Presentation to the Air Transport Association of Canada 2012 Annual General Meeting

Kathy Fox
Board Member, Transportation Safety Board of Canada
Vancouver, BC
13 November, 2012

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Speaking notes

Slide 1: Title page

Thanks for the kind introduction, and thank you very much for this opportunity to speak today.

Slide 2: Outline

First, I'd like to give you some information about the TSB's most recent edition of the Watchlist.

I'll also be providing a summary of several recent TSB investigations and how they relate to the Watchlist or other issues of concern to the Board.

Finally, I want to provide some food for thought about what role oversight and governance play or should play in safety management.

And I plan to leave some room for a Q&A session, where I look forward to hearing your perspective and answering any questions you may have.

Slide 3: Watchlist: What is it?

We first published our safety Watchlist in 2010 - a list of the nine issues posing the biggest risks to Canada's transportation system … at the time. We wanted to raise public awareness and launch a call for action to both regulators and industry, so they in turn would make the necessary improvements to make moving people and goods safer in Canada.

That first version of the Watchlist was intended to be a “blueprint for change”, and that's exactly what happened. Over the next two years, we saw some positive action to make transportation safer. In fact, 14 of the 41 original Watchlist recommendations—34% of them—have been assessed as Fully Satisfactory by the Board.

Because of this change, we were able to remove some issues from the Watchlist:

  • Emergency preparedness on ferries
  • Operation of longer, heavier trains

We also saw some positive action in Safety Management Systems in rail and some movement on data recorders in all three modes.

Permit me to digress for a moment to speak of data recorders: as investigators, we want as much information as possible. Not just flight plans, or even interviews with survivors or witnesses. I'm talking about hard data—objective facts. Our large investigations have long demonstrated the value of recorders, but they just aren't present in smaller carriers—commuter operators, air taxis, FTUs. And that means more accidents where the cause is undetermined, or we have barely been able to skim the surface in our findings. I'll give a couple of examples later.

The big barrier, of course, has always been cost. Now, though, there are smaller, lighter, lower-cost options—recorders that can capture facts critical to the investigation—including actual weather, ambient sound, pilot actions and aircraft response. In other words, the business case is changing, and the time may now be approaching where we reconsider their feasibility.

Voice and video recordings are another matter. We would like to see them in smaller operations, and we would like to see them used for safety purposes because we think that not only will they help us learn more when there is an accident, but they could help companies and crews learn more day to day. Having said that, there are some legal hurdles: as the law now stands, video and voice recordings cannot be used in an SMS or similar safety program. That has to change.

But back to the Watchlist—specifically, the 2012 version.

Slide 4: Watchlist 2012

As I said, given the amount of progress made, we felt it was time for an update. We removed some of the old issues, and added new ones that had become prominent since 2010.

However, many of the issues still persist, particularly those in aviation, where not enough progress has been made. These four issues are:

  • Landing Accidents and Runway Overruns
  • Safety Management Systems
  • Risk of Collisions on Runways
  • Collisions with Land and Water

Let's look at them individually.

Slide 5: Landing accidents and runway overruns

Every year, millions of landings occur at Canadian airports. The landing is one of the most critical phases of flight. An accident can happen on the runway, or the aircraft may fail to stop in time and run off the side or end. In fact, since 2010, the annual number of these accidents has not decreased.

Although these runway excursions can occur both during takeoff and landing, landing excursions outnumber takeoff excursions by a ratio of approximately 4:1.

Many of these accidents happen in bad weather, when it is crucial that pilots receive timely information about runway conditions to calculate the distance required to land.

Almost everyone, of course, remembers the Air France occurrence in 2005 in Toronto. But these overruns are more common than many people think.

Here's a picture of just one example: Just over two years ago, on March 24, 2010, Cargojet flight 620, a Boeing 727, overran a Moncton runway. The aircraft came to rest in deep mud, the nose wheel approximately 340 feet beyond the runway end and 140 feet beyond the edge of the paved runway end strip. (A10A0032)

And it's not just the big jets. These accidents happen to all sorts of aircraft, and they happen often. In fact, the TSB has investigated, or is currently investigating, at least 10 other overruns—all of them within the last few years.

Slide 6: More common than you might think

There are eight overruns currently under investigation by the TSB, and they happened at airports large and small.

