Aviation Safety Recommendation A09-02

Reassessment of the response from Transport Canada to Aviation Safety Recommendation A09-02

Crew resource management training

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Background

On 07 January 2007, Transwest Air Flight 350 (TW350), a Beech A100 King Air (registration C-GFFN, serial number B190), departed La Ronge, Saskatchewan, at 1930, under instrument flight rules to Sandy Bay, with two flight crew members and two emergency medical technicians aboard. TW350 was operating under Part VII, Subpart 3, Air Taxi Operations, of the Canadian Aviation Regulations. At 1948, air traffic control cleared TW350 out of controlled airspace via the Sandy Bay Runway 05 non-directional beacon approach. The crew flew the approach straight-in to Runway 05 and initiated a go-around from the landing flare. The aircraft did not maintain a positive rate of climb during the go-around and collided with trees just beyond the departure end of the runway. All four occupants survived the impact and evacuated the aircraft. The captain died of his injuries before rescuers arrived. Both emergency medical technicians were seriously injured, and the first officer received minor injuries. The aircraft sustained substantial damage from impact forces and was subsequently destroyed by a post-impact fire. The accident occurred at 2002 during the hours of darkness.

The investigation concluded that ineffective crew resource management (CRM) contributed to the accident. Examples of ineffective CRM included trans-cockpit authority gradient, communications, problem solving and decision making, conflict resolution, and operating practices that were substantial deviations from SOPs. The crew members' inability to work effectively as a team to avoid, trap, or mitigate crew errors encountered during the flight is likely, in part, because they had not received recent CRM training.

Ineffective CRM also affected the performance of other King Air pilots employed by the company. None of the company's King Air pilots had received recent CRM training. It is likely that recent CRM training would have assisted the crew of TW350 and Transwest Air's other King Air pilots in managing risks present during flight to an acceptable level.

Many air taxi and commuter operators provide their pilots with CRM training voluntarily, although there is currently no regulatory requirement for them do so. However, some CAR 703 air taxi and CAR 704 commuter operators do not provide their pilots with any initial or recurrent CRM training, and others do not provide recurrent CRM training on an annual basis.

The investigation concluded that some operators are unlikely to provide CRM training in the absence of a regulatory requirement to do so. Therefore, some commercial pilots may be unprepared to avoid, trap, or mitigate crew errors encountered during flight.

The Board released its report (A07C0001) on 14 October 2009.

Board Recommendation A09-02 (October 2009)

CRM training has developed over the years as an effective tool. Modern, well-designed CRM training now includes such things as the concept of threat and error management. This accident has demonstrated that current defences are less than adequate. In light of the risks associated with the absence of recent CRM training for air taxi and commuter crew members, the Board recommends that:

The Department of Transport require commercial air operators to provide contemporary crew resource management (CRM) training for Canadian Aviation Regulations (CARs) subpart 703 air taxi and CARs subpart 704 commuter pilots.
TSB Recommendation A09-02

Transport Canada's response to Recommendation A09-02 (January 2010)

Transport Canada has accepted the recommendation in principle and in accordance with the Cabinet Directive on Streamlining Regulations, the rulemaking process will commence with a more detailed risk assessment. Transport Canada is expecting to present the risk assessment and supporting recommendation to the Civil Aviation Regulatory Committee (CARC) in the spring of 2010. The resulting recommendation from CARC will trigger the rulemaking process.

Board assessment of the response to Recommendation A09-02 (March 2010)

Transport Canada's written response to the recommendation indicates that it accepts the recommendation in principle, and intends to conduct a more detailed risk assessment. The risk assessment is expected to be complete in the spring of 2010, with resulting recommendations to be presented to the CARC to trigger the rulemaking process. However, Transport Canada has not yet issued or recommended specific courses of action that, if implemented, would reduce or eliminate the deficiency identified in Board Recommendation A09-02.

The response is assessed as Satisfactory Intent.

Transport Canada's response to Recommendation A09-02 (January 2011)

TC completed the risk assessment. The CARC accepted a balanced approach that included acceptance of TSB recommendation A09-02, regulatory action, training, and guidance. The project plan is currently being reviewed in the context of existing priorities.

Board reassessment of the response to Recommendation A09-02 (March 2011)

The risk assessment conducted by TC validated the TSB's finding as to risk regarding the absence of recent CRM training and broadened the scope of the safety deficiency to include commercial single-pilot operations. The risk assessment also concluded that current training issues extended beyond CARs 703 and 704 pilots, and recommended better defining training requirements and integrating contemporary CRM into existing training requirements.

