50 WINGS | March/April 2015 WWW.WINGSMAGAZINE.COMON
FINAL
By Kathy Fox | Chair, Transportation Safety Board
PHOTO: TSBO
n a November morning in
2012, eight people boarded a
Cessna 208B in Snow Lake,
Man., bound for Winnipeg.
The trip was expected to
take a little over two hours, but barely one
minute into the flight, tragedy struck. Ac-
cording to our investigation report released
earlier this year, the aircraft was overweight,
and its takeoff and climb performance was
reduced by accumulated ice on the leading
edges of its wings and tail, and it crashed
into a nearby wooded area, killing the pilot
and seriously injuring all seven passengers.
In most respects, Canada has a very safe
air transportation system. In fact, prior to
the 2011 crash of First Air flight 6560 in
Resolute Bay, Nunavut, there had not been
a fatal accident involving a major Canadian
scheduled airliner in the previous 10 years.
That record, unfortunately, is dramatically
different for smaller carriers. For the 10-
year period ending in December 2013, al-
most 60 per cent of all commercial aviation
accidents – and 65 per cent of the fatalities- involved air taxi aircraft; those carriers
operating under Canadian Aviation Regu-
lations (CARs) subpart 703.
Yes, every accident is unique – a singular
combination of causes and contributing
factors, be they human, mechanical, en-
vironmental or organizational. But what
happened at Snow Lake is in some ways
all too typical of some air taxi accidents.
TSB investigators continue to see certain
underlying causal and contributing factors
frequently: a small operator, for example,
flying out of a remote aerodrome usually
with less infrastructure; deficiencies in pi-
lot decision-making and crew resource
management, especially in poor weather;
and deficiencies in operational control, es-
pecially in self-dispatch operations.
To address these problems, the TSB has
previously called for a wider implementa-
tion of safety management systems (SMS),
mandatory training in modern crew re-
source management techniques, and the
installation of ground proximity warning
systems to name just a few. In 2012, Trans-
port Canada (TC) responded, mandating
Terrain Awareness Warnings Systems
(TAWS) with the goal of reducing the num-
ber of aircraft involved in controlled flights
into terrain (CFITs).
However, change, even well-intentioned
change, is often resisted by those who have
to implement it, and sometimes new safety
measures are viewed as an inconvenience,
or worse, a burden to be avoided if possible.
That’s because safety initiatives cost money,
which isn’t always easy to find for a small
operator with thin margins. And while it’s
easy to quantify the cost of implementing
new technology, or additional training, or
hiring more staff – it’s not always easy to
quantify the safety benefits.
Put another way, while you may be able
to calculate the costs avoided by not invest-
ing in new safety initiatives, it’s extremely
hard to calculate the increased level of risk
by not making that investment.
More however, must be done, because
the current number of accidents and fatali-
ties involving air taxis – 175 fatalities in the
last decade alone – is too high a cost to pay.
Therefore, starting in early 2015, the
TSB will conduct a Safety Issues Investiga-
tion (SII) into risks associated with air taxi
operations. The scope will be much broader
than our normal accident investigations:
we’ll be analyzing historical data along with
case studies of selected accidents in Canada,
and occurrences from other nations. We’ll
also be engaging industry, the regulatorand other stakeholders to
gain a full understanding of
the issues involved. This in-
cludes identifying the major
safety issues and how they
are being managed, as well as
examples of “best practices.” In the end, we
may make recommendations to address
any identified systemic deficiencies.
This won’t be the first such investigation
we’ve conducted. The TSB has carried out
SIIs into Survivability in Seaplane Acci-
dents, VFR Flight into Adverse Weather,
and Post-Impact Fires Resulting from
Small Aircraft Accidents to name a few.
In the meantime, we will continue our
push for safety. In addition to the current
SII and our accident investigation reports,
we have recently released our updated
Watchlist, which identifies the eight is-
sues currently posing the greatest risk to
Canada’s transportation network. A num-
ber of these issues are aviation-related,
including safety management systems and
regulator oversight, the risk of collisions on
runways, and an unacceptable number of
approach-and-landing accidents. It is our
hope that, by working together, regulators
and industry will be able to effect key safety
improvements that will lead to safer flights
for everyone – and making what happened
at Snow Lake a tragedy that won’t be re-
peated. | WKathy Fox is Chair of Canada’s
Transportation Safety Board (TSB).The air taxi commitment
TSB stepping up its investigations into air taxi accidents
change, even well-intentioned
change, is often resisted by those
who have to implement it.