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TSB Recommendation A19-03

Promoting proactive safety management processes and safety culture

The Transportation Safety Board of Canada recommends that industry associations (e.g., ATAC, HAC, AQTA, FOA, NATA) promote proactive safety management processes and safety culture with air-taxi operators to address the safety deficiencies identified in this safety issue investigation through training and sharing of best practices, tools, and safety data specific to air-taxi operations.

Air transportation safety investigation report A15H0001
Date the recommendation was issued 7 November 2019
Date of the latest response October 2022
Date of the latest assessment February 2024
Rating of the latest response Unable to assess
File status Dormant

Summary of the occurrence

In May 2015, the Transportation Safety Board of Canada (TSB) launched an in-depth safety issue investigation (SII) into the risks that persist in air-taxi operations across Canada. This SII reviewed 15 years of data to identify safety issues in air-taxi operations in Canada that have not been sufficiently mitigated. This SII examined air-taxi operations as a whole and considered safety issues that are germane to the entire air-taxi industry and not just to one specific segment of the industry.

The Board concluded its SII and released report A15H0001 on 07 November 2019.

Rationale for the recommendation

In recent years, organizations such as the Floatplane Operators Association, the Air Transport Association of Canada (ATAC), the Helicopter Association of Canada (HAC), the Medallion Foundation, the Federal Aviation Administration (through its Circle of Safety program), and the Tour Operators Program of Safety have come together to improve safety in sectors with a high number of accidents. The initiatives they have organized go beyond the regulations and set high standards for members. These initiatives can provide a roadmap for improving safety in the air-taxi sector in Canada, and participation by operators can also provide confidence and incentives for clients and passengers.

As these initiatives show, associations within the air-taxi sector are well positioned to influence safety within the sector. They have a responsibility to their members and the industry and can play a role in positively influencing the 3 competing pressures described in the SII. Industry associations can provide seminars, training and tools, as well as documentation and guides. As an example, industry associations have worked together successfully in the past to address a critical shortage of skilled personnel in the Canadian aviation maintenance industry.Footnote 1

In 2016, the TSB recommended that Transport Canada (TC) require all commercial aviation operators in Canada to implement a formal safety management system (SMS).Footnote 2

An SMS is generally defined as a formalized framework for integrating safety into an organization's daily operations, including the necessary organizational structures, accountabilities, policies and procedures, so that “it becomes part of that organization's culture, and of the way people go about their work.” While individual employees routinely make decisions about risk, SMS focuses on organizational risk management, yet includes and supports the decision makers at the sharp end. An SMS is scalable and can be designed to meet the needs of a given operation in a way that respects the nature of the sector.

In advance of an SMS regulation, associations can play an important role in making available and accessible to operators, modern promotion and education products and tools on safety culture and proactive safety management that will advance safety in their operations. This will foster the development of a culture of operating safely that is supported by all stakeholders.

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 could provide a venue for sharing best practices, tools, and safety data specific to air-taxi operations. They could also provide assistance and training in implementing proactive safety management that incorporates a positive safety culture.

Therefore, the Board recommended that

industry associations (e.g., ATAC, HAC, AQTA, FOA, NATA) promote proactive safety management processes and safety culture with air-taxi operators to address the safety deficiencies identified in this safety issue investigation through training and sharing of best practices, tools, and safety data specific to air-taxi operations.

TSB Recommendation A19-03

Previous responses and assessments

February 2020: response from the Air Transport Association of Canada

Overall ATAC is impressed with the thoroughness of the report and the effort obviously made to include many different perspectives of stakeholders within the Canadian Air-Taxi community. The report is very comprehensive, factual and should be useful for several years to come. ATAC considers this report to be an excellent primer and checklist for developing future safety enhancements while at the same time working closely with Transport Canada Civil Aviation (TCCA) to ensure their resources are focused and comprehensive initiatives are appropriately and accurately developed and implemented.

With this in mind, ATAC would like to emphasize that we have long encouraged TCCA to develop and implement Safety Management Systems (SMS) appropriate to the size and complexity of all commercial aviation operators. In fact, some years ago ATAC previously developed just such guidelines for our smaller operators. Although this is not something an association would normally do, we saw the need, and still do, of encouraging the 703 and 704 operators to adopt these SMS requirements voluntarily while TCCA is still considering the appropriate regulatory action.

With regards to the Report Section 6.6.2 New TSB Recommendations, ATAC will now provide specific comments to each of the new TSB recommendations.