In Canada, if we include incidents and accidents, runway overruns occur at a rate of about 3.3 per year for these larger aircraft, and the rate is even higher when runways are wet. So even though the numbers are fairly small, we are all exposed to the possibility of a runway overrun, with potentially catastrophic consequences.

Slide 7: Stopping distance …

This slide shows that 90 percent of all aircraft involved in an overrun stop within 300 m of the end of the runway. And roughly two-thirds of aircraft stop within 150 m.

Slide 8: A complex problem

The Board recognizes that runway length is not the sole determinant of whether a plane will overrun, nor whether there will be any damages or injuries to passengers and crew. Numerous lines of defence are needed to both:

  • prevent overruns from occurring in the first place;
  • prevent injury, loss of life, or damage to property or the environment in case an overrun occurs.

Solving this complex problem will require a coordinated approach by regulators, manufacturers, and aerodrome operators.

Slide 9: TSB recommendations

Following the Air France accident, the Board issued 3 recommendations to prevent runway overruns from happening in the first place by enhancing operational standards, pilot training, and operational procedures as follows: [click for each item]

A07-01: That regulators establish clear standards to limit landings in bad weather. TC has taken some action to raise the awareness of Canadian operators and initiated international discussion on the issue. The Board has assessed this response as Satisfactory in Part.

A07-03: That pilots receive mandatory training to better enable them to make decisions about landing in deteriorating weather. The Board is concerned with the pace of TC's activity related to the deficiency identified in this Recommendation. However, the planned action, if and when fully implemented, will substantially reduce or eliminate the safety deficiency. Consequently, the Board has assessed this response as having Satisfactory Intent.

A07-05: That crews be required to establish the margin of error between landing distance available and landing distance required before conducting approaches in deteriorating weather. While TC has taken some action, the Board continues to be concerned about the length of time being taken regarding the proposed regulatory action designed to address the deficiency and has assessed TC's response as having Satisfactory Intent.

Slide 10: Recommendation A07-06

In 2007, the Board recommended an additional line of defence. When all else fails, adequate runway end safety areas, or RESAs, will greatly increase the chances for an aircraft to stop safely in case of an overrun. This safety area must be sufficiently clear of obstacles, appropriately graded, and have a surface that will aid in stopping the aircraft as quickly as possible.

Recommendation A07-06 urges TC to require all Code 4 runways (those longer than 1800 m) to have a 300 m runway end safety area (RESA) or some other means of stopping aircraft that provides an equivalent level of safety.

[on screen: The Department of Transport require all Code 4 runways to have a 300 m runway end safety area (RESA) or a means of stopping aircraft that provides an equivalent level of safety.]

Why 300 m? As I said a few moments ago, 90 percent of all aircraft that overrun stop within 300 m. And two-thirds of aircraft stop within 150 m.

The TSB is not demanding the construction of a 300-m RESA on every runway in Canada. That kind of one-size-fits-all approach wouldn't be feasible, nor do we feel it would be necessary to address the risk. The key is a balanced approach. We know that all runways do not present the same risks; that is why the Board's recommendation focuses on Code 4 runways at Canada's largest airports. And we've also given careful consideration to the phrase “a means of stopping aircraft that provides an equivalent level of safety.”

However, as of March 2012, TC's Notice of Proposed Amendment (NPA) webpage stated that the RESA minimum length requirement remains at 150 m for runways greater than 1200m or less than 1200 m if the runway type is non-precision or precision, excluding airports located north of the 60th degree parallel that only serve air carrier operations utilizing small aircraft.

The Board feels that these changes might reduce but would not eliminate the deficiency, and so our assessment remains Satisfactory in Part.

In the meantime, until new regulations are in place and whatever they may require, the Board believes that airport operators should be assessing the risks of each of their runways under the airport operator's SMS. They should evaluate the nature of terrain off the end of each runway and the risks involved based on the types of aircraft operating there.

And now, moving on to the next Watchlist item …

Slide 11: Risk of collisions on runways

The likelihood of a collision on runways at Canada's airports is low. However, should two aircraft collide, or an aircraft collide with a vehicle, the consequences could be catastrophic.

From 2001 to 2009, there were over 4000 conflicts or “runway incursions”, where two aircraft or an aircraft and a ground vehicle were on an active runway at the same time. And since 2010, the number of these occurrences has not gone down significantly. That is why this issue is still on our Watchlist.

Airports are complex environments, where aircraft and ground vehicles must coexist in a confined area. While efforts are being made to share information and improve procedures at airports, very few new technological defenses are being considered in Canada.

