Speaking Notes
Charles H. Simpson

Interim Chairman
Transportation Safety Board of Canada
To The International Helicopter Safety Symposium 2005
Montréal, Quebec
September 27, 2005


Thank you for those kind words of introduction.

I cannot tell you how pleased I am to be here today to participate in this safety symposium, and one that is entirely devoted to vertical flight safety issues.

I am delighted to share the stage with other keynote speakers who are recognized around the world for their leadership in transportation safety. It is an honour to see my name listed alongside Dr. "Bud" Forster, Dr. Taïeb Chérif and so many other leaders in the air safety world.

International Helicopter Safety Symposium 2005

It is also an honour for Canada to play host to the International Helicopter Safety Symposium 2005, especially since this meeting could very well begin changing the face of helicopter safety here at home and abroad.

Your commitment to commencing this dialogue here in Montréal and then following it up with the creation of a Safety Committee - with a strong mandate to design a plan and to take action - is impressive for its vision and energy.

Your goal to reduce helicopter accidents (both civilian and military) by 80 per cent over the next 10 years is both exciting and challenging, and I commend you for setting such an ambitious objective.

And I want to tell you that the time is right.

Everyone involved in the transportation safety business in Canada is on the same page when it comes to stepping up our efforts to understand why accidents happen, share data, encourage action and ultimately reduce accidents.

Before I take the opportunity to speak to you about the work of the Transportation Safety Board (TSB), let me say that my organization supports this pivotal international initiative, and we will do everything we can to contribute to dramatically improving helicopter safety, both domestically and internationally. We are ready to work with all of the organizations and agencies present here and we are anxious to share our perspectives, methodologies and information resources.

You'll find some of the TSB staff in the audience with you today, and I encourage you to seek them out and talk to them about our Canadian experiences.

Here today are Nick Stoss, the Director of Air Investigations, and Leo Donati, the Acting Manager of Human Factors - these two will be leading panel sessions on Thursday.

Then there is André Turenne, a Senior Investigator Technical Specialist, who is on the organization committee for this safety seminar.

Finally, Brian MacDonald, a Senior Investigator Operation Specialist, will be making a presentation on Wednesday on "Lessons Learned from Transportation Safety Board Investigations of Helicopter Accidents," a presentation that highlights the lessons we've learned from our investigations into helicopter accidents between 1994 and 2003.

The Transportation Safety Board of Canada

As I have mentioned, the TSB offers Canadians the assurance that accidents and incidents are thoroughly and professionally investigated so we can learn and apply the knowledge we've gained to preventing accidents in the future.

The TSB is the principal Canadian government agency with responsibility for conducting the investigation into all accidents and incidents within the federally regulated transportation sector in Canada. And we operate at arm's length from other government and transportation regulators.

I believe we are well positioned to support your initiative on helicopter safety and we have some specific ideas to put on the table today as well. Let me tell you how our mandate, and our work, fits with what you are trying to achieve.

  • We adhere to an integrated investigation methodology that provides us with consistent results. This methodology allows us to reach conclusions about how and why an accident happened, and lets us address the contributing factors as well. In all cases, we carefully examine all of the information available to determine what happened, how and why it happened, and how future occurrences can be prevented. We know that many of our recommendations have led to significant changes in the Canadian transportation sector over the years.
  • We continue to be involved in ongoing investigations of helicopter incidents and accidents involving civilian helicopters in Canada and abroad. Over the last 10 years, we've investigated 113 helicopter accidents within a wide spectrum of circumstances. Of those, 103 were accidents and 10 were serious incidents.
  • We look at all kinds of helicopter "occurrences" - those involving power loss, structural failure, loss of visual reference, loss of control, and maintenance and operational issues. The purpose of our investigations is always to identify safety deficiencies on which regulators, operators, individuals and/or manufacturers can take preventive safety action. I'll have more to say about this specific issue in a moment.
  • As the Canadian agency responsible for transportation occurrence investigations, the TSB is responsible for supporting foreign investigations of accidents involving Canadian operators and Canadian-manufactured and certified products. In the past 10 years, we have supported many such investigations.
  • We employ a highly skilled team of investigators and experts with core knowledge of their transportation modes. I can't say enough about the calibre of TSB investigators and staff. We are fortunate that a strong culture of professionalism and objectivity has taken root in our organization. Our officials know that they work in the public interest and understand the importance of the TSB's independent investigative role.
  • We are the keepers of a huge and impressive collection of investigative reports that contain quality information and recommendations about occurrences involving airplanes and helicopters. I am particularly proud to direct you to the TSB's website, which contains a virtual library of investigative reports and updates, many of which touch on helicopter safety.
  • We also communicate extensively. Recently, we've been working hard to make our findings and data more accessible and more transparent. We publish and promote all our reports, in a very public fashion, along with an annual magazine (Reflexions) that looks at specific reports and trends in air safety.
  • We are trying harder these days to ensure that our key stakeholders have ready access to our investigative reports and recommendations via our website, receive direct electronic dissemination of reports, and are provided with other safety communications and briefings. Gone are the days when we were quiet professionals, shy to share our knowledge and perspectives.
  • We generate and track the data and statistics that help us understand trends in aviation safety. I can report to you that we have noticed a definite downward trend in accidents involving helicopters over the past few years in Canada.
  • While the average over five years came in at 49 accidents per year, we experienced a drop to a new low of 41 last year. Over the same period, fatal accidents dropped from six to four per year - a good trend.
  • One of our main advantages in the safety business is that our investigators are engaged in an ongoing dialogue and are in constant contact with the Canadian safety community and with industry. Governments, other investigative agencies, regulators, operators and manufacturers talk to us all the time about their approach to safety and the innovations they are working on, whether we are engaged in a specific investigation or not.
  • We also keep an eye on the implementation of our recommendations. Soon, the TSB will take the step of going public with our internal evaluation or assessments of responses (especially the inadequate ones!) to our investigation recommendations. Our goal is to be a bit more proactive and to encourage action by keeping a close watch on those of our recommendations that we consider "open and active."