A19-02: ATAC confirms its intent to continue to support and collaborate with Transport Canada to develop strategies, education products, and tools to help Air-Taxi operators eliminate the acceptance of unsafe practices.

A19-03: As mentioned above, ATAC has been for many years, proactively seeking and promoting the development and use of safety management processes and the accompanying safety culture within all of our members including those within the Air-Taxi sector. This has included development of specific SMS tools and training that we have made available to our members. ATAC continues to foster an SMS environment for our member companies during our committee meetings, symposiums and conferences.

A19-04: ATAC fully supports Transport Canada Civil Aviation undertaking a review of the gaps identified within the referenced TSB Report relating to CAR [Candian Aviation Regulations] 703 Regulations and associated standards. With regards to such amendments being identified as necessary to update these documents, ATAC supports and expects due consultation through the CARAC [Canadian Aviation Regulation Advisory Council] consultation process.

A19-05: With regards to the requirement for operators to collect and report hours flown and movement data for their aircraft by CARs subpart and aircraft type, ATAC supports such a recommendation on a voluntary basis only. In addition, the Governement of Canada through Statistics Canada must be tasked with developing a simple and not time-consuming data collection method that is not onerous in any way for Air-Taxi operators given their limited resources. ATAC considers this a Government of Canada responsibility and thus such a project must have all costs associated with this data collection absorbed by the Government of Canada and not passed on to the Air-Taxi operators. ATAC will however agree to work with the Government of Canada to provide relevant input in such a data gathering methodology and program.

ATAC wishes to emphasize that we are keen to support the TSB on working with the Air-Taxi industry and Transport Canada Civil Aviation to move forward on adopting initiatives that will improve the safety record of this part of our industry.

February 2020: response from the Northern Air Transport Association

The Northern Air Transport Association (NATA) appreciated the diligent efforts of the research group to produce a report that is helpful to improve overall system safety. NATA supported the study and will continue to do so with supportive events taking place at NATA 44, the northern and remote aviation conference, this year being held in Whitehorse, April 27-29, 2020.

NATA accepts the Recommendation A19-02 and A19-03 as all Associations are engaged in trying to help their members understand the issues, their responsibilities and provide tools to help them integrate new rules, programs into their operational business model. The recent decision by the Floatplane Operator’s Association to join NATA with a goal to further the development of the “North Stars Best Practices” supports the TSB Recommendations. 

Recommendations A19-04, and A19-05 identify the importance of NATA and other organizations to continue to work collaboratively with all stakeholders to increase understanding of the operational realities of northern and remote aviation in Canada and develop rules that are appropriate.

March 2020: TSB assessment of the responses (Unable to assess)

In its response, the Air Transport Association of Canada (ATAC) indicated that it continues to promote the development and use of safety management processes and safety culture. ATAC has developed tools for and provided training to all its members and will continue its support and collaboration with Transport Canada (TC) to help in eliminating the acceptance of unsafe practices in the air-taxi sector.  

In its response, the Northern Air Transport Association (NATA) indicates its engagement in supporting its members and in helping them with the integration of new rules and programs within their operations. The TSB recommendations published as a result of the Safety Issue Investigation (SII) report, Raising the Bar on Safety: Reducing the Risks Associated with Air Taxi Operations in Canada, will be the focus of presentations at NATA’s 44th annual conference and forum for Aviation in Northern and Remote Canada. The Board is pleased that the Floatplane Operators Association, which has now joined NATA, will continue developing the “North Stars Best Practices.”

The Board is encouraged that both ATAC and NATA support Recommendation A19-03 and will continue their work with their respective members. However, the details provided in both ATAC’s and NATA’s responses do not contain sufficient details with regards to future initiatives and actions planned to enable the Board to make a meaningful determination on whether the safety deficiency will be reduced or eliminated. Furthermore, the TSB did not receive any response from the Helicopter Association of Canada (HAC) or the Association québécoise du transport aérien (AQTA).

Therefore, the Board is unable to assess these collective responses to Recommendation A19-03.

October 2022: response from the Northern Air Transport Association

The COVID crisis with the associated federal travel/gather restrictions has decimated the aviation industry but has maintained an outstanding level of service and commensurate safety standard.

The operator-members of NATA have cooperated with the federal government and responsible agencies with the implementation of initial safeguards, distributing the various vaccines, and supporting the vaccine mandate even with its aggressive deadlines.

