Air transportation safety issue investigation A15H0001
Update: The TSB has completed this investigation. The report was published on 7 November 2019.
Table of contents
Raising the bar on safety: Reducing the risks associated with air-taxi operations in Canada
View final report
In May 2015, the Transportation Safety Board of Canada (TSB) launched an in-depth Safety Issues Investigation (SII) into the risks that persist in air taxi operations across Canada.
An SII is broad in scope and involves looking at multiple occurrences in order to identify the underlying safety issues, and the Board may make recommendations to address any identified systemic deficiencies. The TSB will communicate its findings once the investigation is complete.
Terms of reference
The air taxi sector of the Canadian aviation industry which is regulated by Canadian Aviation Regulations (CARs) Part 703 has seen 229 deaths over the last 15 years. These deaths represent 62% of all commercial aviation fatalities. TSB investigation reports have repeatedly drawn attention to critical safety issues that contribute to these accidents in these types of operations. In spite of this, the air taxi sector continues to have the highest number of commercial aviation accidents and fatalities. The TSB wants to identify and communicate the underlying systemic safety issues that need to be addressed so that action can be taken to reduce the risks that persist in air taxi operations across Canada. At the conclusion of the SII, the Board may make recommendations to address any remaining systemic deficiencies.
The SII will be broad in scope and will include all Canadian air taxi operations in order to identify the underlying recurring safety issues. The Board has observed that accident investigation findings for occurrences in this sector of aviation include multiple recurring issues and themes that are common. Some of the issues that have been previously identified include:
- Pilot experience and training;
- Ineffective pilot decision making (PDM) / crew resource management (CRM);
- Crew adaptations from standard operating procedures (SOPs);
- Inadequate risk analysis of operations;
- Operational control;
- Other organizational factors; and
- TC oversight.
The SII will examine these and other issues as appropriate.
There is no plan to re-examine the issues related to post-impact fires or survivability following an aircraft crash on water which have been examined in previous TSB Safety Issues Investigations.Footnote 1
The SII will review 15 years of data to identify safety issues in Air Taxi Operations in Canada that have not been sufficiently mitigated. The SII will examine air taxi operations as a whole and will consider safety issues that are germane to the entire air taxi industry and not just to one specific segment of the industry. To accomplish this, the SII will be conducted in a two phase approach.
Phase 1 – Safety issues identification (May 2015 – October 2015)
The study will start by the collection and review of contextual information about the air taxi sector to ensure a good understanding of the operating context.
The project team will then proceed to review 15 years of TSB accident and incident data (2000 to 2014). Information will be extracted from TSB investigation reports and the ASISFootnote 2 database. Each occurrence will be coded for underlying factors and the information will be tabulated in order to identify recurring safety issues.
Historical occurrence data from other sources (both internal and external to the TSB) such as CADORSFootnote 3 and SECURITASFootnote 4 will also be examined.
The project team will conduct a review of previous studies such as the BC Coroner's death review panel studyFootnote 5, the FAA (Federal Aviation Administration) Alaska studyFootnote 6 and the SATOPSFootnote 7.
Once the project team has completed the data collection and analysis, the team will:
- synthesize the common themes or common safety issues;
- review mitigations that are in place or planned to be in place for these issues;
- review outstanding TSB recommendations to identify ongoing unmitigated risks that have not yet been addressed;
- define the research topics for phase 2 of the study;
- develop a stakeholder consultation package and methodology;
- refine the Terms of Reference, timeline and resources required based on management review of the proposal for phase 2; and
- report to the Board on phase 1 results and plans for phase 2.
Phase 2 - Safety analysis (November 2015 - December 2017)
Phase 2 will focus on the research topics identified in Phase 1. It will include direct interaction with operators, the regulator and other stakeholders as appropriate with regards to the specific air taxi issues identified.
Following the detailed fact finding and discussions, the findings will be analyzed, validated and a draft report prepared.
The Board will review the initial draft report and may choose to engage outside parties in a designated reviewers (DR) process.
Following the SII, the Board will report publically on its findings as well as make recommendations if required.
A15H0001 (SII Air Taxis): Opening Remarks
Kathy Fox, TSB Chair
Glen Witney, Manager, Air Investigations Ontario Region
Glen Whitney joined the TSB in June 2008 as an investigator/operations specialist in the TSB Air Investigations Branch at Head Office, in Gatineau, Quebec. He has over 26 years of civil aviation experience and has accumulated over 14,000 flight hours.
Prior to joining the TSB, his experience was gained flying floats, northern and gravel operations as well as scheduled commuter airline flying. He was also involved in flight crew training and checking and was the chief accident investigator at the airline.
Class of investigation
This is a class 1 investigation. These investigations—also known as safety issue investigations (SII)—analyze a series of occurrences with common characteristics that have formed a pattern over a period of time. These investigations, which may result in recommendations, are generally completed within 730 days. For more information, see the Policy on Occurrence Classification.
TSB investigation process
There are 3 phases to a TSB investigation
- Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
- Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
- Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.
For more information, see our Investigation process page.
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.