TSB Recommendation A19-04

TC agrees in principle with the recommendation.

In its initial response to this recommendation in January 2020, TC focused on the three areas specifically identified in the preamble to the recommendation: training and qualifications, improvements to older aircraft and fatigue among Aircraft Maintenance Engineers (AMEs). Additional updates related to these three areas are provided below.

In its assessment of TC’s response to the recommendation, the TSB indicated that it was unable to assess TC’s response as it did not provide a detailed response with respect to plans to address the gaps in the regulations and standards identified in the Safety Issues Investigation (SII) other than the three areas cited in the recommendation. A discussion of this question is provided at the end of this update.

Training and qualifications

In its initial response, TC described two initiatives underway that have the potential to enhance training and qualification requirements in the air taxi sector to increase the focus on managing the types of operational risks highlighted in the air taxi investigation report while maintaining crew competence in basic aircraft maneuvers.

Civil Aviation Regulatory Review Project

TC mentioned, as part [of] the Civil Aviation Regulatory Review project, [that] a regulatory review was underway to identify training irritants specifics to Parts IV, VI and VII - Personnel Training, Qualifications and Licensing of the CARs.

Since it began, 172 training irritants, including many respecting 703 operators, were identified by various sources^{Footnote 3} and will be addressed in a regulatory proposal that will improve the clarity of Parts IV, VI, and VII as well as help in the modernization of the CARsby addressing the advancements seen in aviation technology. Presently, those 172 irritants are under review by the various subject matter experts (SMEs) in Civil Aviation to confirm relevancy as many irritants go back 20 plus years.

Once this internal review is complete, a call out for an external task team will take place to get together and review and recommend a way forward on addressing the issues. It is anticipated to have a regulatory package developed for consultation in the Fall of 2021.

Working Group (WG) on the Modernization of Training and Checking

In its initial response to this recommendation, TC provided details of a review of training and qualification requirements in all subparts of the CARsthat includes, among others, an examination of pilot proficiency check schedules, training captain and instructor qualification requirements, operator training curriculum requirements, approved check pilot manuals and flight test guides, and the expanded approval of flight training devices, particularly for subparts 702 and 703.

This work is underway. TC announced its intent to establish a WG with industry to collaborate and evolve pilot training and checking practices in commercial and general aviation in CARssubparts 604, 702, 703 and 704. The WG will evaluate options to enhance the development of core competencies during training and checking and consider regulatory changes to optimize the use of Flight Simulation Training Devices (FSTDs) across the subparts under review.

With respect to subpart 703, air operators who conduct operations under this subpart will benefit from all stated goals in the Terms of Reference.^{Footnote 4} Specifically, these operators will benefit from:

• More relevant and productive pilot training that focuses on the core competencies that greatly influence the prevention, or outcome, of incidents and accidents;
• Better qualified and trained persons who conduct training on other pilots;
• Regulatory changes that incentivize operators to incorporate the use of Flight Training Devices in operator flight training programs. This will significantly enable effective training in the management of abnormal events and emergencies, which cannot be effectively replicated in an aircraft.

Next steps include:

• A review of the International Civil Aviation Organization (ICAO) recommendations on Evidence-Based Training (EBT), Competency Based Training and Assessment (CBTA) and use of Flight Simulation Training Devices (FSTDs), and a review [of] training and checking practices in other countries by the end of 2020;
• A draft NPA and any required ACs or TPs for alternate training programs. This will be circulated to TC regions for consultation by September 2022; and,
• The publication of regulatory changes and issue AC and/or TP as applicable by July 2023.

Improvements to older aircraft

In its initial response, TC described work in progress to update the Airworthiness Manual (AWM) Chapter 523,^{Footnote 5} Normal, Utility, Aerobatic and Commuter Category Aeroplanes with the intention to facilitate design changes on normal category airplanes.

In early 2021, TC will publish proposed amendments to AWM Chapter 523 that will harmonize Canada’s design standards for small aeroplanes with those of Title 14 of the United States Code of Federal Regulations (14 CFR) part 23 at amendments 23-64. These amendments intend to provide greater flexibility to applicants seeking certification of their aeroplane designs, and to facilitate faster adoption of safety enhancing technologies (e.g., angle of attack indicators, moving-map GPS displays) in type-certificated aeroplane designs. At the same time, the proposed amendments intend to reduce regulatory time and cost burdens for the aviation industry and TC. The proposed amendments reflect a safety continuum philosophy, which balances an acceptable level of safety with the societal burden of achieving that level of safety, across the broad range of certificated small aeroplane types. This safety-continuum philosophy would maintain aviation safety while enabling a relaxation of the design certification burden for both new aeroplane types, and design changes to existing types, in proportion to the number of passengers and performance of the aeroplane.

