Safety Issues Investigations: identifying the underlying problems

ISSN 2369-873X

29 January 2015
Posted by: Peter Hildebrand

There is an old saying that “every accident is different.” Because it is true that no two accidents are alike, the Transportation Safety Board of Canada (TSB)’s methodology emphasizes that investigators keep an open mind throughout each investigation.

They do so by first gathering all relevant information and then analyzing it to understand what it means, and what actions must be taken to prevent such incidents from happening again. But what if the same issues keep coming up, again and again?

In recent years, TSB investigators have been travelling repeatedly to accident sites involving air taxi aircraft. An air taxi, or Canadian Aviation Regulations (CARs) 703 operation, is a single or multi-engine aircraft (other than turbo-jet) that has a maximum certificated take-off weight of 19,000 pounds or less, and a seating configuration, excluding pilot seats, of nine seats or fewer.

Although one might think that each of the individual air taxi accidents we investigate may affect a relatively smaller number of people, collectively, the numbers add up. Over the last 10 years, the air taxi sector of the aviation industry has seen 175 deaths—65% of all commercial aviation fatalities.

That is why the TSB Chair, Kathy Fox, recently announced that the TSB is launching 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, and the Board may make recommendations to address any identified systemic deficiencies.

As air taxis operate throughout Canada, they face a number of challenges, such as taking off and landing at smaller, more remote airports with less-developed infrastructure. Air taxi crews may fly smaller, older aircraft with less sophisticated navigation and warning systems, which can cause higher workloads for crew. Plus, flight crews working for these operators are often working their way up in the system; they may have less training and experience, and are often self-dispatching, without the benefit of established airline operational control staff familiar with the route and destination conditions. This can result in accidents such as the 2012 plane crash in North Spirit Lake, Ontario, where operational pressures, adverse weather conditions, and lack of experience were identified as contributing factors.

Aircraft wreckage in North Spirit Lake, ON
Aircraft wreckage in North Spirit Lake, ON

The TSB has conducted SIIs in the aviation sector before. For example, Safety Issues Investigation Report SII A05-01 on post-impact fires resulting from small-aircraft accidents found that post-impact fires (PIF) continue to contribute to injuries and fatalities in accidents involving small aircraft. The study found that in the accidents in which PIF contributed to serious injuries or fatalities, the aircraft occupants were in close proximity to fire or smoke for some time following an impact. It also went on to analyze the defences which could be improved to reduce fire-related injuries should fire occur in these otherwise-survivable accidents.

Since the release of that SII report, some manufacturers have introduced “crashworthy fuel systems” and changed the design of some of their fuel tanks. There is still work to be done to eliminate the risks post impact fires, but that is what SII reports are for: outlining the actions that need to be taken and pressing for change.

In the SII on air taxi operations, the TSB wants to find out what the accidents in the air taxi sector have in common, and what can be done about them. And the Board may make recommendations to address any systemic deficiencies identified. The study will begin in 2015, and as usual, the TSB will communicate its findings once the investigation is complete.

Image of Peter Hildebrand

Peter has been with the TSB for over 20 years and is the manager (Air) at the Central Regional office in Winnipeg. He lives near Stonewall, Manitoba, with his wife, Hermina, and cat, Freckles.

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