And most importantly:

  • We are advocates for improved transportation safety and we are ready to work with you to leverage what we do, and the data we collect, in the interests of improving air safety across the board.

Achieving the IHSS Goal

What I have said so far should give you some insight into the ways that our mandate and our work at the TSB can complement and support your action plan for the future. But I would like to take a moment to speak to one specific and important area.

It is our strong recommendation that your action plan also should address the issue of the reporting and investigation of helicopter incidents. In terms of helicopter safety, it has long been a concern of ours that much goes unreported and that many incidents are not thoroughly investigated.

It has been our experience that there is much to be gained from looking at incidents - even those that seem insignificant on the surface - for important clues about where there are holes in our transportation safety net.

If you apply the same investigative principles - a quality, independent investigative process and well-trained investigators - to a review of incidents, we firmly believe that you will begin to unearth the potential contributing factors to future accidents. Of course, this provides the benefit of giving everyone the information they need to plan more effective mitigation strategies.

From an investigator's perspective, the reporting of these incidents to the safety management system is the key to being able to learn from them. Currently, we rely a lot on pilots to report incidents voluntarily - what is not reported cannot be investigated.

Next, investigations of incidents tend to be cursory and shallow, and the actions taken to prevent a recurrence tend to be local and "band aid" solutions.

Another important factor is that very few of our helicopters have on-board recordings that would support a true evaluation of an accident and its causes.

The tendency is to live with and accept a lot of "near accidents" associated with helicopter operations. We all know we can do a lot better than this. You wouldn't be here if you didn't.

At the TSB, we think you need to start with more careful monitoring of helicopter "incidents" so that investigators can gather and share vital information, with a view to preventing the accidents that injure people, take lives and damage property.

TSB as a Partner

In Canada, the TSB has the role to identify and validate deficiencies, and to present compelling reasons for changes to mitigate the risks in air transportation.

However, making changes to improve safety is up to regulators, manufacturers, operators, maintainers and their motivated and expert employees.

I hope I have encouraged you today to view the Transportation Safety Board of Canada as a key source of information and experience in helping you meet your ambitious safety goals.

You don't need to read between the lines to recognize our passion and our commitment to supporting change and improvement.

The Time Is Right

With this first ever symposium, you've put a stake in the ground. You've declared a goal to substantially reduce the rate of accidents and incidents in current commercial and military helicopter operations. You (or maybe I should say "all of us") are determined to provide the tools, the information and the processes to make that goal a reality.

The time is clearly right for an international initiative focused on vertical flight safety. And the stars are aligned this week in Montréal.

All of the right people, with the right resources and the right attitudes, are in place, here at this symposium, to make a significant difference.


As I leave you, I have a few final thoughts about how we can proceed together. To make this initiative a success, we'll need to focus on:

Good Processes
We need to share our best practices in terms of the investigative methodologies we use, and how we share information, to build and sustain safe systems.

Good Data
We need to pool our data resources where we can. We collectively know a lot already about what causes incidents and accidents.

I've recommended to you today that you zero in on helicopter incidents, in addition to reported accidents.

There's a lot of information to be mined there, and we at the TSB believe this approach will make a major contribution to the achievement of your goals, our goal.

Effective Implementation
When you get down to writing the terms of reference for your Safety Committee, I encourage you to give them a strong mandate. I have every faith that the people who comprise that committee will design a process that engages the right people and delivers the right results.

And we need safety leaders - starting at the top of all of our organizations. Many of you in this room are leaders or have the capacity to inspire the leaders in your organizations. How you move forward and how you implement will be critical to your success.

Solid Evaluation
Finally, let's make sure we never let things drop and that we constantly evaluate our progress. I know I sound like an investigator (I can't help it!), but it is essential that we proactively follow up to see if actions are being taken so that we can assess the degree to which risks have been mitigated.

This symposium is a great opportunity to launch our objective to reduce vertical flight safety issues.

In conclusion, I want to thank the International and Montréal/Ottawa chapters of the American Helicopter Society, who are hosting this symposium, for including the Transportation Safety Board of Canada in these proceedings.

Thank you.

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