In particular, these amendments will allow the use of industry consensus standards accepted by the Minister as a means of compliance to the design standards of airworthiness. The use of these consensus standards as a means of compliance intends to streamline the certification process. However, consensus standards are one means, but not the only means, of showing compliance to the performance-based standards. Applicants will also have the option to propose their own means of compliance, as they do today, but with reduced administrative burden by requiring fewer special conditions or exemptions, lowering costs and causing fewer project delays.

This change addresses the unintended excessive certification burden for smaller, lower performance aeroplanes that has resulted from the evolution of design standards towards the safety needs of complex and high performance aeroplanes (e.g., very light jets).

Additionally, recent developments in the United States (U.S.) general aviation aftermarket industry have made available certain equipment aimed at enhancing the safety of operation of small aeroplanes. In the U.S., the Federal Aviation Administration (FAA) has approved the production under 14 CFR 21.8(d) of certain Non-Required Safety Enhancing Equipment (NORSEE), where these equipment may be installed in small aeroplanes under FAA rule as an alteration, without necessarily requiring a design approval. In many cases, the NORSEE installation would constitute no more than a minor change to type design of the aeroplane. TC is investigating a means to permit these parts to be installed in Canada on Canadian-registered small aeroplanes.

Fatigue in aircraft maintenance engineers

In its initial response to this recommendation, TC described ongoing work with both the aviation industry and Employment and Social Development Canada (ESDC) to encourage an appropriate balance to manage operational needs of the aviation industry while providing sufficient rest for employees.

The Canada Labour Code (CLC) proposed amendments, described in TC’s initial response, target work life balance. The scope of the ESDC amendments, which apply to scheduling, breaks and leave provisions to improve work-life balance, have the potential to positively impact on the overall well-being of AMEs in general and to reduce the likelihood of AME fatigue.

In addition to supporting these regulatory changes, TC has a number of provisions in place to address the potential for fatigue in aircraft maintenance organizations. Since 2002, Approved Maintenance Organizations (AMO) require human factors training that includes human performance, factors influencing human error caused by fatigue and error management (Standard 573 – Approved Maintenance Organizations^{Footnote 6}and Standard 726 – Air Operator Maintenance^{Footnote 7}in the CARs). TC has also published several documents on fatigue including AC SUR-001 - Development and Implementation of Fatigue Risk Management Systems in the Canadian Aviation Industry^{Footnote 8}, which contains guidance for small operators and AMOs. However, these requirements were developed between 10-18 years ago, and TC does recognize that it may be time to review our current tools with regards to fatigue and its impact on AMEs.

TC is of the opinion that a change to the CARsis not warranted at this time. In addition to the measures described above, TC favours an approach to this issue based on awareness and education. As such, TC will conduct a review of our current guidance materials to determine if new guidance is required in order to provide up-to-date expectations on how certificate holders should be managing fatigue that may affect AMEs. TC expects our initial review to be completed by the end of winter 2021. Further steps, depending on findings and subsequent analysis, will be determined following this initial review.

Closing the gaps in regulation and associated standards

Overall, TSB assessed TC’s initial response to this recommendation as “unable to assess”, stating that “TC did not provide a detailed response with regards to how they plan to address the gaps in the regulations and standards identified in the SII [safety issues investigation] other than the details listed above.”

Given the length and complexity of the SII, TC sought a meeting with the TSB in November 2020 to clarify expectations and to better understand the gaps referred to by the TSB. From this meeting, it was understood that TSB’s expectation is that TC review the 19 safety themes identified in section 4 of the report to identify areas where operators were exceeding regulatory requirements to determine if any of these best practices should be reflected in the regulations.

The ICAO Manual of [Aircraft] Accident [and Incident] Investigation (ICAO Doc 9756) states that “a safety recommendation would be warranted if the analysis of the investigation information determines the existence of an underlying factor(s) with high risks for which the defenses are less than adequate.”^{Footnote 9} A comprehensive analysis is necessary since, determining appropriate safety action requires a clear understanding of the hazard and the effectiveness of existing defenses to facilitate an analysis of the additional mitigations required to bring the residual risk to an acceptable level.

The 19 safety themes described in the SII do not meet this threshold of validated safety deficiencies, but represent high level descriptions of issues and best practices identified throughout the consultations with operators.^{Footnote 10} While the SII provides a valuable review of issues facing operators and identifies a significant number of best practices, additional work would be required to determine if any of these are indicative of a safety deficiency that would require a regulatory approach to address.

