tsb watchlist2020 and key recent investigations
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TSB Watchlist 2020 and Key Recent InvestigationsKathy Fox
Chair, Transportation Safety Board of Canada
HAC Virtual Safety Forum and AGM
01 December 2020
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The day following every major news story in 2020
[Internet memes: But wait, there’s more!]
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Aircraft parked at CYHZ during 9/11
[Image: aircraft parked at CYHZ, September 2001]
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Empty airports …
[Image: empty airport terminal]
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What’s Next?
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Watchlist 2020: Issues
Commercial fishing safety
Following railway signal indications
Uncontrolled movement of rail equipment
Risk of collisions from runway incursions
Runway overruns
Slow progress addressing TSB recommendations
Fatigue management
Safety management
Regulatory oversight
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Watchlist 2020: Multi-Sector Issues
Regulatory SurveillanceFatigue Management
Safety Management
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Fatigue Management
Crews often work long and irregular schedules
sometimes crossing multiple time zones or
in challenging conditions that are not always conducive to proper restorative
sleep.
Fatigue poses a risk to the safety of operations because of its potential to
degrade several aspects of human performance.
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ACTIONS REQUIRED
The issue of fatigue management in air transportation will remain on the Watchlist until the following actions are taken:
Canadian air operators that operate under CARs subparts 703, 704 and 705 implement, and comply with, the new regulations on flight crew fatigue management.
The impact of these new regulations on aviation operations in Canada is assessed by the TSB.
Fatigue Management
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Safety Management
Some transportation operators are not managing their safety risks effectively,
and many companies are still not required to have formal safety
management processes in place. Moreover, those operators that have
implemented a formal Safety Management System (SMS) are not always able
to demonstrate that it is working and producing the expected safety
improvements.
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ACTIONS REQUIRED
This issue will remain on the Watchlist for the air transportation sector until:
TC implements regulations requiring all commercial operators to have formal safety management processes; and
Transportation operators that do have an SMS demonstrate to TC that it is working—that hazards are being identified and effective risk-mitigation measures are being implemented.
Safety Management
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Regulatory surveillance has not always proven effective at verifying whether
operators are, or have become, compliant with regulations and able to
manage the safety of their operations.
Furthermore, Transport Canada hasn’t always intervened on a timely basis to
ensure transportation operators in the air, marine and rail sectors take
appropriate corrective actions.
Regulatory Surveillance
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ACTIONS REQUIRED
This issue will remain on the Watchlist until the following measures have been taken:
In the Air sector, TC demonstrates, through surveillance activity assessments, that the new surveillance procedures are identifying and rectifying non-compliances; and that TC is ensuring that a company returns to compliance in a timely fashion and is able to manage the safety of its operations.
Regulatory Surveillance
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Accident statistics: last 5 years
• 265 incidents
• 149 accidents
• 24 detailed investigations completed or ongoing
• 16 fatal accidents resulted in 27 fatalities
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Occurrences Involving Helicopters 2015 2016 2017 2018 2019
(Jan-June)2020 Total
Incidents 47 38 52 43 77 8 265
Accidents 33 28 27 26 28 7 149
Fatal accidents 5 2 2 4 3 0 16
Fatalities 8 3 5 6 5 0 27
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Accident statistics: last 5 years
17
47
33
58
38
28
2 3
52
27
2 5
43
26
4 6
77
28
3 58 7
0 00
10
20
30
40
50
60
70
80
90
2015
2016
2017
2018
2019
2020
Incidents Accidents Fatal accidents Fatalities
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Accident statistics: last 5 years (Commercial vs Private)
18
43
33
58
36
28
2 3
50
27
25
39
26
46
74
28
35
7 7
0 00
10
20
30
40
50
60
70
80
0
10
20
30
40
50
60
70
80
2015 Private 2016 Private 2017 Private 2018 Private 2019 Private 2020 Private
2015 Commercial 2016 Commercial 2017 Commercial 2018 Commercial 2019 Commercial 2020 Commercial
Incidents Accidents Fatal accidents Fatalities
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Accident statistics: causal factors (January 2015 to June 2020)
n = 133 non-fatal accidents
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Accident statistics: causal factors (January 2015 to June 2020)
n = 16 fatal accidents
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Ongoing investigation of interest: A19A0055
Key issues under examination:
• Establishing robust stabilized approach procedures for offshore
instrument and visual approaches
• Recognizing the risks, and implementing defences such as
automation, for operations in degraded visual environments
• Enhanced GPWS/TAWS, optimized for offshore helicopter operations
(i.e., modes 1-7), as a defence against CFIT
• Protecting CVR audio
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TSB air investigation report A18O0134
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1 nm
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A18O0134: Safety issues
• The helicopter was not equipped with a flight data recorder or cockpit
voice recorder, nor were these required by regulation.
• The investigation was unable to determine what weather information
the pilot had reviewed prior to the flight. However, first responders
described the weather at the time as foggy and misty with light rain.
• Loss of visual reference with the ground can result in a pilot becoming
disoriented and losing control of the helicopter.
• Flying in deteriorating weather conditions is challenging, especially
when flying at low altitudes.
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Air transportation safety issue investigation A15H0001
Air taxi operations take place in a very different context from other
sectors of commercial aviation.
Key causal factors in air taxi accidents:
• An acceptance of unsafe practices
• The inadequate management of operational hazards
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A15H0001: recommendations
A19-02
TC: “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.”
Status as of 2020: Satisfactory intent
A19-03
Industry associations: “promote proactive safety management processes and
safety culture with air-taxi operators” by “training and sharing of best
practices, tools, and safety data” specific to their operations.
Status as of 2020: Unable to assess
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A15H0001: recommendations (continued)
A19-04
TC: “review the gaps identified in this safety issue investigation … and
update the relevant regulations and standards.”
Status as of 2020: Unable to assess
A19-05
TC: “require all commercial operators to collect and report hours-flown and
movement data for their aircraft by Canadian Aviation Regulations sector
and aircraft type, and that [TC] publish those data.”
Status as of 2020: Unable to assess
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The challenge
We know that the helicopter industry is doing good work:
• some operators are proactively implementing SMS; and
• others are assessing risks posed by fatigue.
But the TSB can’t assess what we don’t know about.
So … spread the word, and then tell us!
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QUESTIONS?
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