Raising the bar on safety: Reducing the risks associated with air-taxi operations in Canada
New TSB recommendations
Eliminating the acceptance of unsafe practices
This safety issue investigation (SII) highlights what types of unsafe practices have been happening for years and continue to happen: from flying overweight to flying in marginal weather to flying with minimal fuel reserves. Deviations from standard operating procedures, company policy, regulations, or safe practices can result in outcomes similar to those that have contributed to numerous accidents and incidents over the years.
At the same time, though, the safety margin built into these operations may allow an unsafe flight to be completed successfully. When operations are conducted successfully with a reduced safety margin, this may lead to an acceptance of unsafe practices and make it difficult to know how much of the safety margin has been eroded.
An important step in raising the bar on safety in air-taxi operations is getting clients, passengers, and operators not to accept unsafe practices even when there seems to be a sufficient safety margin, and to speak up to prevent them from happening. This requires strategies, promotion and education to change values, attitudes and behaviours, which will eventually result in a change of culture.
Safety culture is defined as the way safety is perceived, valued, and prioritized in an organization. Establishing a positive safety culture has many challenges; however, it is a necessary first step in creating the values, attitudes and behaviours required for operators to effectively manage the risks associated with their operations. In practical terms, a positive safety culture can in part be built or supported by proactive safety management.
The evidence of this change in culture will be an operation that supports and reinforces pilot decision making and crew resource management (PDM/CRM) practices through a strong company culture, including support for decision making by managers, supervisors, and peers. Supportive influences and actions from all stakeholders can help operators prioritize safety and manage risks to an acceptable level. But to do this, time and resources must be invested before the flight, and investments must be made as part of increasing safety pressures through training and education, company-wide safe decision making, the use and support of PDM/CRM practices, and safety management that includes a culture of operating safely. To be effective, all this must be done with the knowledge of the operating context of air-taxi operations and the hazards and risk factors specific to this sector.
The emphasis now needs to be on using a positive safety culture and proactive safety management to increase safety pressure that will eventually lead to a culture where unsafe practices are considered unacceptable.
Therefore, the Board recommends that
the Department of Transport 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.
TSB Recommendation A19-02
Promoting proactive safety management processes and safety culture
In recent years, organizations such as the Floatplane Operators Association (FOA), the Air Transport Association of Canada (ATAC), the Helicopter Association of Canada (HAC), the Medallion Foundation, the Federal Aviation Administration (through its Circle of Safety program), and the Tour Operators Program of Safety have come together to improve safety in sectors with a high number of accidents. The initiatives they have organized go beyond the regulations and set high standards for members. These initiatives can provide a roadmap for improving safety in the air-taxi sector in Canada and participation by operators can also provide confidence and incentives for clients and passengers.
As these initiatives show, associations within the air-taxi sector are well positioned to influence safety within the sector. They have a responsibility to their members and the industry and can play a role in positively influencing the 3 competing pressures described in this SII. Industry associations can provide seminars, training and tools, as well as documentation and guides. As an example, industry associations have worked together successfully in the past to address a critical shortage of skilled personnel in the Canadian aviation maintenance industry.
In 2016, the TSB recommended that TC require all commercial aviation operators in Canada to implement a formal safety management system (SMS).
An SMS is generally defined as a formalized framework for integrating safety into an organization's daily operations, including the necessary organizational structures, accountabilities, policies and procedures, so that “it becomes part of that organization's culture, and of the way people go about their work.” While individual employees routinely make decisions about risk, SMS focuses on organizational risk management, yet includes and supports the decision makers at the sharp end. An SMS is scalable and can be designed to meet the needs of a given operation in a way that respects the nature of the sector.
In advance of an SMS regulation, associations can play an important role in making available and accessible to operators, modern promotion and education products and tools on safety culture and proactive safety management that will advance safety in their operations. This will foster the development of a culture of operating safely that is supported by all stakeholders.
Many operators belong to a variety of associations, such as the Air Transport Association of Canada (ATAC), the Helicopter Association of Canada (HAC), the Association Québécoise du Transport Aérien (AQTA), the Floatplane Operators Association (FOA), and the Northern Air Transport Association (NATA). Such associations could provide a venue for sharing best practices, tools, and safety data specific to air-taxi operations. They could also provide assistance and training in implementing proactive safety management that incorporates a positive safety culture.
Therefore, the Board recommends that
Industry associations (e.g., ATAC, HAC, AQTA, FOA, NATA) promote proactive safety management processes and safety culture with air-taxi operators to address the safety deficiencies identified in this safety issue investigation through training and sharing of best practices, tools, and safety data specific to air-taxi operations.
TSB Recommendation A19-03
Closing gaps in the air-taxi regulatory framework
The hazards and risks in air-taxi operations have persisted over many years, with data directly showing the persistence of operational hazards from 1998 to 2015. The SII has illustrated that regulations and standards alone cannot guarantee safety in the sector, but they do provide necessary controls that contribute to safety in the sector. That said, there are gaps in this regulatory framework, namely with regard to training and qualifications, improvements to older aircraft, and fatigue in aircraft maintenance engineers (AMEs).
Training and qualifications
The CARs set out the required training for operators, but the actual training provided can vary widely, as operators observed. While some operators provide training only to a level that meets the requirements in the regulations, others provide extra training beyond the requirements to address needs and/or to derive benefits that mitigate risk in their operation. However, several operators mentioned that without updated regulations and standards forcing all operators to work under the same rules, the playing field is not level.