TC takes the safety of the air taxi sector seriously and will continue to focus its efforts on clearly identified safety deficiencies. Significant work is underway to address the specific issues identified in the SII (see updates to recommendations [A19-02 and A19-05] and the specific areas cited in this recommendation [updates above]). In addition, TC welcomes further analysis from the TSB in identifying the existence of specific underlying factors with high risks for which existing defenses are demonstrably inadequate in any of the themes identified in the SII.

TC agrees in principle with the recommendation.^{Footnote 11}

In its initial response to this recommendation in January 2020 and the subsequent one in December 2020, TC focused on the three areas specifically identified in the preamble to the recommendation: training and qualifications, improvements to older aircraft, and fatigue among Aircraft Maintenance Engineers (AMEs).

The TSB noted in its evaluation of TC's response to the recommendation that it could not fully assess it as it did not provide a detailed response with respect to plans to address the gaps in the regulations and standards identified in the Safety Issues Investigation (SII) other than the three areas cited in the recommendation.

Given the length and complexity of the SII, TC sought a meeting with the TSB in November 2020 to clarify expectations and to better understand the gaps referred to by the TSB. From this meeting, it was understood that TSB’s expectation is that TC review the 19 safety themes identified in section 4 of the report to identify areas where operators were exceeding regulatory requirements to determine if any of these best practices should be reflected in the regulations.

The ICAO Manual of Accident Investigation (ICAO Doc 9756) states that: “A safety recommendation would be warranted if the analysis of the investigation information determines the existence of an underlying factor(s) with high risks for which the defenses are less than adequate.”^{Footnote 12} A comprehensive analysis is necessary since determining appropriate safety action requires a clear understanding of the hazard and the effectiveness of existing defenses to facilitate an analysis of the additional mitigations required to bring the residual risk to an acceptable level.

The 19 safety themes described in the SII do not meet this threshold of validated safety deficiencies but represent high level descriptions of issues and best practices identified throughout the consultations with operators.^{Footnote 13} While the SII provides a valuable review of issues facing operators and identifies a significant number of best practices, additional work would be required to determine if any of these are indicative of a safety deficiency that would require a regulatory approach to address.

TC takes the safety of the air taxi sector seriously and will continue to focus its efforts on clearly identified safety deficiencies. Significant work is underway to address the specific issues identified in the SII. Out of the 18 recommendations that are applicable to the air-taxi sector and referenced in the SII,^{Footnote 14} 3 were closed in the past 2 years, and TC is actively working and providing updates to the TSB on more than 10 of them. In addition, TC welcomes further analysis from the TSB in identifying the existence of specific underlying factors with high risks for which existing defenses are demonstrably inadequate in any of the themes identified in the SII.

In its responses from both December 2020 and December 2023, Transport Canada (TC) indicated that it agrees in principle with Recommendation A19-04.

TC has initiated work in the following 3 areas: training and qualifications, improvements to older aircraft, and fatigue in aircraft maintenance engineers (AMEs). TC indicated that it will be taking the following approach to address the safety deficiency identified in Recommendation A19-04.

Training and qualifications

The 2 following initiatives are underway that have the potential to enhance training and qualification requirements in the air taxi sector.

Civil Aviation Regulatory Review project

TC continued work on a Civil Aviation Regulatory Review project to identify irritants regarding personnel training and licensing.

Since the last update, TC has confirmed that a multi-disciplinary task team was convened in 2021 to consult on proposed regulatory changes in relation to personnel training and licensing. To that end, TC added a new activity to Notice of Proposed Assessment (NPA) 2022-001.^{Footnote 15} TC anticipates publication of the proposed regulatory changes in the Canada Gazette, Part I in April 2024.

Working group on the modernization of training and checking

TC indicated that work is underway to review training and qualification requirements in all subparts of the Canadian Aviation regulations (CARs). This includes an examination of pilot proficiency check schedules, training captain and instructor qualification requirements, operator training curriculum requirements, approved check pilot manuals and flight test guides, and the expanded approval of flight training devices, particularly for subparts 702 and 703.

TC also stated its intention to establish a working group (WG) with industry to develop pilot training and checking practices in CARs subparts 604, 702, 703, and 704 operations. The intention of the WG is to assess options to enhance the development of core competencies during training and checking, and to consider regulatory changes to optimize the use of flight simulation training devices (FSTDs) across the subparts under review.

Specific to the air-taxi sector, TC stated the benefits will be:

• more relevant and productive pilot training;
• better qualified and trained persons who conduct training; and
• an incentive for operators to incorporate the use of flight training devices in their flight training programs.

