The investigation
This safety issue investigation (A18Q0140) examines a series of 18 occurrences that took place at certain airports undergoing construction in Quebec and Nunavut between 2013 and 2018. In these occurrences, the width of the runway was reduced rather than the length. In all but two cases, aircraft had manoeuvred on the closed portion of the runway during takeoff or landing.
The Transportation Safety Board of Canada (TSB) is issuing a Board recommendation and a safety concern as a result of this safety issue investigation.
TSB Recommendation A21-01
NOTAM publishing procedures
If an airport operator plans to carry out construction activities at their airport, they must communicate the necessary information to pilots, by having a NOTAM issued. A NOTAM is a “notice distributed by means of telecommunication containing information concerning the establishment, condition or change in any aeronautical facility, service, procedure or hazard, the timely knowledge of which is essential to personnel concerned with flight operations.” (Source: NAV CANADA, TERMINAV terminology database).
The process for issuing a NOTAM is quick and well known by airport operators. Once a NOTAM is written, the airport operator submits the necessary information to NAV CANADA who in turn will issue the NOTAM for use by pilots, flight dispatchers and air operators. However, NOTAMs are currently limited to text and do not include graphics.
The occurrences under review in this investigation highlighted a deficiency with NOTAMs, that is, the fact that they are limited to text and do not include graphics. The pilots involved in the occurrences studied in this investigation had consulted the NOTAMs issued for the construction activities and were aware of the reduced runway width. However, when they read the NOTAMs, they were unable to form an accurate mental image of the situation or visualize what the runway undergoing construction would look like. As a result, the mental models and expectations they had regarding airport construction prevailed over the reality, and the pilots were not able to distinguish the closed portion from the open portion of the runway.
All of these elements that hindered the readability and effectiveness of NOTAMs are directly related to human factors. According to ICAO, aeronautical information services should take these factors into consideration, particularly in the design and distribution of aeronautical data and information. Currently, NOTAMs in Canada are only issued in a text format, which limits how clearly a pilot can visualize areas that are closed due to construction.
Therefore, the Board 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.
TSB Recommendation A21-01
Safety concern
Regulatory surveillance of airports by Transport Canada
Historically, the safety of flight operations was strictly related to regulatory compliance and was based on reactive risk management in response to incidents and accidents. However, it became evident that regulatory requirements alone could not foresee all of the risks associated with a particular activity. It was then that the concept of a safety management system (SMS) was introduced, which was endorsed and recommended by ICAO in 2000.
Transport Canada Civil Aviation (TCCA) required the implementation of safety management systems (SMS) within civil aviation, in 2005 for airlines and approved maintenance organizations, and in 2008 for airports.
TCCA also decided to apply the principles of safety risk management to its own activities by adopting a national safety program, which includes the Integrated Management System (IMS). The IMS was intended to enable TCCA to implement a program that integrates all of its activities consistently across the country, both at Headquarters and in the regions.
These systems, introduced to add a level of safety to safety management and oversight of the aviation industry and to proactively manage risks, were intended to identify the factors and risks that had contributed to the occurrences under review, but they did not meet this goal. The implementation of SMS at airports implied that TCCA would evaluate the systems within a set timeframe. However, TCCA was not able to complete all of the SMS evaluations or follow-ups necessary to assess the effectiveness of safety management at the airports under review within the required timeframes.
This investigation revealed that TCCA inspectors, who are tasked with traditional regulatory oversight as well as surveillance of airports’ SMS did not have a nationally standardized and current guide at their disposal to evaluate construction plans, which could hinder the detection of certain risk factors. Furthermore, information gathered during the investigation showed that TCCA’s oversight policies and procedures were not being followed consistently, and that some of the key procedures in TCCA’s IMS were not fully understood by the inspectors. Consequently, potentially repetitive or widespread hazards may not be identified, preventing risk control measures from being put in place.
Although the occurrences under review primarily took place in Quebec, it is concerning to note that they all resulted from systemic underlying causes or contributing factors that a national safety program should have identified. Inevitably, the question arises as to whether the situation is the same in other TCCA regions.
The Board is concerned that if TCCA 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.