Northern Air Transport Association 2015

Kathy Fox
Chair, Transportation Safety Board of Canada
Yellowknife, Northwest Territories, April 28, 2015

Check against delivery.

Thank you very much for that introduction and for the invitation to speak to you today. It is a real pleasure to be here.

Jon Lee has just spoken to you about a number of recent or ongoing investigations of relevance to northern operators. I'd like to zoom back up to the 30 000 feet level and speak about issues that affect all air operators, regardless of location.

Today, I'd like to talk about balance, specifically, how air operators must always balance their priorities, even if these priorities are competing with one another. The list of priorities to balance is long, but here are a few: safety, customer service, productivity, keeping up with technology, cost-effectiveness, and return on shareholder investment. I understand first-hand how challenging this can be. From 1982 until 1992, I was co-owner and operator of an air taxi company and flight training school near Montreal. This was pre-CARs.Footnote 1 In today's terms, it would have been described as a 702Footnote 2/703Footnote 3/ FTUFootnote 4 operator with an Approved Maintenance Organization.

Furthermore, I have done a lot of flying in the north. In the early ‘80s, I flew a rented C172 from Abbotsford, BC, all the way to north of Fairbanks, Alaska, and also up the Mackenzie River across the Arctic Circle north of Fort Good Hope. I also flew medevacs from Montreal to Iqaluit using a Cessna 441, Conquest II in the early ‘90s. Since 2005, I have come north almost every year as a passenger flying on a number of different northern operators – as far north as Lake Hazen on Ellesmere Island. I have been dropped off by a Twin Otter on an unprepared shelf on Devon Island with a group of hikers. And I landed in Resolute Bay, only 3-4 days before the tragic crash of FAB6560, one of about 95 passengers on a First Air B737 charter to undertake a cruise through the Northwest Passage. I love the far north; and I understand first-hand just how unforgiving it can be.

And so balance can be a complicated business. Yes, we all know that most organizations publicly assert, “Safety is our first priority,” but there is some convincing evidence that the scales often tip in another direction, and that they're really prioritizing profitability. And that's understandable. Companies need to make money if they want to stay in business. Safety initiatives often cost money, something that isn't always easy to find for a small operator with thin margins. And some things, like risk, are really difficult to measure.

Let me give you an example.

In 1995, the TSB recommended that Transport Canada require GPWSsFootnote 5 on certain categories of commuter and airline aircraft capable of carrying 10 or more passengers. Well, it took until 2003 for the draft regulatory changes to wind their way through TC's industry-consultation process, and the final regulations weren't published until July 2012. That's 17 years, and during the final 10 years, there were 113 CFIT accidents in Canada, or an average of just over 11 per year. As I just mentioned, one of these happened in August 2011, when First Air flight 6560 crashed in Resolute Bay, killing 12 of the 15 people on board. Yes, there were many human, technical and organizational factors that caused or contributed to this accident … but the absence of a newer generation GPWS—or TAWSFootnote 6—certainlydeprived the flight crew of information that would have enhanced their situational awareness.

Of course not every operator delays implementing new safety technology until regulations require it; some are proactive. But given the costs associated with GPWS, which can easily be 50 or 60 thousand dollars per aircraft, you can understand why waiting may be an option some operators might consider—at least from a financial perspective. That, however, puts you in the difficult-if-not-impossible position of trying to balance a known and an unknown quantity. To put it bluntly, not having to install a GPWS or TAWS may save you 50 or 60 thousand dollars, but how many accidents does it avoid? 1? 2? 3? None? Or how much riskier are your flights as a result? 1 percent? 20 percent? You simply cannot measure.

So … with all of the risks that a business must face, with all of the “top priorities” that they must balance every day, how can companies identify where they should invest their safety dollars?

One way to address this concern is via the implementation of a safety management system—SMS. This is a formalized, systematic way for companies to identify hazards in advance, and then pro-actively mitigate the risks. In other words, an SMS helps companies find trouble before trouble finds them. No, it's not yet required for every transportation company, but in many ways it makes a lot of sense. After all, companies have HR and financial management systems; why not safety management systems?