Although Subpart 703 of the CARs has mandatory training requirements for certain specialized operations, such as night flying, there are no such requirements for many other specialized operations such as mountain flying and coastal flying. There is also no regulation addressing line indoctrination for air-taxi operations. Mandatory training requirements may therefore be inadequate to meet the many unique aspects of air-taxi operations. Without the requirement for specialty training for high-risk operations, pilots may lack the knowledge and skills to ensure safe flight operations.
Furthermore, pilots conducting medical evacuation operations would benefit from specialized training to help them manage the psychological and traumatic challenges of this type of operation.
The qualifications of key personnel within an air-taxi operation were also identified in the SII as a potential issue. TSB investigations from the study period showed that key positions (e.g., operations manager or chief pilot) do not appear to be given sufficient attention when the regulator approves the appointment of individuals to these positions. More attention needs to be given to an individual's credentials and qualifications, as well as the operational requirements for the key positions at the operator. Furthermore, although there are regulatory requirements relating to the roles and responsibilities that these key positions must fulfill, there are no training requirements for individuals appointed to these positions.
Improvements to older aircraft
The SII also identified the difficulty in making improvements to older aircraft such as installing new avionics because it would require a change to the original aircraft type design. The approval process required by TC requires a supplemental type certificate to be developed, which can be a costly and burdensome process; for some smaller operators, the costs may be prohibitive.
Fatigue in aircraft maintenance engineers
The industry consultations revealed that AMEs often experience fatigue when working, especially when they are working in a remote location or away from their main base. Duty days can be long, and duty-day hours for AMEs are not subject to TC's regulations. Some operators stated that duty days for AMEs are often not defined by operators and that AME duty-day regulations are required.
Closing the gaps
Some operators have identified gaps in the existing regulations and standards. Some operators' recommended practices go beyond the current regulatory requirements or include concepts that are not yet addressed by regulations, for example
- carrying out all flights under instrument flight rules
- using 2 pilots for all operations
- establishing their own minimum requirements for pilot flight experience
However, in the face of the competing pressures illustrated by the safe operating envelope model, operators may choose to simply comply with the regulations even though exceeding them would increase safety pressure (e.g., limiting training expenses by providing only the training required by regulation, even when specialized mountain or survivability training would mitigate risks associated with the operation). As long as gaps, such as the ones identified in the SII exist in the regulatory framework, there will be an uneven level of safety in the air-taxi sector.
Therefore, the Board recommends that
the Department of Transport review the gaps identified in this safety issue investigation regarding Subpart 703 of the Canadian Aviation Regulations and associated standards, and update the relevant regulations and standards.
TSB Recommendation A19-04
Collecting activity data specific to the air-taxi sector
A key indicator of aviation safety is the aircraft accident rate, which is calculated as the number of accidents per hours flown or per number of movements (a movement can be a takeoff or a landing). Performing a trend analysis of accident rates for different types of operators can detect emerging safety issues associated with specific operator types and activities. In addition, accident rate data makes it possible to compare accident risk for different operator types, in different countries or on different continents. For example, the U.S. Federal Aviation Administration (FAA) compiles scheduled and non-scheduled flight hours and departures under Title 14 Code of Federal Regulations (CFR). Operators governed by Part 135 of Title 14 CFR include on-demand carriers, which are similar to Canadian air-taxi operators. The U.S. National Transportation Safety Board (NTSB) uses these activity data to compute accident rates and fatal accident rates across sectors.
Activity data (e.g., flight hours) broken out by operator type is required to calculate the accident rates that enable trend analysis of specific operator types over time, or comparisons across operator types or geographical regions.
Until 2010, TC provided activity data broken out by operator type, and the TSB used these data to calculate and publish accident rates across operator types. In 2010, however, TC informed the TSB that it would no longer provide hours-flown activity data breakouts by operator type, because it had concerns regarding the accuracy of those data. The data were reported to TC by the commercial operators who were allowed to report all hours under the most restrictive subpart of the CARs, even if they conducted operations under more than one subpart.
Reporting all hours for all subparts under a single total conflates and confounds airline and commuter activity, as well as the activity of many smaller aviation operators that may carry out operations under multiple subparts of the CARs (commuter, air taxi, and/or aerial work) and report their activity as a single total. Furthermore, the movement data as presently reported by Statistics Canada come from a survey that covers all aircraft movements at Canadian airports, with or without NAV CANADA air traffic control towers and flight service stations. Air-taxi operations are conducted at these locations, as well as in locations such as lakes, unprepared landing sites, remote locations, etc. where movements are not recorded by air traffic service providers.
Because hours-flown and movement data are currently not categorized by CARs subpart when collected by the government, the rate data calculated is for the commercial aviation sector as a whole; there is no differentiation between sectors (e.g., air-taxi operators versus airline operators) or between different types of aircraft (airplane, helicopter, floatplane). Therefore, the accident rate cannot be calculated for just the air-taxi sector.
Without hours-flown and movement data that are categorized by CARs subpart and aircraft type, it will be more difficult for sector stakeholders to assess risks and determine if mitigation strategies being carried out to improve safety are actually working.
Therefore, the Board recommends that
the Department of Transport require all commercial operators to collect and report hours flown and movement data for their aircraft by Canadian Aviation Regulations subpart and aircraft type, and that the Department of Transport publish those data.
TSB Recommendation A19-05