Presentation to the Association québécoise du transport aérien
Kathy Fox, Board Member
Transportation Safety Board of Canada
Gatineau, Quebec
March 17, 2011

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Slide 1: Title Page

Thank you for the kind introduction. It is a pleasure to speak to Quebec's leading aviation industry organization.

Slide 2: Outline

Today, I will give you an overview of the Transportation Safety Board of Canada (TSB) and its role in advancing aviation safety. I will also talk about our Watchlist, the greatest risks to the public and the progress we've made in addressing them. Then I will talk about what else needs to be done to make flying safer.

Slide 3: About the TSB

The TSB is an independent organization investigating marine, pipeline, rail, and air occurrences.

We are notified of approximately 4,000 occurrences each year. Roughly 40 per cent of those are from the air sector. Since we can't possibly investigate every occurrence, we marshal our resources to look for the greatest safety payoff. We deploy, assess the situation and determine if a full investigation is needed - usually when it is very likely that doing so will improve transportation safety.

In practice, over all four modes, this means we carry out approximately 70 full investigations each year. About 40 of these are aviation investigations.

Slide 4: Watchlist

In March 2010, the TSB launched its Watchlist. It describes the nine safety issues in the marine, rail, and air transportation modes posing the greatest risk to Canadians. Some of these are mode-specific, but some apply to all the modes.

In addition to posing the greatest risk, these issues were selected because they had proven stubborn. In investigation after investigation, these were the ones that kept coming up. This meant that not enough was being done, despite numerous recommendations, safety concerns, safety advisories, safety information letters, investigative findings and occurrence trend analyses.

A total of 42 Board recommendations underpin the Watchlist issues, including 11 Air recommendations.

Slide 5: Watchlist: Four Key Objectives

We had four main objectives:

  • To raise public and media awareness about the safety risks in transportation.
  • To demonstrate how concrete action will advance transportation safety.
  • To deliver messages about the TSB and its role.

And most importantly,

  • To build on existing credibility, stimulate dialogue AND TRIGGER ACTION by you, the people who can change things to make flying safer.

In other words, we wanted greater acceptance of our findings and recommendations by regulators and industry leaders. And then we wanted to make sure they took action.

Slide 6: Aviation Issues

From our Watchlist, the main issues we would like to see get resolved in aviation are:

  • Risk of collisions on runways
  • Collisions with land and water
  • Landing accidents and runway overruns

There are also the multi-modal issues of safety management systems and data recorders, which have an impact on aviation.

I will talk about these in a bit more detail, but first, let's take a look at aviation accident statistics.

Slide 7: Number of Accidents and Fatalities in Canada

In the past five years, in Canada, the number of accidents has been trending downwards. However, the number of fatalities is rising slightly.

Slide 8: Number of Accidents and Fatalities in Quebec

Looking at the number of accidents in Quebec in the past five years, both the number of accidents and fatalities is on an upward trend. As we know, 2010 has been a particularly deadly year in aviation, as seen here.

We cannot yet highlight a cause for this upward trend because several of these accidents are still under investigation.

I will now talk about the aviation-specific issues contained in the Watchlist.

Slide 9: Risk of Collisions on Runways

The first Watchlist issue is the risk of collisions on runways, or runway incursions.

The likelihood of a collision on one of Canada's runways is low. However, should two aircraft collide, or an aircraft collide with a vehicle - the consequences could be catastrophic. This is why this issue is on our Watchlist.

Between 1999 and 2008, there were 3,831 runway incursions in Canada. That's approximately one per day.

There are a number of causes, and crews, operators, airport and air traffic services personnel need to work together to reduce the risks. For example:

  • Loss of situational awareness;
  • Restricted visibility due to runway and taxiway geometry;
  • Deficiencies in signs, markings and lighting;
  • Unclear or non-standard communications/phraseology; and
  • Lack of warning systems or not using them even if they're available.

Slide 10: Runway Incursions - Possible Solutions

In the Watchlist, we called for improved procedures and enhanced collision warning systems to reduce runway incursions.

These include:

  • Runway status light systems;
  • Final approach runway occupancy system;
  • "Low cost" surveillance technology;
  • Using tools and procedures from low-visibility operations, such as stop bars.

Slide 11: Collisions with Land or Water

Now, controlled flight into terrain, or CFIT, is a major cause of aircraft accident fatalities. While they account for just 5 per cent of accidents, they also account for 25 per cent of all fatalities!