By focusing on improved procedures and enhanced collision warning systems, we think the risk of these incursions at Canada's busy airports can be lowered.

Slide 12: TSB findings

In 2010, the TSB recorded 351 of these runway incursions, followed by another 446 in 2011. 

Here are some of the findings from recent TSB investigations:

From investigation A07O0305: In November 2007, at Toronto's Pearson International Airport, a Learjet 35A came within 60 feet of a collision with a an Israel Aircraft Industries IAI 1124 Westwind, which was on the landing roll on Runway 05. Upon observing the Learjet in front of them, the Westwind's crew manoeuvred to pass behind it.

Slide 13: More TSB findings

From investigation A08H0002: In July 2008, the north ground controller—also at Pearson International—cleared three emergency services vehicles to enter Runway 33L en route to the fire training area. Thirty-seven seconds later, a Boeing 737-700 was cleared for take-off from Runway 33L. The aircraft was approximately one-third of the way down the runway when the vehicles entered the runway, and became airborne approximately 2500 feet from the vehicles.

From investigation A09W0026: An even more serious occurrence took place in 2009, in Fort McMurray, Alberta, when a Sunwest Aviation Limited Beech 1900D with two crewmembers and 18 passengers passed about 100 to 150 feet over a snowplow that was operating on the runway. The snowplow operator had not been instructed to vacate the runway prior to the Beech 1900D's departure—nor had the aircraft's crew been advised of the presence of the snowplow on the runway.

Slide 14: TSB safety concerns

The 2007 occurrence in Toronto is particularly noteworthy because, following the investigation, the TSB report contained three Board concerns:

“Two heads up”

The practice of performing non-essential checklists while taxiing for departure is a common one and results in only one pilot monitoring the taxi route and the aircraft's compliance with traffic instructions. The Board is concerned that, unless explicitly curtailed,  completion of non-essential checklists during taxiing in order to expedite take-off will continue to remove a primary defence against potential runway incursions.

“ASDE/RIMCAS at Toronto / Lester B. Pearson International Airport”

It was reported that the existing airport surface detection equipment / runway incursion and monitoring and conflict alerting system (ASDE / RIMCAS) at Toronto / Lester B. Pearson International Airport is at its limits and cannot be enhanced due to the type and age of its software. The Board was concerned that Canada's busiest commercial airport is apparently operating with an ASDE / RIMCAS that does not provide the same level of protection as that available at other airports in Canada.

“Direct warnings of runway incursions to flight crews”

Even with an improved ASDE / RIMCAS, the improved system will continue to rely on the timely interpretation of warnings by controllers and their subsequent radio communication with aircraft and vehicles.

The Board is concerned that until flight crews in aircraft that are taking off or landing receive direct warnings of incursions onto the runway they are using, the risk of high-speed collisions will remain.

In 2009, an Air Canada Jazz flight was making an instrument landing system approach to Whitehorse International Airport, in light snow as a winter snow storm was moving through the area. Although the aircraft was advised that sweeping was in progress on Runway 31L, it landed nine minutes later without clearance after flying over two runway snow sweepers operating on the portion of the runway located before the displaced threshold for Runway 31L.

And so, as you can see, the risk of collisions persists.

Now, moving on to our next Watchlist issue…

Slide 15: Collisions with land and water

In low visibility or at night, pilots may lose track of exactly where they are in relation to the ground or water. The risk is greatest for smaller planes venturing into remote wilderness or into mountainous terrain, as they do not have ground proximity warning systems. But as we saw in August 2011 in Resolute Bay, these accidents can also affect larger aircraft as well.

In our Watchlist, we urge wider adoption of technology such Terrain Awareness Warning Systems for smaller Canadian aircraft. We are also looking for improvements to instrument approach procedures to prevent these types of accidents.

Slide 16: TAWS

Back in 1995, the TSB recommended that TC “require the installation of Ground Proximity Warning Systems (GPWS) on all turbine-powered, IFR-approved, commuter and airline aircraft capable of carrying 10 or more passengers” (A95-10).

The TSB is pleased to note that, as of this summer (albeit 17 years later), amendments to the Canadian Aviation Regulations were published in the Canada Gazette, Part 2. These regulations exceed the criteria of our original recommendation, and will substantially reduce the safety deficiency.