Since its latest responses, TC indicated that a joint WG was established with industry stakeholders in late 2020; however, meetings ended in 2022 due to resource issues. Notwithstanding, WG activities led to the publication of Advisory Circular (AC) 700-062: Alternate Pilot Proficiency Check – Phased PPC.^{Footnote 16}The purpose of the AC is “to describe an alternate means of conducting a recurrent [emphasis in original] Pilot Proficiency Check (PPC) under subparts 702, 703, and 704 of the Canadian Aviation Regulations (CARs).”^{Footnote 17}

As described in the AC,

The Phased PPC integrates training and checking in a manner that promotes learning over checking. It is a three-phased model that mirrors the assess – train – reassess concept embodied in advanced training programs such as Evidence-Based Training (EBT) and the Advanced Qualification Program (AQP). […] The Phased PPC differs from traditional checking by providing a candidate with the opportunity to improve sub-standard performance before declaring the PPC unsuccessful. It is compliant with the CARs and Commercial Air Services Standard (CASS) and does not require a regulatory exemption. It is assessed and documented in the same manner as the existing PPC, except as noted in this AC.^{Footnote 18}

Additionally, TC noted that work is still underway to assess opportunities to optimize the use of flight simulation training devices (FSTDs) across the CARs subparts.

TC indicated that its review of the International Civil Aviation Organization (ICAO) recommendations on evidence-based training, competency-based training and assessment and use of FSTDs, and that its review of training and checking practices in other countries would be completed by the end of 2020; however, it did not provide the status of these reviews in its December 2023 response.

The Board is pleased with the progress made in the areas of training and qualifications, and is encouraged that TC continues to move towards regulatory amendments; however, until the regulations are amended, the risk associated with the safety deficiency related to this theme will persist.

Improvements to older aircraft

TC published amendments to Chapter 523 of the Airworthiness Manual in 2021. The amendments harmonize Canada’s design standards for small airplanes with those of Title 14 of the United States (U.S.) Code of Federal Regulations (14 CFR), Part 23 at amendment 23-64. TC also indicated in its response that the amendments are intended to provide greater flexibility to applicants seeking certification of their airplane designs, and to facilitate faster adoption of safety enhancing technologies in type-certificated airplane designs. It further stated that the changes are also intended to reduce regulatory time and cost burdens for the aviation industry and TC. It is unclear whether the changes will directly benefit air-taxi operators.

TC also indicated in its response that it is looking at what the U.S. Federal Aviation Administration (FAA) is doing regarding non-required safety enhancing equipment (NORSEE) with a view to seeing if something similar could be implemented in Canada. The FAA has the ability to approve the production of certain equipment aimed at enhancing the safety of operation under 14 CFR 21.8(d). In the U.S., this equipment may be installed in small airplanes under FAA rule as an alteration, potentially allowing installation as a minor change to the airplane type design. Although rotorcraft were not mentioned in TC’s response, it is the TSB’s understanding that the FAA NORSEE approval is also applicable to products designed for rotorcraft, which could address the cost and burden associated with a rotorcraft design change for installation of safety equipment.

Following its latest update, TC has confirmed that upon review, while CARs Subpart 521 (Approval of the Type Design or a Change to the Type Design of an Aeronautical Product)requires a supplemental type certificate to be developed, the cost burden is reduced with the performance-based requirements, as compared to the previous prescriptive design requirements.

The Board is encouraged by the changes that TC has made to date and believes that these actions have the potential to address the risk associated with the safety deficiency related to this theme.

Fatigue in aircraft maintenance engineers

In its December 2020 response, TC reiterated that it has provided input to Employment and Social Development Canada with regards to proposed changes to the Canada Labour Code (CLC).

On 19 December 2020, proposed amendments to the CLC that support work-life balance were published in the Canada Gazette, Part I. However, the proposed amendments are being implemented with a phased-in approach. As stated in the Canada Gazette, Part I:

The pandemic prevented stakeholders in other sectors, including aviation […] from making submissions following the second round of consultations held in February and March 2020. As a result, regulatory development will resume once these stakeholders indicate they are ready to re-engage.^{Footnote 19}

It remains unclear when proposed amendments applicable to AMEs in the aviation sector will be published in the Canada Gazette, Part I, as the proposed regulations only apply to federally regulated employees and employers in the road transportation, postal and courier, the marine (pilotage, marine transportation and long-shoring), and the grain sectors.

In its response, TC stated that the proposed CLC changes have the potential to positively impact the overall well-being of AMEs in general and to reduce the likelihood of AME fatigue. This indicates that TC is uncertain of the extent to which changes to the CLC will affect fatigue in AMEs. It also appears that TC is relying on changes to the CLC to mitigate the risk associated with the safety deficiency related to this theme.