TC has made progress in implementing TSB Recommendation A09-02. The accepted course of action, if implemented, would reduce or eliminate the deficiency identified in Board Recommendation A09-02.

The response is assessed as Satisfactory Intent.

Transport Canada's response to Recommendation A09-02 (May and September 2011)

May 2011

ToRs for the creation of a Working Group will be presented at the Sept. 2011 CARAC Technical Committee meeting.

September 2011 update

On September 19th, the Civil Aviation Regulatory Committee directed that a Focus group be established as soon as possible in the Fall to address this issue.

Board reassessment of the response to Recommendation A09-02 (March 2012)

The newly formed focus group met for the first time on 23 January 2012. TC has continued to make progress in implementing TSB Recommendation A09-02. The accepted course of action, if implemented, would substantially reduce or eliminate the deficiency identified in TSB Recommendation A09-02.

The response is considered Satisfactory Intent.

Transport Canada's response to Recommendation A09-02 (December 2012)

On April 24, 2012, CARC determined that contemporary CRM training standard would be developed for 702, 703, 704 and 705 to include the Threat and Error Management Model (TEM) to enhance flight crew's ability to assess conditions and make appropriate decisions in critical situations. Associated recs are A00-06 and A07-03

Board reassessment of the response to Recommendation A09-02 (March 2013)

TC has continued to make progress in implementing TSB Recommendation A09-02. However, until the new training standards are developed and implemented, the deficiency identified in Recommendation A09-02 will continue to exist.

The accepted course of action, if implemented, would substantially reduce or eliminate the deficiency identified in Board Recommendation A09-02. However, for the present, the action has not been sufficiently advanced to reduce the risks to transportation safety.

The response is considered Satisfactory Intent.

Transport Canada's response to Recommendation A09-02 (November 2013)

This item remains a regulatory priority, and work to amend the Standard has begun.

Based on the findings and recommendations of the Crew Resource Management (CRM) focus group and the 2012 risk assessment, Transport Canada is developing a project plan, with the following expected to be accomplished over the next year:

  • Develop project plan and timelines for 702, 703, 704 and 705 CRM, including information to help determine whether a single rule set or keeping distinct requirements in individual parts is best;
  • Consolidate existing information into an Advisory Circular; and
  • Publish Advisory Circular following consultation with regional staff.

Board reassessment of the response to Recommendation A09-02 (April 2014)

Since the last time this recommendation was assessed, the TSB has released the final report into the crash of FAB6560 in Resolute Bay, Nunavut (A11H0002). That investigation identified ineffective crew interactions as a significant contributing factor to the accident. The crew's CRM training was abbreviated and based on the current, outdated TC standard. The Board issued a safety concern to the effect that without a comprehensive and integrated approach to CRM by TC and aviation operators, flight crews may not routinely practice effective CRM.

This recommendation was first issued in 2009. The project plan has been under development since December 2012. TC progress during the past 12 months in implementing TSB Recommendation A09-02 and proposed actions are preparatory in nature, and changes to regulations and standards are unlikely to occur in a timely manner. Given the number of fatal accidents involving ineffective CRM (including A09A0016), the Board is concerned about the slow pace of action to address this recommendation.

If implemented, the proposed course of action will eventually substantially reduce or eliminate the safety deficiency identified in Board Recommendation A09-02. In the interim, this safety deficiency will continue to exist.

The response is considered Satisfactory Intent.

Transport Canada's response to Recommendation A09-02 (January 2015)

Transport Canada agrees with the intent of this recommendation.

Work continues on the development of Standards and Guidance material for Crew Resource Management (CRM) and updated Pilot Decision Making (PDM) to be incorporated in the CRM modules. Public consultation on proposed amendments to the standards is underway, and the standards are expected to come into effect in late 2015.

Board reassessment of the response to Recommendation A09-02 (March 2015)

The Board is encouraged that action on this recommendation is nearing completion. The proposed course of action should substantially reduce or eliminate the safety deficiency identified in Board Recommendation A09-02. Until the standards are amended and fully implemented, this safety deficiency will continue to exist.

The response is considered Satisfactory Intent.

Next TSB action

The TSB will continue to monitor the state of CRM training and TC's follow-up project to implement Recommendation A09-02. Any further delay in completing the proposed action may warrant a change in the assessment rating of the response.

The deficiency file is assigned Active status.