TSB concerned with deficiencies in regulatory surveillance related to the safety of flight operations during airport construction
Dorval, Quebec, 15 December 2021 — Following its safety issue investigation (A18Q0140) on a series of 18 occurrences on runways under construction at certain airports in Quebec and Nunavut, the Transportation Safety Board of Canada (TSB) is issuing today a recommendation to NAV CANADA to publish graphic depictions of runway closures so that the information communicated on these hazards is more easily understood. The Board is also concerned with the adequacy of regulatory surveillance of airports undergoing construction activities.
The events examined in the investigation occurred when the width of the runway was reduced, rather than the length, to allow for construction work without closing the runway. The investigation found that issues such as the construction method chosen, the visual aids used during construction, and the way that airport construction information is communicated to pilots can lead to pilots not being able to identify the open portion of the runway. Some of these hazards result from the complexity of the regulations and the absence of clear standards for airport construction and for preparing and approving construction plans. The investigation also found that, if the airport construction planning process places too much emphasis on external economic pressures to avoid closing the runway, there is an increased risk that not enough emphasis will be placed on safety.
In the absence of both information on which method should be used for runway rehabilitation and standards and recommended practices, decisions in regards to operations during airport construction lie entirely with the airport operator. It was determined that construction operations plans were approved by Transport Canada (TC) using informal procedures, without assessing the risk that pilots might not be able to recognize or distinguish the closed portions of the runways, and without including control measures to mitigate this risk.
"Our investigation revealed an important systemic issue: the lack of Canadian standards or official recommended practices to be followed during airport construction," said TSB Chair Kathy Fox. “This lack of operational safety standards can leave pilots without sufficient visual aids to clearly distinguish the closed parts on the runways.”
The investigation also found issues with the the safety management systems (SMS) in place at the airports under review. Despite that all these airports had an SMS, the investigation identified that they were not effective at proactively managing the risks associated with the reduction in the runway width. Information gathered during the investigation also showed that TC’s surveillance policies and procedures were not being followed consistently, and that some of the key oversight procedures were not fully understood by TC’s inspectors.
In light of this, the Board is concerned that if TC does not provide adequate surveillance of airports in Canada, the risk of an accident related to flight operations at airports increases, particularly when the airports are undergoing construction.
Also, when an operator plans to carry out construction activities at their airport, they must communicate the necessary information to pilots by having a Notice to Airmen (NOTAM) issued by NAV CANADA. Currently, NOTAMs in Canada are only published in text format and cannot include graphics, which can hinder the effective communication of information. Consequently, even though the pilots had all read the available NOTAMs related to the partial runway closures, their mental models were inaccurate and they were not able to recognize or distinguish which portions were closed.
The Board therefore recommends that NAV CANADA make available, in a timely manner, graphic depictions of closures and other significant changes related to aerodrome or runway operations to accompany the associated NOTAMs, so that the information communicated on these hazards is more easily understood (Recommendation A21-01).
Safety management and regulatory surveillance are TSB Watchlist 2020 issues. The TSB has repeatedly emphasized the benefits of an SMS that allows companies to manage risk effectively and make operations safer. However, implementing an effective SMS is only part of the issue: proper regulatory surveillance is also needed.
See the investigation page for more information.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
For more information, contact:
Transportation Safety Board of Canada