TC stated that human factors training, which includes factors influencing human error caused by fatigue and error management, is already a requirement in the current regulations. TC has previously published fatigue-related guidance material to be used by small operators and aircraft maintenance organizations. TC indicated that because the guidance material is 10 to 18 years old, it would conduct a review of the material; however, it has recently acknowledged that it has not completed a review on this subject. The subject of fatigue and the effect on maintenance personnel will be discussed at future ICAO Airworthiness Panel meetings. Should ICAO make changes to its Standards and Recommended Practices or guidance material that address the subject of fatigue in maintenance personnel, TC may reassess its position at that time.

The Board remains concerned that TC is not considering any regulatory changes to address fatigue in AMEs at this time. However, TC’s response suggests it may be open to such action in the future.

Closing the gaps in regulations and associated standards

In its December 2020 response, TC indicated that it understood, from the high-level meeting with the TSB held in November 2020, that it was expected to “review the 19 safety themes identified in section 4 of the report to identify areas where operators were exceeding regulatory requirements to determine if any of these best practices should be reflected in the regulations.” The understanding that a simple review of the 19 safety themes alone would suffice to address the gaps in regulations and associated standards is incorrect.

The hazards and risk factors for which defences were demonstrably inadequate were highlighted throughout the report and were grouped under 19 safety themes.

The research methods used to perform the analysis of all the data collected followed quantitative and qualitative research methods for which details and references can be found in Section 3.0 Methods, and the appendices of the Safety Issue Investigation (SII) report. The safety analysis performed throughout the study applied the TSB’s Integrated Safety Investigation Methodology. The 19 safety themes emerged from the analysis of the results of the accident data (Phase 1), industry consultation (Phase 2), and a review of previous safety studies (both phases). To clarify, each theme section of the report includes:

• an analysis and a discussion of the hazards / safety pressures (the context);
• an analysis of previous TSB findings and recommendations (accident data); and
• an analysis of previous safety studies.

Section 4.2 Information from consultations with industry contains the data and analysis from industry consultation, i.e., what operators said, but it also contains the detailed analysis of all the data gathered in Phase 1 and Phase 2 of the SII organized by theme. The title of Section 4.2 may be misleading, as the 19 safety themes found within this section in fact representhazards / safety pressures for which the defences were demonstrably inadequate. As TC mentioned, the SII provides a valuable review of issues facing operators, and identifies a significant number of best practices. However, the SII also highlights gaps in regulations and associated standards for each safety theme in Section 4.2.

The intent of the SII was to identify any underlying systemic safety issues that need to be addressed, so that action can be taken to reduce the persistent risks in air-taxi operations across Canada. The regulatory framework safety theme is only 1 of the 19 hazards / safety pressures identified in the report, and it is where gaps in regulations are discussed the most. The scope of the SII was not limited to identifying issues related to Subpart 703 of the CARs and associated standards. As a result, and due to the diversity and complexity of the air-taxi sector, gaps in regulations also appear in the other 18 safety themes. Therefore, the TSB would like to direct TC to review the report in detail, specifically, but not limited to:

• Section 4.0 Information gathered during the investigation:
  • The 19 safety themes (hazards / safety pressures), with particular attention to Section 4.2.18 Regulatory framework.
• Section 5.0 Discussion:
  • The accident type discussion of how the underlying factors emerged.
  • The list found in the blue box in Section 5.1.2 Accident types and operating context, that “identified weak or missing defences that, if improved or addressed, have the potential to enhance safety.”
  • Descriptions of risks and conclusions found in tables 27, 28, and 29 (that were not derived from actions suggested by operators or TC inspectors) for each of the 19 safety themes (hazards).
• Section 6.0 Conclusion:
  • The rationale leading to the safety actions required.
  • Section 6.6.1 Active TSB recommendations.
  • Section 6.6.2.3.4 Closing the gaps, where “[s]ome operators have identified gaps in the existing regulations and standards. Some operators’ recommended practices go beyond the current regulatory requirements or include concepts that are not yet addressed by regulations.” This corroborated the TSB findings of the accident data, which themselves emerged from the TSB analysis.

The Board recognizes and is encouraged by TC’s continued work to address specific parts of the recommendation related to training and qualifications, improvements to older aircraft, and fatigue in AMEs.

However, these are only 3 of the 19 hazards / safety pressures (safety themes) identified in the SII, and the Board remains very concerned that TC did not provide a detailed response with regard to how it plans to address the gaps in the regulations and associated standards other than those detailed above.

Therefore, the Board is unable to assess the overall response to Recommendation A19-04 specific to closing the gaps in the regulations and associated standards.