TSB Investigation into 703 fatalities

[BE20 Driver]

http://www.cbc.ca/news/business/air-tax ... -1.2840659

Canadian safety regulators are launching an investigation into air taxis, concerned over the numbers of deaths associated with those operations each year.

Announced Tuesday evening, the Transportation Safety Board of Canada said the probe will aim to determine why that sector of the aviation industry has seen 175 deaths over the last decade, dating back to 2004.

"We'll be analyzing historical data and case studies of selected accidents in Canada as well as occurrences from other nations," said TSB chair Kathy Fox. "We'll also be engaging industry, the regulator and other stakeholders in the coming months to gain a full understanding of the issues affecting air taxi operations."

At focus will be single and multi-engine planes (except for turbo jets) that seat nine or fewer people, excluding pilot seats. They're also referred to as 703 carriers.

Their services are often used to transport miners and other workers to remote locations, or groups of people to hunting or fishing camps that are difficult to access.

Last year, of the 39 accidents involving Canadian-registered commercial planes, 18 of them were air taxis. Five were fatal, with 19 people killed.

"We want to take a closer look at why that is, and hopefully identify safety deficiencies and make recommendations that will make this sector safer," said TSB spokesperson Chris Krepski.

The safety board has said for several years the government should make changes to air taxi regulations. One suggestion is to require flight data recorders and cockpit voice recorders on those aircraft, since the recorders are already required on larger ones and 94 per cent of commercial air accidents are with small aircraft.

The TSB says it will begin its investigation early next year, after which the board could make recommendations to the government

[Prairie Chicken]

Finally!!!

Widow will be pleased, as the rest of us should be.

Now let's hope the TSB do a good job. And someone listens.

[North Shore]

Flight data recorders?! In a Navajo or -100? Given the costs of certification for just about any gizmo nowadays, I wonder how much they'd cost? And, sad to say, they don't really add much safety - they just tell the investigators what went wrong after the fact...

Id even go so far as to venture that there aren't too many 'new' accidents out there - just the same old ones ( CFIT, VFR into IMC, Gear up landings) over and over again...

That being said, I do sincerely hope that something good comes of this.

All IMHO, of course

[Rockie]

That being said, I do sincerely hope that something good comes of this.

As do we all, but we also know an exhaustive, all encompassing investigation isn't going to reveal anything we don't already know. The government has been completely deaf to every criticism of SMS and their total lack of oversight so I find it difficult to believe this will be any different. We can only hope it presents the evidence in such a concentrated, overwhelming way that the press seizes onto it and doesn't let go.

[Illya Kuryakin]

The only thing that will come from this is small operators will be forced to put more bells and whistles on airplanes. Translated, this means giant expenses! This may come as a total shock to some, but a CVR a will do NOTHING to prevent an accident! Everybody's allready DEAD! GPWS? In a HO? When pilots operate Navajos to .. run (SOP, for way too many) the GPWS system has its breaker pulled! Spending big bucks on toys will have no affect on twits landing gear up, driving into the ground because the pilot pushed the weather. Caravans will still spiral in because the pilot flew with wing contamination. Pilots will continue to descend below limits. Overshoots will continue into the ground because nobody maintained a positive rate of climb.
TCAS is good, but CVRs are a total fiasco.
But the TSB will force operators to spend many hundreds of thousands of dollars, in the entirely mistaken state of mind that they're actually doing some good. Joe public will sleep better at night, with the warm and fuzzy feeling that air travel will suddenly become safer......and the accidents will continue.
You really want to make 703 safer? Really? Do t bull shit me now. You REALLY want to make it safer? Ground operators who do things like running out of gas....because the pilots aren't allowed to carry enough gas.
Close operators who push weather and end up driving the aircraft into the ground short of the runway.
When Transport Canada gets off their collective asses and pulls some OC's......then 703 will be a safer place.
Illya

[Illya Kuryakin]

I want somebody to give me ONE example of an accident that would have been prevented by having a CVR and/or an FDR on the airplane! Just ONE! Should be simple enough. The mighty TSB a seems to think they should be mandatory. I've been doing this longer than most of you, and i can't think of a single accident that would not have happened if the aircraft was so equipped.
Illya

[Cat Driver]

I am making this post for widow, hopefully she will read it.