I'll come back to this idea in a moment——but first I'd like to give you a very quick recap of how our work at the TSB has evolved a great deal over the years, along with the way people think about accidents in general. It used to be that the focus of accident investigation was on mechanical breakdowns—equipment that failed. Then, as technology improved, investigators started looking at the contributions of crew behaviour and human-performance limitations. Nonetheless, people still thought things were “safe” so long as everyone followed standard operating procedures. Don't break any rules or regulations, went the thinking; pay attention to what you're doing. And above all, don't make any “stupid” mistakes.

Even today, in the immediate aftermath of an accident, people on the street and in the media want to know quickly if it was caused by “mechanical failure” or by “human error.”

But “human error,” we now know, is not a cause of failure. “Human error” is rather the effect, or symptom, of deeper trouble. It's connected—systematically—to people's tools, to their tasks, and to the environment in which they operate. And the people who establish the goals and the priorities, the people who assign the resources and determine the rules for the operating environment, are typically higher up in an organization … meaning management. And their decisions can have a huge impact.

And so, in keeping with modern accident causation theory, which says most accidents are organizationally based, TSB investigators started to look beyond just “what happened,” and instead focused more closely at organizational factors … including safety culture and regulatory oversight.

I used the example of First Air flight 6560 earlier. So let me cite a second example that you've all heard of:

In August 2013—almost two years to the day after the First Air crash—a Buffalo Airways Douglas DC-3 took off from Yellowknife, on a flight to Hay River. As my colleague Jon Lee has already pointed out, there was an engine fire after takeoff, leading to a collision with terrain—and yet, very fortunately, no injuries.

But as I said, TSB investigations go beyond finding out just “what happened.” We also dig into why, and so we looked at the organization and at the oversight provided by the regulator. This is key, because if our investigation of the Buffalo Airways crash had stopped after determining the source of the original engine fire, we might have sent out a safety letter urging companies to make sure engine cylinders were well-maintained, or to check the bushings on their feathering pumps. Maybe we'd have even sent a reminder to be more careful not to exceed maximum takeoff weight.

But we didn't stop there, and what we uncovered were some pretty big issues.

To start, we found a company with some fundamental flaws in its safety culture, a company at odds with Transport Canada—indeed, a company that questioned the motivation, and the very competence, of TC inspectors. A company that fabricated weight and balance calculations after departure, and which had an SMS that was ineffective at identifying and correcting unsafe operating practices.

We also found issues with Transport Canada. Inspections that might have been expected to identify unsafe practices, did not. Instead, the focus of all surveillance activities was on company processes—their existence, not their application and effectiveness.

These two elements—the processes that companies use to identify risk, and the oversight provided by the regulator—are two elements of a solution. But they're not the only parts. Because processes alone are unlikely to catch everything, nor will simply increasing the number of inspections. You need that catalyst, that favorable, encouraging, non-punitive environment created by a company that understands how to balance safety, customer service, productivity, keeping up with technology, cost-effectiveness and return on shareholder investment, and which has decided to trulymake safety its “number one priority.”

In other words, you need a strong safety culture. Now, that's a term that gets thrown around a lot, so it can mean a lot of things to a lot of people. But I think personally, one of the best definitions is also the simplest: safety culture is “the way we do things around here.” In other words, are new ideas welcomed? Do employees actually feel safe to report incidents? Or do they feel they'll be “blamed” or “punished?” Does management actively encourage worker participation in recognizing and resolving potential safety problems? Do employees have confidence that management will actually take steps to fix the identified problems? How is responsibility for incorrect crew actions handled? When incidents happen, is punishment the first and only response, or does the incident lead to soul-searching and to systemic changes?

Sometimes asking these kinds of questions can lead to insight, and sometimes all you get is an uncomfortable silence. But asking them is still important, because merely telling employees to follow the rules or the regulations isn't enough to ensure safe operations.

