A15H0001 (SII Air Taxis) Opening remarks

Kathy Fox, TSB Chair
Glen Whitney, Manager, Air Investigations Ontario Region
Ottawa, Ontario
07 November 2019

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Kathy Fox

Good morning.

Canada's aviation industry is as diverse and unique as the country itself, and nowhere is this better illustrated than in the commercial aviation sector known as “air taxi.” These smaller aircraft—carrying less than 10 passengers, by regulation—provide Canadians with a broad array of services: helicopters that transport injured or ill patients to hospitals; floatplanes to take commuters from harbour to harbour in coastal cities or to hunting or fishing camps; and aircraft to bring workers to remote areas, or deliver food, equipment, and passengers to small communities.

And although these vital air links have helped build Canada and sustain its population, air taxi operations are at higher risk than other sectors of the commercial aviation industry. Now, overall, commercial aviation in Canada has shown improved safety performance over the past 10 years. However, the air taxi sector continues to have more accidents, causing more fatalities, than all other sectors of commercial aviation in Canada—combined.

Why? Partly because of the nature of the work. Air taxi operations take place in a very. different. context. from other sectors of commercial aviation—very unlike large scheduled airlines. Air-taxi services often have no set schedule and fly into remote areas in uncontrolled airspace with few or no aerodromes or navigation aids. Flights tend to be shorter, resulting in more takeoffs and landings. Access to basic weather information, or the latest aircraft technology, may be limited, especially when the aircraft themselves are sometimes decades old.

But the larger reason for so many accidents is more insidious, and boils down to two things: an acceptance of unsafe practices, and the inadequate management of operational hazards. And while most air taxi operators strive to operate safely, many are still vulnerable to these underlying factors.

That's why today the TSB is releasing a safety issue investigation report—an exhaustive analysis of the sector as a whole, one that identifies the major risks faced by those who operate in this sector, as well as how those risks impact safety on every single flight.

We are also issuing 4 new recommendations aimed at:

• eliminating the acceptance of unsafe practices;
• promoting proactive safety management and a culture of operating safely;
• updating aviation regulations to reduce identified safety gaps; and
• tracking data so that mitigation strategies can be better assessed.

And these 4 new recommendations are on top of 22 others, older recommendations that the TSB has issued previously and which still need to be addressed to improve safety in this sector.

I'll talk more about the report and the four new recommendations shortly, but first I'll turn things over to the Investigator in Charge, Glen Whitney. He'll walk you through the broader context behind the investigation, along with some of what we learned.

Glen Whitney:

Thank you, Kathy.

Air taxi safety is not a new issue. There have been studies going back 30 years that show the air taxi sector operates in a unique context with very different risks. For this investigation, we studied over 700 occurrences that were reported to us from 2000-2014; we also looked at 167 TSB investigation reports. We then conducted interviews with 125 people from almost 3 dozen operators nationwide, as well as Transport Canada.

After sifting through all those data, we identified 19 safety themes, illustrating the day-to-day challenges of operating in the air-taxi sector. But these accidents really boil down to a pair of key underlying factors:

• First, a slow, incremental drift toward accepting unsafe practices. And I'm not talking about flagrant rule violations; I'm talking about a gradual drift that occurs over time with every successful (though not necessarily safe) flight. For instance: flying overweight, flying into marginal weather or forecasted icing, or flying with minimal fuel reserves.

• These unsafe practices, however, which operators may not see as “unsafe” because they're viewed as part of getting the job done … are compounded by factor number two: inadequate management of operational hazards. Here I mean things like sub-optimal crew pairing, dispatching a flight with a different pilot after a first pilot has refused, or not having scales available so that aircraft aren't flown overweight.

How does that look on a day-to-day basis—in the real world? Well, there's no such thing as a typical accident, but let me give you a scenario to illustrate some of what's involved.

Like any business, air taxi operators face competing pressures—pressures that they have to manage in order to deliver a service, stay safe, and also stay economically viable.