The risk is greatest at night or in low-visibility conditions. Pilots may lose track of exactly where they are in relation to the ground or water. Smaller planes venturing into remote wilderness or into mountainous terrain are at the greatest risk. These planes do not have ground proximity warning systems like larger airliners do.

Thanks to advancements in technology, there are more systems available that can significantly improve pilots' situational awareness. Some of this technology is now cost effective to install in smaller aircraft. This is why our Watchlist called for wider installation of terrain awareness warning systems to help pilots assess their proximity to terrain.

Slide 12: Landing Accidents and Runway Overruns

I will now speak about landing accidents and runway overruns.

Landing is one of the most critical phases of flight. Accidents can happen on the runway or aircraft can fail to stop in time and run off the side or end.

Many of these accidents happen in bad weather. Typically, these crews are faced with a dynamic and quickly changing environment requiring split-second decision making. In these situations, it is crucial that pilots receive timely information about weather and runway surface conditions to help them make the safest decisions.

Aircraft running off the end of runways is a problem worldwide. In fact, almost 30 per cent of all aircraft accidents between 1995 and 2008 were runway excursions according to the Flight Safety Foundation's figures from May 2009.

And here in Canada, we have the vivid reminder of the Air France plane running off the end of Runway 24L at Toronto's Pearson Airport in 2005 (TSB Report A05H0002). Fortunately, nobody died. But this accident taught us some hard lessons, which should not be forgotten.

Slide 13: Preventing Runway Overruns

So what do we need to do to address this problem?

We at the TSB recognize that this is a complex problem. Numerous lines of defence are needed to:

  • prevent overruns from happening in the first place; and
  • prevent injury, loss of life and damage in case an overrun occurs.

In our Watchlist, we said pilots need to receive timely information about runway surface conditions. This important information will help them assess whether they can land safely and make the safest decision.

And when all else fails, the terrain at the end of runways plays a vital role in increasing the chances that an aircraft stops safely following an overrun.

As such, we called for longer runway end safety areas or other engineered systems and structures, such as the Engineered Materials Arresting System, or EMAS, if lengthening the runway and safety area isn't possible.

I will now talk to you about the issues affecting all modes of transportation.

Slide 14: Safety Management Systems

To start, our Watchlist raises concerns about the implementation of safety management systems, or SMS.

SMS is an internationally recognized management tool to proactively manage safety risks. A well-functioning safety management system integrates sound risk management policies, procedures and practices into a company's day-to-day operations.

Put simply, SMS is a tool that helps organizations find trouble before trouble finds them. They help companies foresee what might go wrong so they can take pre-emptive action.

The Transportation Safety Board of Canada has emphasized the advantages of SMS. However, we have found during our investigations in all the modes that the implementation and regulatory oversight of SMS has been problematic in the transportation industry.

As you know, SMS is progressively being implemented throughout the aviation industry and we are pleased that larger carriers have successfully transitioned to SMS. However, for smaller air operators - air taxi, commuter, flight training units - the transition may be more challenging. As such, our Watchlist calls for Transport Canada to closely monitor all sectors of the aviation industry to ensure that they make a smooth transition to SMS.

Slide 15: Data Recorders

Data recorders are a critical tool for our investigators for finding out what happened during an accident and why.

Aviation has long been the leader in requiring flight recorders, which contain valuable information such as engine and equipment settings, navigation details, voice recordings, and computer data.

Without this information, the search for hard evidence becomes more difficult. This translates into longer investigations, which then cause delays that place public safety at risk. However, with objective data, it is easier to pinpoint safety deficiencies which, when corrected, will make the system safer.

Regarding data recorders in aviation, the Watchlist called for better data recorders, enhanced quality and duration of recordings and the ability to continue recording when the aircraft's power supply fails. These stem from recommendations that came out of the Swissair investigation (TSB Report A98H0003). Another effective option would be to install an image recorder. This would be of benefit to investigating accidents both in single pilot and multi-crew operations.

Slide 16: Data Recorders (cont.)

We have a unique and troubling situation with some air taxi operations flying Beech King Air 100s without cockpit voice recorders (CVRs) aboard. The Canadian Aviation Regulations (CARs) were unclear on the requirements for a CVR as I will now explain.