Slide 17: Exact Air (A09Q0203)

On the evening of December 9, 2009, a Beech A100 operated by Exact Air Inc. was on an instrument flight rules flight between Val–d'Or and Chicoutimi/Saint–Honoré, Quebec, with 2 pilots and 2 passengers on board. After the crew descended prematurely below the published approach minima, the aircraft suffered a CFIT on approach. The 2 pilots were fatally injured, and the 2 passengers were seriously injured. The aircraft itself was destroyed on impact.

Slide 18: Descent techniques

To maintain a safe flying altitude over obstacles, pilots commonly use a step-down approach. (click)

This type of descent requires several power and attitude changes, thus increasing pilot workload as well as the chances of error. The airplane is also flown at a low altitude for a longer period of time. (click)

The night of the accident, the airplane was supposed to stop the descent at 900 feet, then descend to 860 feet until visual contact with the runway (click), in order to complete the approach and touch-down visually. (click)

Unfortunately, the airplane continued its descent (click) and collided with trees long before reaching the runway. However, in this case, without a cockpit voice recorder, we do not know why the crew did this! (click)

Slide 19: Exact Air recommendations

Two recommendations emerged from the TSB's investigation into the Exact Air occurrence.

First, Transport Canada (TC) needs to require that the design and depiction of the non-precision approach charts incorporate the optimum path to be flown. (A12-01)

Slide 20: Exact Air recommendations (continued)

The Board also recommended that TC require the use of the stabilized constant descent angle approach technique in the conduct of non-precision approaches by Canadian operators. (A12-02)

We have received Transport Canada's formal response to these recommendations. Once the Board has completed the assessment, this will be published on our website. I can say that we are encouraged to learn that NAV CANADA plans to move ahead with changing the depiction standards for non-precision approach procedures, which will help mitigate the safety deficiency identified by this TSB investigation.

Slide 21: Exact Air — safety concern

In 1998, the Flight Safety Foundation (FSF) Approach and Landing Accident Reduction (ALAR) task force issued recommendations targeting the reduction and prevention of Approach and Landing Accidents. An internationally recognized ALAR Toolkit which incorporates these recommendations was developed and distributed by the FSF as a resource to mitigate the risks of ALA.

In 1998 and 1999, TC published articles related to the reduction of CFIT accidents. Both articles make reference to the FSF ALAR Toolkit. The 1998 TC article was reprinted 13 years later.

To date, approximately 40 000 copies of the toolkit have been distributed worldwide. However, the majority of Canadian air taxi operators have not reviewed the contents of the ALAR Toolkit and are unaware of the details of FSF recommendations. Therefore, these recognized mitigation strategies for reducing ALAs are not being implemented into their operations.

Reducing the number of CFITs isn't just about TAWS and NPA procedure depictions: we want commercial operations to start using the tools and strategies in the FSF toolkit.

Slide 22: CFITs in Canada

Counting all types of operations and aircraft, there were 129 CFIT accidents in Canada and 128 fatalities between 2000 and 2009. CFIT accidents account for 5 percent of accidents, but nearly 25 percent of all fatalities. Considering only aircraft registered in Canada for air taxi service, there were 26 CFIT accidents over the same period of time, resulting in 42 fatalities. Furthermore, for air taxi operators, these accidents accounted for 7 percent of total accidents, but 35 percent of fatalities during this 10–year period.  And since we first put this issue on the Watchlist, the number of accidents per year of this type has not gone down.

Slide 23: Approach and landing accidents

According to data compiled by the TSB, the ALA rate for commercial operations seems to have generally decreased only slightly over the past decade, whereas the number of fatalities has remained constant. Between 2000 and 2009, ALAs accounted for 62 percent of all accidents involving air taxi services in Canada.  The number of accidents involving air taxi operations is still considerably higher than the number of accidents for airline and commuter operations, accounting for approximately 70 percent of all commercial operation ALAs. The result is that, on average, there are 12 times more ALAs in air taxi service than in airline operations.

Approximately 80 percent of commercial operation ALAs has taken place at airports that are only equipped with non–precision instrument approaches which are primarily used by air taxi operators.

Moving on to the final Air Watchlist issue …

Slide 24: Air SMS

In the TSB's 2010 edition of the Watchlist, we highlighted the challenges of implementing SMS throughout the aviation industry. It continues to be challenging and thus we have kept this issue on the Watchlist.