Her struggle will have no affect on aviation safety if all we get is bureaucrats hand wringing and foisting bull shit requirements on the industry like recorders.

This is what will improve aviation safety.

You really want to make 703 safer? Really? Do t bull shit me now. You REALLY want to make it safer? Ground operators who do things like running out of gas....because the pilots aren't allowed to carry enough gas.
Close operators who push weather and end up driving the aircraft into the ground short of the runway.
When Transport Canada gets off their collective asses and pulls some OC's......then 703 will be a safer place.

[iflyforpie]

+1

CVRs and FDRs are there to expose complex accident chains in transport category aircraft to develop new SOPs, safety equipment, or maintenance standards.

We know why 703 aircraft crash.... .having a very expensive system tell us they ran out of gas, got caught in icing, or lost situational awareness will tell us nothing further.

[Cat Driver]

Put Doc and me in charge of how to improve aviation safety and we will soon overhaul the TSB and TC.

And there will be a lot less 703 / 704 operators in Canada.

[CD]

This was already accomplished in the 1990's - it was called the Safety of Air Taxi Operations (SATOPS).

Executive Summary

The Safety of Air Taxi Operations (SATOPS) Task Force was established in January 1996 following a review of accident data from 1990 through 1995 by Transport Canada Safety and Security senior management. This data indicated that the vast majority of commercial aircraft accidents involve Air Taxi aircraft and that the number of fatal accidents was not improving. For the purposes of this project, Air Taxi aircraft are helicopters and fixed-wing aircraft, excluding jets, operated in a commercial air service carrying 9 or fewer passengers or conducting aerial work.

There are approximately 1040 Air Taxi operators currently operating in Canada. Partnership between Transport Canada and the aviation industry was critical to the success of this safety initiative. The joint Transport Canada/aviation industry SATOPS Task Force comprised representatives from the Commercial and Business Aviation, System Safety, and Airworthiness branches of Transport Canada Safety and Security. In addition, the Air Transport Association of Canada, the Alberta Aviation Council, the Canadian Seaplane Pilots Association, the Helicopter Association of Canada and the Northern Air Transport Association were represented.

SATOPS - Final Report (TP 13158)

There were 71 recommendations that came from that project and Widow did a good job of reproducing each of them here in the forums to remind everyone of those recommendations and to see which had actually been followed-up. Curiously, of those 71 recommendations, I don't think any suggested CVR/FDR installations...

[timel]

I agree FDR won't change anything to safety...

- Enforce the use of TCAS for all 703 operators
- Put some normal work duties and rest time that include all of the extra work done before and after the flight.
- Give pilot decent equipment to work with, the TAWS recently enforced is a good start
- The SCDA procedures is also a good move instead of the step-downs
- Real SMS systems with traceability

[Illya Kuryakin]

This was already accomplished in the 1990's - it was called the Safety of Air Taxi Operations (SATOPS).

Executive Summary

The Safety of Air Taxi Operations (SATOPS) Task Force was established in January 1996 following a review of accident data from 1990 through 1995 by Transport Canada Safety and Security senior management. This data indicated that the vast majority of commercial aircraft accidents involve Air Taxi aircraft and that the number of fatal accidents was not improving. For the purposes of this project, Air Taxi aircraft are helicopters and fixed-wing aircraft, excluding jets, operated in a commercial air service carrying 9 or fewer passengers or conducting aerial work.

There are approximately 1040 Air Taxi operators currently operating in Canada. Partnership between Transport Canada and the aviation industry was critical to the success of this safety initiative. The joint Transport Canada/aviation industry SATOPS Task Force comprised representatives from the Commercial and Business Aviation, System Safety, and Airworthiness branches of Transport Canada Safety and Security. In addition, the Air Transport Association of Canada, the Alberta Aviation Council, the Canadian Seaplane Pilots Association, the Helicopter Association of Canada and the Northern Air Transport Association were represented.