As long as those competing pressures stay in relative balance, the flight should operate safely. But those pressures are always shifting, pushing the operation toward certain … boundaries. Cross any of those boundaries and there are … consequences.

• For instance, let's say maintenance costs go up—way up. Bankruptcy may be likely, unless costs can be reduced, for example by delaying that maintenance work.
• Or maybe the pilot is sick, or fatigued from long hours, and the flight cannot depart. So the company has to call in a second pilot.
• Let's say that pilot arrives to find the aircraft is overloaded, and the weather's not optimal. Now … there's pressure from the clients and the boss for that flight to depart.

That's where the problem lies: as you approach those boundaries. Because these competing pressures can force air taxi operations into a space that isn't safe. That doesn't mean the result is always an accident, but it almost always means a reduced margin of safety.

The fix is to improve the balance of those pressures, especially the safety pressure.

So how do you fix things?

For that, I'll turn to TSB Chair Kathy Fox, who will explain the details of today's 4 new recommendations.

Kathy Fox:

Thanks, Glen.

Hydro workers will always need to get to transmission sites … safely. People in remote communities will always need to get to a hospital … safely. Commuters. Tourism … The need for air taxi operations is not going away. But at the same time, air taxi flight crews and their passengers should not have to accept a reduced level of safety compared to those who fly on scheduled airlines.

And so things need to change. That will mean getting clients, passengers, crews, and operators to stop accepting unsafe practices—even unwittingly—and to speak up to prevent them from happening. And it will mean proactive safety management … all aimed at creating a culture of operating safely.

That's what today's first recommendation is all about: raising the bar on safety. And to help us do that, we want Transport Canada “to collaborate with industry associations to develop strategies, education products, and tools to help air-taxi operators and their clients eliminate the acceptance of unsafe practices.”

Our second recommendation is about how to promote proactive safety management processes and a positive safety culture.

In recent years, many industry organizations have promoted initiatives that go beyond current regulations, setting higher standards for members. A roadmap, as it were, toward best practices and safer flights.

To that end, we want the major industry associations to promote proactive safety management processes and a positive safety culture with air-taxi operators … by training and by the sharing of best practices, tools, and safety data specific to their operations. Many are already on this path, but we think more can be done.

Our third recommendation is about what we learned from discussions with operators across the country as well as our study of TSB investigation reports—specifically, about some of the gaps in the existing Transport Canada regulations and standards.

For instance, some operators choose to do only the bare minimum—just what's required by regulation and no more. They:

•  limit training expenses by providing only the training required by air-taxi regulation and standards; or
• they don't make safety improvements to older aircraft because the process is too costly and burdensome.

Meanwhile, other operators' and clients' practices go beyond what's required to include concepts that are not yet addressed by regulations. For example:

• establishing their own higher minimum requirements for pilot flight experience, or scheduling 2 pilots even if only 1 is required; and
• implementing a safety management system, as the TSB has urged for years.

This difference in practices creates an uneven level of safety across the country and across the industry—one that is largely unknown to the passengers.

Again, it's time to raise the bar on safety. It's time for Transport Canada “to review the gaps identified in this safety issue investigation … and update the relevant regulations and standards.”

Our fourth and final recommendation today is about evaluating the impact of these safety actions—specifically, activity data such as hours-flown or movements.

Currently, hours-flown and movement data for commercial aviation in Canada are not broken down by sector when collected by the government. As a result we know how many accidents and fatalities occur in the air taxi sector each year, but we cannot calculate the accident rate per hour flown. This is critical, because if there's a change in the number of accidents, we have no way of knowing whether it's because there were fewer flights, or because of something else. And stakeholders need this data to determine if their actions are actually working.

Therefore, today we recommend that TC require all commercial operators to collect and report hours-flown and movement data for their aircraft by Canadian Aviation Regulations sector and aircraft type, and that TC publish those data.

If Transport Canada and industry take action on today's four new recommendations, as well as the previous 22 aimed at this sector, that will go a long way to raising the bar on safety for the air taxi industry in Canada.

Thank you.