The Auditor General of Canada found deficiencies in Transport Canada's planning, implementation and oversight of SMS. And recent TSB investigations have highlighted the difficulties faced by operators, in particular smaller ones, in adopting SMS in their daily operations.

SMS has been a requirement for airline operations since 2005. But for the smaller air operators—702s, 703s, and 704s —implementation of SMS has been delayed to provide more time to refine procedures, training and guidance material. The smaller operators incurred 91% of commercial aircraft accidents and 93% of commercial fatalities from 2002 to 2011.

To reduce the risks to Canadians, SMS practices need to be adopted by all air companies. Moreover, TC must effectively monitor the integration of SMS practices to ensure a smooth transition.

Slide 25: Aéropro (A10Q0098)

In June 2010, seven people were killed when a Beech A100 King Air operated by Aéropro crashed in the city of Québec. The investigation determined that the pilots did not use maximum available power during the take-off run and encountered an unidentified problem with the right engine after rotation.

The TSB's investigation into the occurrence found numerous safety deficiencies in the areas of pilot training, company operating procedures and maintenance documentation. Use of reduced power on take-off was encouraged as a cost-saving measure. While training met regulatory requirements, it did not prepare the crew to effectively manage the emergency. The emergency checklist was designed for use by a single pilot, and there were no written directives specifying who was to perform which task during two-pilot operations. These deficiencies may have led to confusion and omissions by the crew during the emergency. Once again, the aircraft was not equipped with a voice recorder, so we never could determine exactly what was going on in the cockpit prior to the crash.

Slide 26: Aéropro: findings as to risk

The investigation also determined that the operator had a poor safety culture. Here are some of the findings from the TSB's investigation report.

  • “The maintenance procedures and operating practices did not permit the determination of whether the engines could produce the maximum power of 1628 ft-lb required at take-off and during emergency procedures, posing major risks to flight safety.”
  • “Besides being a breach of regulations, a lack of rigour in documenting maintenance work makes it impossible to determine the exact condition of the aircraft and poses major risks to flight safety.”
  • “The non-compliant practice of not recording all defects in the aircraft journey log poses a safety risk because crews are unable to determine the actual condition of the aircraft at all times, and as a result could be deprived of information that may be critical in an emergency.”

Slide 27: Aéropro: findings as to cause and contributing factors

Although inspections performed by TC revealed unsafe practices, the measures TC took to ensure compliance with regulations were not effective. As such, the unsafe practices continued.

  • “The poor safety culture at Aéropro contributed to the acceptance of unsafe practices.”
  • “The significant measures taken by TC did not have the expected results to ensure compliance with the regulations, and consequently unsafe practices persisted.”

Some short-sighted operators may not be truly committed to implementing sound risk management policies, processes and practices, believing these to add more bureaucracy than value.

Slide 28: Who holds decision-makers to account?

So, that begs the question: who holds decision makers (typically senior management) to account for the consequences of their trade-offs and the decisions they make about risk?

  • Board of Directors/Owner
  • Shareholders/ Financial backers
  • Customers
  • Insurance Companies
  • Regulators
  • All of the above?

Ultimately, transport regulators and regulations are in place to protect the public by requiring operators to meet certain minimum standards governing aircraft certification, manufacture, maintenance, pilot training and qualifications, and various other operating limitations. But are regulators doing enough?

Slide 29: The role of oversight in safety management (continued)

At the end of the day, what evidence and processes are necessary to substantiate a regulator's decision to shut-down a non-compliant operator?

Regulators are increasingly encouraging operators to adopt new technology, training and safety programs on a voluntary basis to avoid lengthy and costly rulemaking processes which don't always pass the cost-benefit analysis based on an already low accident rate.

Slide 30: Regulatory oversight

In a recent message (AeroSafety World, July 2012), William Voss, President and CEO of the Flight Safety Foundation, wrote: “A major U.S. airline that implements all the voluntary FAA programs is clearly very safe, but that airline may have to compete with another carrier that decides to cut costs and not implement any of the same programs. The gap between what is legal and what is safe already is large, and it will get bigger. … Is this regulatory approach sustainable? Is it fair to airlines that do everything right? Is it fair to an unknowing public?”

Slide 31: For further information…

Thank you again for the opportunity to speak to you today. I'd be pleased to take any questions.

Slide 32: Canada wordmark


  1. Source: TSB website.
  2. Source: TSB Investigation Report A09Q0203 (Exact Air)
  3. ibid