SATOPS - Final Report (TP 13158)

There were 71 recommendations that came from that project and Widow did a good job of reproducing each of them here in the forums to remind everyone of those recommendations and to see which had actually been followed-up. Curiously, of those 71 recommendations, I don't think any suggested CVR/FDR installations...

And they accomplished.....what, exactly? Operators like Keystone still fly the friendly skies, depositing dead passengers just short of their destinations. What was really done? Spiffy name though. SATOPS. Right up there with all the other feel good warm and fuzzy bull shit.
Illya

[timel]

You really want to make 703 safer? Really? Do t bull shit me now. You REALLY want to make it safer? Ground operators who do things like running out of gas....because the pilots aren't allowed to carry enough gas.
Close operators who push weather and end up driving the aircraft into the ground short of the runway.
When Transport Canada gets off their collective asses and pulls some OC's......then 703 will be a safer place.
Illya

Sure I agree TC is closing their eyes on a few operators, and they allow a few OC's to operate for ever, even if they should not.


On the other hand, it is up to the pilots to say no.
Worst case you get fired and you get rid of your bond? For refusing dangerous work?

I mean jeez, don't pop the TAWS braker, don't silence the gear horn, bring enough fuel or just don't go, don't take off over weight. Are we not done with this yet?

Regs are here for that and it is up to pilots to apply them, you brake the law, you kill people, you get sued, not your boss.

[ajet32]

I haven't flown an "Air taxi" aircraft since before 703 came into existence. I agree whole heartedly with Ilya and Cat that CVR'S and FDR'S won't help at all in accident prevention. Shutting a few operators down or hitting them in the pocket where it hurts is the only thing that will ever cause change. I always find it easy to say well don't fly if you aren't sure it's safe. That is easy if you are somewhere home or don't have a mortgage, kids and other payments. Then the responsibility thing kicks in and well if I don't go he'll just get "Fred or Bill" to go so ok this one time.
I was guilty of it lived through a few very close scrapes. A few good friends didn't in places like Inuvik, NWT and the Mackenzie Lake area.
It is time for change let's hope something positive comes of this investigation.
Safe flying everyone.

[Cat Driver]

Regs are here for that and it is up to pilots to apply them, you brake the law, you kill people, you get sued, not your boss.

Great idea, make the pilots the regulator and get rid of TC.

While we are at it lets get rid of all the police forces in Canada and turn over law enforcement to the citizens.....

.......hmmmm wait a second....that is vigilanteism.

[JigglyBus]

With regard to CVR/FDR, who is everyone arguing against? Who said a CVR/FDR would prevent an accident?

I'm pretty sure the TSB meant that if they had CVR/FDR data they could better determine what happened, and therefore make recommendations in relation to.

[single_swine_herder]

Very pressed for time, forgive the point form.

1- Better training for ALL personnel to reach and maintain a high level of proficiency

2- True Operational Control of flights (when and where they fly)

3- Making Operational Control personnel aware they are responsible through the concept of "vicarious liability," and conduct prosecutions

4- Suspend AOCs and or issue large fines which function as a behavioral deterrent rather than a cost of doing "normal business."

5- Reduce the number of CAR 703 operations to decrease the degree of price-cutting competition which drives profit margins into the basement making it impossible to properly fund a compliant and safe operation from gross revenues.

6- Pilot decision making training, and a mentoring system rather than new pilots being tossed out the door into below limits weather and being threatened with being fired if a flight is cancelled or they write a snag in a logbook.

7- Supervisory personnel to enforce SOP use, and do line indocs & line checks.

8- Companies to introduce a functional SMS in small carriers conjunction with the establishment of a "Just Culture" manner of operating the company

Gotta run for awhile ...... apologies for an incomplete list.

