The TSB has completed this investigation. The report was published on 7 November 2019.
Safety issue investigation (SII)
Raising the bar on safety: Reducing the risks associated with air-taxi operations in Canada
The air-taxi sector provides a diverse array of air services to Canadians. These include helicopters to transport injured or ill patients to hospitals, floatplanes to take commuters from harbour to harbour in coastal cities, and airplanes to bring workers to remote areas, provide search and rescue, or deliver food, equipment, and passengers to communities. These vital air links have helped build Canada and sustain its people.
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.
In the 18-year period from 01 January 2000 to 31 December 2017, there were 789 accidents in the air-taxi sector, resulting in 240 fatalities—representing 55% of all accidents in commercial air services in Canada and 62% of the fatalities in this timeframe.
The purpose of the SII was 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. 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 results of the SII pointed to two factors that reduce the safety margins for air-taxi operations: the acceptance of unsafe practices and the inadequate management of operational hazards.
Air-taxi services operate in a very different context from other sectors of aviation. They often have no set schedule and fly into remote areas in uncontrolled airspace with few aerodromes or navigation aids. What aerodromes there are may be small, with fewer services and less infrastructure. Access to current and forecast weather information or the latest technology may be limited. Operators tend to be smaller. Flight crew have a more direct role in managing many of the operational hazards, and pilots often have direct contact with clients. Pilots may not have operational support from dispatch and other personnel. Flights tend to be shorter, resulting in more takeoffs and landings.
Aircraft are exposed to severe weather because they fly at lower altitudes and over rugged, coastal, or northern topography. The aircraft can be small (carrying fewer than 10 passengers, by regulation), in many cases, old (some more than 70 years old), and with less sophisticated technology. Pilots often fly by visual reference to the ground, rather than navigating using instruments alone. Flight crews may have to land on gravel airstrips, on lakes, or on frozen surfaces, especially helicopter crews who often have to land at unprepared sites.
To address these problems, the TSB issued four recommendations aimed at industry associations and Transport Canada calling on them to eliminate the acceptance of unsafe practices (A19-02), promote proactive safety management and a positive safety culture (A19-03), close the gaps in the air-taxi regulatory framework (A19-04) and to collect activity data specific to the air-taxi sector (A19-05).
Media materials
News release
Backgrounders
Speeches
A15H0001 (SII Air Taxis): Opening Remarks
Kathy Fox, TSB Chair
Glen Whitney, Regional Senior Investigator, Operations, Air Investigations Branch (Ontario Region)
Investigation information
Investigator-in-charge
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.
Download high-resolution photos from the TSB Flickr page.
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.