Clearly, though, not every company provides that encouraging, non-punitive, strong safety culture. Some operators consider safety to be adequate as long as they are in compliance with regulatory requirements—the bare minimum. So, if an operator is unable to demonstrate that their processes exist and are working, what happens? Well, then it is up to Transport Canada to intervene, and to do so in a manner that changes those unsafe operating practices.

Here's how we see that happening: 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.

Now—again—as a former owner/operator of small air taxi operation myself, 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, as I said earlier, safety initiatives cost money, and risk isn't easily measured. 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 that's all the more reason to conduct a risk analysis of operations, and then put in place mitigating factors to reduce the chances, or the consequences, of an accident. That's what managing risk is all about.

Speaking of risk, last year, the TSB released our latest safety Watchlist, which identifies the issues posing the greatest risk to Canada's transportation system. In general, the Watchlist has been an excellent tool, a real “blueprint for change.” In fact, by shining a spotlight on these outstanding issues, we've helped persuade change agents to take concrete action, and thus we've increased the uptake on our recommendations. Some issues, however, require more work. In addition to the one I've already mentioned, safety management and oversight—which applies not only to the air industry, but to the Marine and Rail sectors as well—there are several air issues where we have seen little or no progress. These include approach-and-landing accidents, and the risk of collisions on runways. For both of these issues, more needs to be done, including risk-based analyses by TC, regulatory changes, a lengthening of runway-end safety areas, and enhanced collision-warning systems at Canada's airports.

I'd like to clarify the issue with respect to lengthening Runway End Safety Areas, or RESAs. In 2007, the Board recommended that Transport Canada require all Code 4 runways (those longer than 1800 m) to have a 300 m RESA ora means of stopping aircraft that provides an equivalent level of safety. We recognize that may not be feasible at all aerodromes, especially here in the North. But we would still expect that, at the very least and pending new regulations, airport operators would do their own aerodrome-specific risk analysis, using their SMS, to identify the risk of serious damage or injury should a large aircraft go off the end of a runway.

The Watchlist, though, isn't our only tool. Last November, the TSB also announced plans to launch an in-depth investigation into the risks that persist in smaller “air taxi” operations across Canada. For instance, these smaller carriers—many of them one- or two-aircraft outfits flying smaller planes in more remote territory—account for a stunning proportion of commercial aviation accidents: almost 60 percent in the past 10 years. And roughly 65% of the fatalities.

Already, the TSB has identified a number of causal and contributing factors that have appeared over and over again in accidents involving these types of aircraft. 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.

Now, the TSB's investigation into air taxi accidents is a long way from complete—we've only just completed setting out the terms of reference—but in addition to seeking the reasons behind those headline-worthy numbers, we will definitely be looking at how these smaller companies manage their safety risks.

To give you a brief outline of what we're planning, we've decided on 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. This will be carried out by a team consisting of a number of investigators, along with experts in statistical analysis and human performance. Jon Lee is a member of this team.

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. In fact, I hope that Jon and his colleagues will be invited back to discuss the specifics of our initial research with you at next year's NATA. We will then be looking to analyze what we've found—including what is going right—and to report publicly on what we've learned. This may also include issuing recommendations if we feel they are required.

Last month, the TSB celebrated its 25th anniversary. We have a clear and focused mandate. And while I recognize that sometimes that puts us in the position of saying things that may be unpopular with industry or with the regulator, our sole task is to advance transportation safety. That's because public confidence is absolutely crucial to a viable Canadian aviation industry. It's also why we 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 NATA and its members to help move the safety bar even higher.

Thank you for your attention. I'd be happy to take a few questions if we have time.


Footnote 1

Canadian Aviation Regulations

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Footnote 2

702 refers to aircraft involved in aerial work, specifically, those involving the carriage of persons other than flight crew members, the towing of objects, or the dispersal of products.

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Footnote 3

703 refers to single- and multi-engine aircraft (other than turbo-jet) that have a Maximum Certificated Take-Off Weight of 19,000 lbs. or less, and a seating configuration, excluding pilot seats, of nine or less.

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Footnote 4

Flight-training unit

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Footnote 5

Ground Proximity Warning Systems

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Footnote 6

Terrain Awareness and Warning System

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