Operator’s report increased occupational stress associated with reduced available workforce, daily changing requirements and a regulator that has been focused on maintain systems security, at the expense of meeting operator’s requirements and maintaining the established service levels to maintain overall system safety. Operators report long over due approvals for aircraft, personnel and operational documents. In some cases, these delays go back years.

Under the cover of the COVID crisis the government has pushed through a variety of regulatory initiatives without the accepted level of consultation. Other regulatory instruments were used to avoid consultation, and input from operators and industry associations has been ignored.

In response to TSB, TCCA issued the following notice with no input or consultation with industry associations:

The TCCA plan is too general, and will require industry resources that are lacking, and will take away resources from TCCA to solve the service crisis.

In closing, what is TSB doing to quantify the Causal impact of TCCA’ poor service delivery and poor rule making? As Workforce issues are critical to system safety, why is TSB not cataloguing the shortages and possible solutions?

NATA and all Associations are engaged every day with their members on a variety of safety and security issues. NATA works closely with all groups and there are all kinds of effort to raise awareness of safety issues underway.

The time is right for TSB, to recognize there needs to be a more involved approach to find solutions, not just point out possible areas of concern based on a study that is now in many ways out of date due to profound changes to the Canadian aviation industry and regulatory oversight.

February 2023: TSB assessment of the response (Unable to assess)

In its response to Recommendation A19-03, the Northern Air Transport Association (NATA) highlighted the many challenges faced by Canada’s aviation industry, particularily with respect to the global COVID-19 pandemic. The Board recognizes the challenges that have been faced by the air-taxi sector during the pandemic and acknowledges the many challenges when implementing new safety initiatives.

Part of the TSB’s mandate is to make recommendations designed to eliminate or reduce safety deficiencies. These recommendations are addressed to the organization that the TSB believes is in the best position to implement the recommended changes. In this case, given the day-to-day interactions associations such as NATA have with the industry, they are well positioned to know the operational challenges faced by their members. The associations addressed in this recommendation are in a unique position to influence safety within the air-taxi sector by providing a mentorship role and helping operators learn how to manage safety on their own, implement proactive safety management processes, and promote a positive safety culture.

The TSB acknowledges the efforts NATA has made to engage with its members and raise awareness of safety issues; however, its response lacks details to demonstrate how these efforts will address the safety deficiency identified in Recommendation A19-03.

Furthermore, the TSB did not receive a response from the Helicopter Association of Canada (HAC), the Air Transport Association of Canada (ATAC), or the Association québécoise du transport aérien (AQTA) regarding TSB Recommendation A19-03.

Therefore, the Board is unable to assess the response to Recommendation A19-03.

Latest response and assessment

February 2024: TSB Assessment of the response (unable to assess)

The TSB did not receive any recent response for this assessment period from industry associations such as the Air Transport Association of Canada (ATAC), the Association québécoise du transport aérien (AQTA), the Helicopter Association of Canada (HAC), or the Northern Air Transport Association (NATA).

The issue of safety management has been on the TSB Watchlist since 2010. In response to the issue, the TSB Watchlist 2022 states that some aviation industry associations are promoting and providing tools for the development of safety management systems (SMS) to their members. Additionally, industry feedback to the TSB indicates that those operators that are not required to have an SMS are nonetheless making efforts to implement scaled versions of SMS; however, Transport Canada (TC) does not monitor the effectiveness of these operators’ SMS, and operators’ efforts are sometimes hindered by insufficient human resources or expertise, cost, and complexity.

Since the issuance of this recommendation in 2019, the Board has been unable to assess whether or not the risk associated with the safety deficiency has been mitigated given the lack of responsiveness from industry stakeholders and insufficient details provided in prior responses; this is both surprising and disappointing. In the absence of concrete actions taken or planned, the Board cannot undertake a meaningful determination on whether the safety deficiency identified in Recommendation A19-03 will be reduced or eliminated

Therefore, the Board is unable to assess  the overall response to Recommendation A19-03.

File status

TSB air transportation safety investigation reports continue to note deficiencies and concerns in the area of safety management.

Given the continued concerns raised by the Board and the lack of response from the industry associations identified in the recommendation, the TSB Chair will be sending letters to the heads of those associations in an effort to prompt concrete action. The TSB will also continue to monitor SMS-related occurrences, as well as TC and industry activity related to the safety deficiency identified in Recommendation A19-03.

At this time, continued reassessment of Recommendation A19-03 will not likely yield further results. Therefore, this recommendation will not be reassessed on a regular basis. However, occasional reviews will be conducted to see if the recommendation should be reactivated.

This deficiency file is Dormant.