PM Law 2015 Aviation Conference
Transportation Safety Board of Canada
Toronto, Ontario, 22 January 2015
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Good morning/afternoon. It’s a pleasure to be here.
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— marine, pipeline, rail and air—and then reporting our findings publically.
Note that the TSB does not assign fault or determine civil or criminal liability. We aren't a regulator, and we don't have powers of enforcement. Neither do we investigate military or criminal occurrences.
The TSB's safety Watchlist was first published in June 2010.
The list identified the most critical safety issues facing the Canadian transportation system. These issues were supported by hundreds of accident investigation reports, thousands of hours of research, as well as Board safety concerns and TSB recommendations. We chose them because they were the stubborn issues, the hard-to-solve issues, the ones that kept appearing in investigation after investigation.
Our goals with that first Watchlist, and with the second version that came out in 2012, were simple. We wanted to:
The Watchlist was first imagined as a blueprint for change and, in the months and years that followed there was enough progress that many of the underpinning Board recommendations received our highest rating—“Fully Satisfactory.”
Last fall we issued “Watchlist 3.0.” That's what I'd like to speak about today.
Once again, with this latest edition of the Watchlist, issues were removed, added—or even expanded.
But not everything has been smooth. There are still some issues where we have seen little or no change since 2010, and where we still have a long way to go.
Let's look 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 in advance, 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.
In fact, as we now know, a weak company safety culture and inadequate Transport Canada oversight were contributing factors in the 2013 tragedy in Lac-Mégantic, Quebec.
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.
And 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.
Watchlist issue removed
As I mentioned, we have also removed one issue from the previous version of the Watchlist—that of collisions with land and water, or what the industry calls 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.
There are still two issues that have remained on the Watchlist since their first appearance in 2010. Let's look at them both.
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. 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, a consequence of which can be a runway overrun. 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
There is an ongoing risk of aircraft colliding with vehicles or other aircraft on the ground at Canadian airports.
Improved procedures and enhanced collision warning systems must be implemented at Canada's airports.
Air taxis — accident statistics
Unfortunately, we continue to see certain underlying causal and contributing factors over and over again in other accidents, particularly in the 703 operations—also known as “air taxis.” Here are some sobering statistics:
Prior to the tragic crash of First Air flight 6560 in Resolute Bay in 2011, we had not had a fatal accident involving a Canadian Part 705 operation (the major carriers) in the previous 10 years. Unfortunately, the record is not as good for the smaller carriers. For the 10-year period ending December 2013, 59% of all commercial aviation accidents involved 703 operations. 65% of the fatalities occurred in 703 operations.
Common risk factors
Every accident is a unique combination of causes and contributing factors, but with air taxi accidents, too often we see the same issues recur. Some of these include: pilot inexperience and insufficient training; deficiencies in pilot decision-making and crew resource management, especially in poor weather. Other issues include: inadequate (if any) risk analysis of operations, crew adaptations from standard operating procedures, and deficiencies in operational control, especially in self-dispatch operations.
Launch of “Special Issues Investigation”
The TSB has decided to take a more in-depth look at these types of accidents. Starting later this year, we will conduct what's called a “Safety Issues Investigation” into risks associated with air taxi operations. The terms of reference are not finalized yet, but we will be speaking with operators and industry associations to obtain input on the major safety issues, how they are being managed, and examples of “best practices.”
This type of investigation is much broader in scope than our normal accident investigations. It will involve looking at multiple occurrences in order to identify the underlying safety issues, and we may make recommendations to address identified systemic deficiencies.
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