck the ground. There were no survivors.

Despite an 18-month investigation, we aren't much closer to knowing with certainty what caused this accident. We had no flight data recorder. We had no cockpit voice recorder. These were not required by regulation, and therefore we have no detailed sequence of what went on in the flight deck.

Slide 11: A16P0186

All we have is a hypothesis: that a pilot without enough recent night flights to carry passengers, with “limited” recent experience flying by instruments, and who was likely dealing with a high workload associated with flying the aircraft alone, experienced spatial disorientation and departed from controlled flight shortly after takeoff.

The absence of verifiable data from an onboard recorder has been an issue in a number of other TSB investigations over the years, and in 2013 the TSB recommended that Transport Canada facilitate the installation of lightweight flight data recorders on board more commercial aircraft.

Slide 12: TSB Recommendation A18-01

This time we went further, recommending that Transport Canada require the mandatory installation of lightweight flight recording systems by commercial operators and private operators not currently required to carry them.

Slide 13: “The guardian of public safety”

The Board also identified a concern about how Transport Canada had conducted oversight of “private business aircraft operators”— those registered under Part 604.

All transportation operators have the primary responsibility to manage the safety risks within their own operations. But where companies are either unable or unwilling to manage safety effectively, it is vital that Transport Canada intervene, and that it does so in a way that changes unsafe operating practices. That's the job of the regulator, the guardian of public safety.

During the course of our investigation, however, the TSB found no record that this operator had ever been inspected by Transport Canada. Before or after the accident. Transport Canada was therefore unable to identify a number of safety risks, including: carrying passengers at night despite the pilot not being qualified to do so, the operator not having received approval from Transport Canada to operate this aircraft with a single pilot, and non-compliance with maintenance inspection schedules for the wing spar caps.

But the TSB's concern goes beyond just one operator. As many of you know, Transport Canada had previously delegated oversight of private business operators to the CBAA, only to take it back in 2011-12 and then, shortly before this accident, temporarily suspend planned surveillance of this sector.

Although Transport Canada recently announced it plans to resume planned surveillance of private business operators, only time will tell whether this actually happens or how effective it will be. One thing, though, is certain: notwithstanding the generally good safety record of this sector, excluding private business operators from planned surveillance means TC “doesn't know what it doesn't know” and leaves the business aviation sector exposed to higher risks that could lead to more accidents.

That's not just concerning to the TSB, it should be concerning to everyone.

Slide 14: A16A0032 (Îles-de-la-Madeleine)

I'd like to return to the subject of recorders for a moment. Many of you already know that recording systems can help companies monitor how their aircraft are being flown. But I'd also like to talk about—no, to show you—the difference they make to an accident investigation.

Earlier this year, the TSB released its report into another high-profile fatal accident, in les Îles-de-la-Madeleine, Quebec. Although that aircraft was registered in the U.S., and operated by a Canadian pilot on the basis of his US private pilot's licence, that same aircraft registered in Canada would have had to be operated under CAR Subpart 604 and is therefore relevant to this sector. The pilot in that occurrence had not only developed a lightweight recorder of sorts, but installed it on board the aircraft—even though it was not required by regulation. It was an initiative that proved invaluable, allowing investigators to piece together a detailed history of the flight, moment by moment—including what happened in the final, fateful seconds.

How detailed? Watch the following animation, which we were able to produce after downloading the recorded data.

Without that data, without the lightweight recorder installed on board, we would have faced the same situation as we did following the accident in the Kelowna: no hard answers, just a hypothesis.

That's the difference a recorder makes, and it's why the TSB is pushing for their mandatory installation by commercial and private operators not already required to have one.

Slide 15: Other business-aviation accidents in the last 5 years:

In addition to our Kelowna investigation, the TSB has carried out 1 other investigation of 604 operators in the last 5 years, and it is an ongoing Class 4:

That basically concludes what I wanted to say today.

As far as final points, I would again draw your attention to the statistics about the number of incidents and accidents involving 604s. Yes, there are relatively few of them compared to 703 and 704 operators, but the key word there is “relative”—because we don't know the activity rate.

How to know for certain? Better data. And how to get that?

Recorders are a good start. Not only do they help investigators after an accident – but they also help you, by allowing companies to monitor how your aircraft are being flown, even before there is an accident.

And that leads to safer skies, for everyone.

Thank you.


Slide 17: Contact us

Slide 18: Canada wordmark