Raising the bar on safety

Kathy Fox

Chair, Transportation Safety Board of Canada

This article was originally published in the January/February 2020 edition of Wings magazine.

A unique sector, with unique challenges

Canada's aviation industry is as diverse as the country itself, and nowhere is this better illustrated than in the air-taxi sector. These smaller aircraft provide Canadians with a broad array of services: helicopters to transport patients to hospitals; floatplanes to take commuters from harbour to harbour in coastal cities or to hunting or fishing camps; and aircraft to bring workers to remote areas, and deliver food, equipment, and passengers to small communities on a daily basis.

However, the air-taxi sector has more accidents, causing more fatalities, than all other sectors in commercial aviation in Canada combined (see Figure 1).

An insidious problem

To find out why, the Transportation Safety Board of Canada (TSB) conducted an exhaustive four-year study on air taxi operations in Canada. After studying over 716 occurrences, interviewing 125 individuals, and analyzing approximately 300 hours of recordings, we determined that the answer was partly because of the nature of the work. Air taxi operations take place in a very different context from other sectors of commercial aviation. They often have no set schedule and fly into remote areas in uncontrolled airspace with few or no aerodromes. Flights tend to be shorter, resulting in more takeoffs and landings. Access to basic weather information, or the latest aircraft technology, may be limited.

But the larger reason for so many accidents is more insidious, and boils down to two things: an acceptance of unsafe practices, and the inadequate management of operational hazards. Examples of the former include: flying overweight, flying into forecasted icing, not recording defects in the aircraft log, flying with unserviceable equipment, “pushing the weather,” and flying with inadequate fuel reserves. Examples of the latter include sub-optimal crew pairing, dispatching a flight with a different pilot after a first pilot has refused, or not having scales available to prevent aircraft from taking off overweight.

But why would these occur in the first place? The short answer is because certain practices have become accepted as the “normal” way to conduct business. As these unsafe practices become more entrenched, and as flights are carried out successfully (though not necessarily safely), the associated risks become just “part of the job.”

Competing pressures

Like any business, air taxi operators face competing pressures—operating pressures, sector pressures, and safety pressures—and these pressures must be managed in order to deliver a service, stay economically viable, and also stay safe. As long as those pressures stay in relative balance, a flight should operate safely. But in the real world, those pressures are always shifting, pushing the operation toward boundaries, and toward a space that isn’t necessarily safe. That doesn’t mean that the result is always an accident, but it almost always means a reduced margin of safety—and an increased likelihood of an accident (see Figure 2).

In the first two frames, you can see the three competing pressures, and what operations look like when they are in relative balance (i.e., the flight operates safely in the middle of the safe operating envelope). In the third frame, you can see that the pressures are out of balance, and the flight is operating at the margins of safety, where they are at increased risk of an accident. In the final frame, the flight is operating outside of the safety margins, where the chances of an accident are greatest.

Raising the bar on safety

Getting clients, passengers, crews, and operators to reject unsafe practices—and to speak up to prevent those practices from happening—will be difficult. Doing so will require strategies, promotion, and education tailored to the sector to change values, attitudes, and behaviours and create a culture where unsafe practices are considered unacceptable.

To help with this, the TSB issued four recommendations to Transport Canada and industry aimed at:

• eliminating the acceptance of unsafe practices;
• promoting proactive safety management and a culture of operating safely;
• updating aviation regulations to reduce identified safety gaps; and
• tracking data so that mitigation strategies can be better assessed.

What’s next?

In order to raise the bar on safety in air-taxi operations, all stakeholders, together, need to change to a culture where unsafe practices are unacceptable. At the TSB, we plan to follow up by:

• communicating these key messages to stakeholders;
• conducting outreach to help stakeholders understand their responsibility in creating a culture where unsafe practices are unacceptable and operational hazards are adequately managed; and
• monitoring air-taxi accident investigations and trends and communicating the results publicly.

Together, it is our goal for everyone to raise the bar on air safety in this vital sector, across Canada.