Assessment of the response to TSB recommendation A19-02

 Recommendation A19-02
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Eliminating the acceptance of unsafe practices


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. This SII reviewed 15 years of data to identify safety issues in Air Taxi Operations in Canada that have not been sufficiently mitigated. This SII examined air taxi operations as a whole and considered safety issues that are germane to the entire air taxi industry and not just to one specific segment of the industry.

The Board concluded its SII and released report A15H0001 on 07 November 2019.

TSB Recommendation A19-02 (November 2019)

This SII highlights what types of unsafe practices have been happening for years and continue to happen: from flying overweight to flying in marginal weather, to flying with inadequate fuel reserves. Deviations from standard operating procedures, company policy, procedures, regulations, or safe practices can result in outcomes similar to those that have contributed to numerous accidents and incidents over the years.

At the same time, the safety margin built into these operations may allow an unsafe flight to be completed successfully. When operations are conducted successfully with a reduced safety margin, this may lead to an acceptance of unsafe practices and make it difficult to know how much of the safety margin has been eroded.

An important step in raising the bar on safety in air-taxi operations is getting clients, passengers, and operators not to accept unsafe practices even when there seems to be a sufficient safety margin, and to speak up to prevent them from happening. This requires strategies, promotion and education to change values, attitudes and behaviours, which will eventually result in a change of culture.

Safety culture is defined as the way safety is perceived, valued, and prioritized in an organization. Establishing a positive safety culture has many challenges; however, it is a necessary first step in creating the values, attitudes and behaviours required for operators to effectively manage the risks associated with their operations. In practical terms, a positive safety culture can in part be built or supported by proactive safety management.

The evidence of this change in culture will be an operation that supports and reinforces PDM/CRM practices through a strong company culture, including support for decision making by managers, supervisors, and peers. Supportive influences and actions from all stakeholders can help operators prioritize safety and manage risks to an acceptable level. But to do this, time and resources must be invested before the flight, and investments must be made as part of increasing safety pressures through training and education, company-wide safe decision making, the use and support of PDM/CRM practices, and safety management that includes a culture of operating safely. To be effective, all this must be done with the knowledge of the operating context of air-taxi operations and the hazards and risk factors specific to this sector.

The emphasis now needs to be on using a positive safety culture and proactive safety management to increase safety pressure that will eventually lead to a culture where unsafe practices are considered unacceptable.

Therefore, the Board recommended that

the Department of Transport collaborate with industry associations to develop strategies, education products, and tools to help air-taxi operators and their clients eliminate the acceptance of unsafe practices.

TSB Recommendation A19-02

Transport Canada’s response to Recommendation A19-02 (January 2020)

TC agrees with the recommendation and is committed to working with its stakeholders to identify unsafe practices and support initiatives to improve safety.

To this end, TC has begun planning to implement a campaign focussed on safety in the air-taxi sector. TC will engage key stakeholders at the next Aviation Safety Forum to be held in January 2020 where key potential safety pillars of the initiative and the need for industry collaboration will be discussed with representatives of the air-taxi sector.

Provided there is industry support, the air-taxi safety campaign will be modelled on the ongoing successful General Aviation Safety Campaign (GASC) where TC partnered with the Canadian Owners and Pilots Association (COPA) and to encourage safe practices within the general aviation community.

Based on knowledge, experience, and safety information gained from the GASC and its related safety initiatives, the air-taxi safety campaign will concentrate on eliminating the acceptance of unsafe practices as identified in the TSB’s investigative report A15H0001.

Examples of some topics that the air-taxi safety campaign could focus on are “pushing the weather” and “flying overweight”.

TC, in collaboration with stakeholders, will finalize the issues on which the Safety Campaign will focus in the spring of 2020 and begin the implementation of the campaign by the end of fall 2020.

TSB assessment of Transport Canada’s response to Recommendation A19-02 (March 2020)

In its response, Transport Canada (TC) indicated that it agrees with Recommendation A19-02 and will be taking the following approach to address the safety deficiency identified in the recommendation:

  • Develop a safety campaign for the air-taxi sector to help eliminate the acceptance of unsafe practices. The campaign will be modelled on the ongoing General Aviation Safety Campaign (GASC).
  • Engage key stakeholders at the Aviation Safety Forum in January 2020 to gather input and support.

The issues that will be the focus of the safety campaign are expected to be finalized in the spring of 2020. The air-taxi safety campaign is expected to be launched by the end of the fall of 2020.

The Board is encouraged by TC’s planned actions to address the safety issues associated with the acceptance of unsafe practices in the air-taxi sector. These actions, when fully implemented, have the potential to substantially mitigate the risk associated with the safety deficiency identified in Recommendation A19-02.

Therefore, the response to Recommendation A19-02 is assessed as Satisfactory Intent.

Next TSB action

The TSB will monitor the progress of TC's planned actions to mitigate the risks associated with the safety deficiency identified in Recommendation A19-02, and will reassess the deficiency on an annual basis or when otherwise warranted.

This deficiency file is Active.

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