The King Air 100's type certificate allows for it to be flown by a single pilot. The air taxi regulations in CAR 703 require two pilots when carrying passengers while flying under instrument flight rules (IFR). The CARs also require a CVR aboard multi-engine turbine-powered aircraft that are configured to fly with six passengers or more and where the aircraft type certificate or the air operator certificate requires two pilots. However, a number of air taxi operators are allowed to fly single-pilot IFR with passengers if they meet the requirements of an operations specification. And while these operators can legally fly single pilot, they often fly with two pilots aboard for improved safety, customer service and passenger comfort.

So there you have it: we have aircraft that can be operated with a single pilot but often operated with two, and air operator requirements for two pilots with an "out." These operators must meet an operations specification and aircraft equipment regulations requiring CVRs but not if the operator or type certificate allows single-pilot operation.

When Transport Canada learned that some King Air 100s were flying without CVRs, they sent letters to three air taxi operators to require their installation. The operators contested the enforcement action in Federal Court. While they lost the first decision, they won an appeal on Federal Court ruling, which now allows them to operate without a CVR even when voluntarily assigning two crew members aboard their King Air 100s.

Slide 17: Data Recorders (cont.)

Since 2009, we have had three accidents in Quebec involving King Air 100s where nine people have died. The lack of CVR information is making these investigations more complex, which in turn causes delays in identifying safety deficiencies and getting any safety-critical information that might arise out to those who can make changes for the better, such as you.

Following the appeal, Transport Canada proposed new regulations requiring CVRs aboard aircraft in this category any time they are operated by two pilots. But as we know, enacting new regulations takes a long time, and there may well be more accidents that will be more difficult to investigate without the objective data that comes from cockpit voice recordings.

Slide 18: One Year Later

That was almost a year ago. What's happened since?

When we launched the Watchlist, it received extensive media coverage that was sustained for weeks both regionally and nationally. Board members conducted numerous interviews from coast to coast.

The same day, the Minister of Transport announced that Transport Canada would take back the oversight of the business aircraft operators as of April 2011, in response to the recommendation on SMS stemming from the Fox Harbour investigation (TSB Report A07A0134). Later that day, the Minister issued TC's response to the TSB Watchlist. These announcements helped bring even greater focus to the Watchlist and helped sustain our presence in the press.

While media coverage and positive announcements from Transport Canada are helpful, the real measure of success, however, is in terms of concrete results.

After all, our mandate isn't to generate media coverage. It's to improve transportation safety. To get things done.

Here, then, is the score so far.

Slide 19: Where are we now?

As I mentioned before, there are 42 TSB Recommendations in the various modes that underpin the Watchlist, 11 of those are Air recommendations.

The figure on screen shows the percentage of the recommendations, and what their status is.

You can see that, out of these 42 recommendations, 24 per cent were fully satisfactory as indicated in green. You can notice in dark blue that 60 per cent were rated as satisfactory intent and in light blue that 14 per cent were rated as satisfactory in part. In red, you can see that 2 per cent of these recommendations were rated as unsatisfactory.

So, we're making progress. But given that our goal is 100 per cent implementation of all outstanding 42 Watchlist recommendations, there's still a long way to go. So let's look at it another way, one that may not be so … rosy.

A total of 10 recommendations out of the 42 recommendations of the Watchlist are now rated as fully satisfactory.

That leaves 32 still to go.

It is important to note that none of the fully satisfactory recommendations are aviation recommendations.

As I said before, our goal is 100 per cent implementation. That means we want these issues—every single one—to eventually become non-issues.

Slide 20: How Can You Help?

How can you help?

The answer to this question is the reason I'm here today: because, when it comes right down to it, if we don't have industry buy-in, nothing will improve. You people are the point at which the rubber meets the road.

While the Watchlist issues are complex, fortunately solutions do exist to make things safer.

  • Work with your airport and air traffic services to assess risks and find solutions to prevent runway incursions;
  • Terrain awareness technology is now more widely available and more affordable;
  • You have a direct interest in knowing whether the ends of the runways are safe in case of an overrun;
  • Data recorders are valuable for us to identify safety deficiencies that you can solve. If you have flight data recorders (FDRs), their data are valuable for quality assurance programs to help you make your operations safer and more efficient.
  • Lastly, SMS, which is a regulatory requirement for some sectors of the industry, is also an opportunity to increase organizational safety and also has proven business benefits.

By implementing solutions such as the ones above, we will achieve the goal of implementing 100 per cent of our safety recommendations.

Slide 21:

I'm very happy to have talked to you today. I will now answer your questions. Thank you.

Slide 22: END