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Assessment of the response to TSB recommendation A19-03

 Recommendation A19-03
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Promoting proactive safety management processes and safety culture


In May 2015, the Transportation Safety Board of Canada (TSB) launched an in-depth safety issue investigation (SII) into the risks that persist in air-taxi operations across Canada. This SII reviewed 15 years of data to identify safety issues in air-taxi operations in Canada that have not been sufficiently mitigated. This SII examined air-taxi operations as a whole and considered safety issues that are germane to the entire air-taxi industry and not just to one specific segment of the industry.

The Board concluded its SII and released report A15H0001 on 07 November 2019.

TSB Recommendation A19-03 (November 2019)

In recent years, organizations such as the Floatplane Operators Association, 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 the 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.Footnote 1

In 2016, the TSB recommended that Transport Canada (TC) require all commercial aviation operators in Canada to implement a formal safety management system (SMS).Footnote 2

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 recommended 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

The Air Transport Association of Canada’s (ATAC) response to Recommendation A19-03 (February 2020)

Overall ATAC is impressed with the thoroughness of the report and the effort obviously made to include many different perspectives of stakeholders within the Canadian Air-Taxi community. The report is very comprehensive, factual and should be useful for several years to come. ATAC considers this report to be an excellent primer and checklist for developing future safety enhancements while at the same time working closely with Transport Canada Civil Aviation (TCCA) to ensure their resources are focused and comprehensive initiatives are appropriately and accurately developed and implemented.

With this in mind, ATAC would like to emphasize that we have long encouraged TCCA to develop and implement Safety Management Systems (SMS) appropriate to the size and complexity of all commercial aviation operators. In fact, some years ago ATAC previously developed just such guidelines for our smaller operators. Although this is not something an association would normally do, we saw the need, and still do, of encouraging the 703 and 704 operators to adopt these SMS requirements voluntarily while TCCA is still considering the appropriate regulatory action.

With regards to the Report Section 6.6.2 New TSB Recommendations, ATAC will now provide specific comments to each of the new TSB recommendations.

A19-02: ATAC confirms its intent to continue to support and collaborate with Transport Canada to develop strategies, education products, and tools to help Air-Taxi operators eliminate the acceptance of unsafe practices.

A19-03: As mentioned above, ATAC has been for many years, proactively seeking and promoting the development and use of safety management processes and the accompanying safety culture within all of our members including those within the Air-Taxi sector. This has included development of specific SMS tools and training that we have made available to our members. ATAC continues to foster an SMS environment for our member companies during our committee meetings, symposiums and conferences.

A19-04: ATAC fully supports Transport Canada Civil Aviation undertaking a review of the gaps identified within the referenced TSB Report relating to CAR [Candian Aviation Regulations] 703 Regulations and associated standards. With regards to such amendments being identified as necessary to update these documents, ATAC supports and expects due consultation through the CARAC [Canadian Aviation Regulation Advisory Council] consultation process.

A19-05: With regards to the requirement for operators to collect and report hours flown and movement data for their aircraft by CARs subpart and aircraft type, ATAC supports such a recommendation on a voluntary basis only. In addition, the Governement of Canada through Statistics Canada must be tasked with developing a simple and not time-consuming data collection method that is not onerous in any way for Air-Taxi operators given their limited resources. ATAC considers this a Government of Canada responsibility and thus such a project must have all costs associated with this data collection absorbed by the Government of Canada and not passed on to the Air-Taxi operators. ATAC will however agree to work with the Government of Canada to provide relevant input in such a data gathering methodology and program.

ATAC wishes to emphasize that we are keen to support the TSB on working with the Air-Taxi industry and Transport Canada Civil Aviation to move forward on adopting initiatives that will improve the safety record of this part of our industry.

The Northern Air Transport Association’s (NATA) response to Recommendation A19-03 (February 2020)

The Northern Air Transport Association (NATA) appreciated the diligent efforts of the research group to produce a report that is helpful to improve overall system safety. NATA supported the study and will continue to do so with supportive events taking place at NATA 44, the northern and remote aviation conference, this year being held in Whitehorse, April 27-29, 2020.

NATA accepts the Recommendation A19-02 and A19-03 as all Associations are engaged in trying to help their members understand the issues, their responsibilities and provide tools to help them integrate new rules, programs into their operational business model. The recent decision by the Floatplane Operator’s Association to join NATA with a goal to further the development of the “North Stars Best Practices” supports the TSB Recommendations. 

Recommendations A19-04, and A19-05 identify the importance of NATA and other organizations to continue to work collaboratively with all stakeholders to increase understanding of the operational realities of northern and remote aviation in Canada and develop rules that are appropriate.

TSB assessment of the Air Transport Association of Canada’s and the Northern Air Transport Association’s responses to Recommendation A19-03 (March 2020)

In its response, the Air Transport Association of Canada (ATAC) indicated that it continues to promote the development and use of safety management processes and safety culture. ATAC has developed tools for and provided training to all its members and will continue its support and collaboration with Transport Canada (TC) to help in eliminating the acceptance of unsafe practices in the air-taxi sector.  

In its response, the Northern Air Transport Association (NATA) indicates its engagement in supporting its members and in helping them with the integration of new rules and programs within their operations. The TSB recommendations published as a result of the Safety Issue Investigation (SII) report, Raising the Bar on Safety: Reducing the Risks Associated with Air Taxi Operations in Canada, will be the focus of presentations at NATA’s 44th annual conference and forum for Aviation in Northern and Remote Canada. The Board is pleased that the Floatplane Operators Association, which has now joined NATA, will continue developing the “North Stars Best Practices.”

The Board is encouraged that both ATAC and NATA support Recommendation A19-03 and will continue their work with their respective members. However, the details provided in both ATAC’s and NATA’s responses do not contain sufficient details with regards to future initiatives and actions planned to enable the Board to make a meaningful determination on whether the safety deficiency will be reduced or eliminated. Furthermore, the TSB did not receive any response from the Helicopter Association of Canada (HAC) or the Association québécoise du transport aérien (AQTA).

Therefore, the Board is unable to assess these collective responses to Recommendation A19-03.

Next TSB action

The TSB will monitor the progress of the actions of ATAC and NATA and will follow up with HAC and AQTA to determine if their actions will mitigate the risks associated with the safety deficiency identified in Recommendation A19-03, and will reassess the deficiency on an annual basis or when otherwise warranted.

This deficiency file is Active.