Backgrounder: A15P0081-20171102-2

Safety communications related to TSB Investigation A15P0081 into fatal in-flight breakup north of Vancouver, British Columbia, in April 2015

Occurrence

On 13 April 2015, Carson Air Ltd. flight 66, a Swearingen SA226-TC Metro, departed Vancouver International Airport, British Columbia, with two pilots on board for a flight to Prince George, British Columbia. At 07:09 Pacific Daylight Time (PDT), approximately six minutes after leaving Vancouver, the aircraft disappeared from air traffic control radar. Deteriorating weather conditions with low cloud and heavy snowfall hampered an air search; however, aircraft wreckage was found on steep mountainous, snow-covered terrain by ground searchers at approximately 16:45 PDT. The aircraft had experienced a catastrophic in-flight breakup. Both pilots were fatally injured and the aircraft was destroyed.

TSB recommendations

The Canadian Transportation Accident Investigation and Safety Board Act specifically provides for the Board to make recommendations to address systemic safety deficiencies posing significant risks to the transportation system and, therefore, warranting the attention of regulators and industry.

Under the Act, federal ministers must formally respond to TSB recommendations within 90 days and explain how they have addressed or will address the safety deficiencies.

Recommendation made on 2 November 2017

The TSB has identified drug and alcohol use as a factor in previous investigations. As well, several incidents involving pilots who reported for work while impaired have been covered prominently in the media. In a number of cases, it was an airport employee or a co-worker of an impaired pilot who ultimately served as the last line of defence and prevented the impaired pilot or pilots from operating an aircraft. While effective in those cases, this defence is insufficient on the whole.

Existing laws, regulations, standards, and guidance may be effective at mitigating some of the risks associated with substance use among pilots and others in safety-sensitive functions; however, there continue to be occurrences in which impaired individuals are not identified or prevented from operating an aircraft.

If there is no regulated drug- and alcohol-testing requirement in place to reduce the risk of impairment of persons while engaged in safety-sensitive functions, employees may undertake these duties while impaired, posing a risk to public safety. Although random drug and alcohol testing can be an effective way to identify individuals who may be at risk of performing safety-sensitive duties while impaired, it is only one aspect of a comprehensive response to inappropriate drug and alcohol use in aviation. Testing programs are most effective when complemented by other initiatives, including education, employee assistance programs, rehabilitation and return-to-duty programs, and peer support.

Therefore, the Board recommends that

Outstanding recommendations

Safety management

In anticipation of a regulatory requirement for a safety management system (SMS), Carson Air had voluntarily developed and implemented an SMS beginning in 2013. However, Carson Air's SMS had not been evaluated by TC, nor was a federal evaluation required by regulation.

In 2016, following its investigation into an occurrence in May 2013 involving a controlled flight into terrain accident in Moosonee, Ontario, the TSB recommended that

In September 2016, Transport Canada (TC) responded to Recommendation A16-12 by stating that it will address this recommendation in two ways. First, by continuing to promote voluntary adoption of an SMS among the balance of commercial air operators. To support this, the department will publish updated guidance material aimed at smaller‑sized operations this year. Secondly, over the next year and a half, the department will be reviewing the policy, regulations and program related to SMSs in civil aviation. The expected outcome of the review is a determination on the scope, regulatory instrument, applicability and oversight model. This review will rely on the input of the department's employees, as well as industry, international authorities and other specialists in this area.

In November 2016, the Board assessed TC's response to Recommendation A16-12, by stating that the TSB is pleased that TC will continue to promote the benefits of SMS, and that it has published updated guidance material to assist smaller operators. TC also advised that it would review the policy, regulations, and program related to SMS in civil aviation. There was no clear indication provided at that time regarding what TC would do once the review is complete and whether or not it intends to initiate a rule-changing process to require all commercial aviation operators to implement a formal SMS. Therefore, the response to Recommendation A16-12 was assessed as Unable to assess.

Also in 2016, the Board recommended that

In September 2016, TC responded to Recommendation A16-13. The regulator stated that while it continually evaluates its tools to ensure it continues to be effective and makes updates, as required, the department is confident in its approach of using a combination of surveillance tools to verify regulatory compliance.

In December 2016, the Board assessed TC's response to Recommendation A16-13, by stating that TC's response does not fully address the underlying safety deficiency that led to this recommendation. Achieving minimum regulatory compliance does not necessarily guarantee that all commercial aviation operators are capable of effectively managing safety within their organization. TC must also confirm that operators have a mature, effective SMS and are managing safety risks effectively. The Board considered the response to the recommendation to be Satisfactory in Part.

Lightweight flight data recording and flight data monitoring systems

The development of lightweight flight data recording systems presents an opportunity to extend flight monitoring to smaller operations. This technology, as well as flight data monitoring (FDM), will allow these operations to monitor activities such as compliance with standard operating procedures, pilot decision making, and adherence to operational limitations. FDM will also allow operators to identify problems in their operations and take corrective actions before an accident occurs. There is currently no CARs requirement for lightweight flight data recording systems to be installed on aircraft.

In the event of an accident, recordings from lightweight flight data recording systems would provide useful information that would better facilitate the identification of safety deficiencies in the investigation.

The Board acknowledges that issues remain to be resolved to facilitate the effective use of recordings from lightweight flight data recording systems, including questions about the integration of this equipment in an aircraft, human resources management, and legal issues such as the restriction on the use of cockpit voice and video recordings. Nevertheless, given the potential of this technology, combined with FDM, to significantly improve safety, the Board believes that no effort should be spared to overcome these obstacles.

Therefore, in the TSB Aviation Investigation Report A11W0048, the Board recommended that

In August 2013, TC held discussions intended to identify obstacles and barriers to FDM.

In February 2014, TC supported the recommendation and planned to draft an advisory circular to describe recommended practices regarding FDM programs.

In November 2015, TC agreed that FDM would enhance aviation safety in Canada. However, TC has not produced an advisory circular, and its revised proposed activity is to prepare an issue paper and revisit the risk assessment on FDM.

In January 2017, in its most recent response to Recommendation A13-01, TC indicated its renewed proposal to conduct a focus group in 2017, which it has been planning to do since 2013. However, until the focus group reaches conclusions as to the challenges and benefits associated with the installation of lightweight multi-function recording devices in small aircraft, and TC provides the TSB with its plan of action moving forward following those conclusions, it is unclear when or how the safety deficiency identified in Recommendation A13-01 will be addressed.

Therefore, the response to Recommendation A13-01 was assessed as Unable to Assess.

While TC has proposed some further study of the safety issue, no concrete actions are being taken to address the TSB recommendation. The TSB is therefore concerned that this could lead to protracted delays as observed on numerous other recommendations.

TSB Watchlist

The Watchlist identifies the key safety issues that need to be addressed to make Canada's transportation system even safer. Safety management and oversight is a Watchlist 2016 issue.

Numerous recent investigations have found companies that have not managed their safety risks effectively, either because they were not required to have an SMS or because their SMS was not implemented effectively.

This issue will remain on the Watchlist until

• Transport Canada implements regulations requiring all commercial operators in the air and marine industries to have formal safety management processes and effectively oversees these processes;
• Transportation companies that do have an SMS in place demonstrate that it is working—that hazards are being identified and effective risk-mitigation measures are being implemented; and
• Transport Canada not only intervenes when companies are unable to manage safety effectively, but does so in a way that succeeds in changing unsafe operating practices.