I agree that an FDR would be useless in a cost vs benefit equation, but any 2 crew AC should have a CVR to assist with investigations after they have killed themselves and an airplane load of people.

More than one operator has installed video cameras to determine how their ac are being flown once they go out of sight.

[Cat Driver]

7- Supervisory personnel to enforce SOP use, and do line indocs & line checks.

There used to be such individuals, we were the company Chief Pilot.

[timel]

Regs are here for that and it is up to pilots to apply them, you brake the law, you kill people, you get sued, not your boss.

Great idea, make the pilots the regulator and get rid of TC.

While we are at it lets get rid of all the police forces in Canada and turn over law enforcement to the citizens.....

.......hmmmm wait a second....that is vigilanteism.

Cat come on.

As apply, I mean to follow the regulations, because if you don't you might get punished.
And if your boss says break the rules, tell him, I will but only if you write me a paper that I can, and you know what? he won't...

It is still a free country people, yes we need mentorship, yes we need safety experience in 703 but I know a lot of pilots that say no. You are paid crap, you are bound to an operator, you can work crazy long days, at least offer yourself the pride to say no where the law tells you to.

[Cat Driver]

Timel you would not have to say no if TC got rid of operators who put you in that situation.

Flying has enough risk when done legally.

The answer is get rid of the operators who operate outside of the law.

T C could identify them in no time at all, but there is just to much wink, wink, we don't see them.

Hint.....follow the money.

[Widow]

Did I hear my name mentioned???

Thanks for "calling" me Cat, Prairie Chicken, CD, and to the friend on facebook who made sure I saw this thread. Salutes also to the others who have helped me in one way or another over the last ten years. You know who you are.

I went on camera today, for the first time in several years. Seemed to me this bullshit needed to be called. I don't have much faith, but I'll keep my toes and fingers crossed. You guys don't need another grieving widow around here!

I may seem gone, but I've not forgotten.

[single_swine_herder]

7- Supervisory personnel to enforce SOP use, and do line indocs & line checks.

There used to be such individuals, we were the company Chief Pilot.

Yes, but ...... they certainly were no better in "the good old days" than they are now, and I would argue that for the most part, Chief Pilots in my experience during the line pilot phase of my aviation career were little more than "placeholders" of the title because TC said that a "Chief Pilot" was required for the company to remain in business.

It was the Ops Mgr or company President who ran around like a rampaging bucking and kicking bull trying to gore the rider and rodeo clowns to get crews out the door in grossly illegal weather. It was frequently inferred that if you didn't want to fly VFR in 1/4 mile vis that you were a lousy pilot, or a coward who had "a yella streak" down your back. (That was 1/8th of a mile on the west coast on floats.)

Refusal meant you were fired on the spot, or left to sit at home "on stand-by duty" for a few weeks with zero income until you "learned your lesson" about having stood up for yourself, or moved on to the next job you hoped would be better. Your wife with a newborn would be wondering what useless horse she'd tied her wagon to, and you wouldn't have the full rent payment.

The former employer would give out a reference like ..... "Uh, yah .... he worked here for awhile, but didn't work out. He expected things to be written down and followed and didn't have what it takes to fly around here. We wouldn't have him back, but maybe he'll be better in your place."


There was absolutely nobody you could turn to for support if you lived in some fictional dreamland of thinking you could ever find an operator who flew at legal weights, at (or even slightly below) weather limits, or within inspection intervals in a serviceable aircraft with enough working equipment to do the job without involving heroics.


In reality, most 703 CPs of the day were little more than some poor garden variety line pilot who was charged with making up the shift schedule and had less than zero actual power to "carry out the responsibilities of the office."

That's my experience, and that of my colleagues for roughly 4 decades of being in or around 703 ops.

There never was any "golden age" of yesteryear in Canadian aviation safety and compliance which has deteriorated to today's situation.

[Bede]

Widow,

Glad to see you check in. I hope you stay a while.

[jpilot77]

A big help for 703 operation safety would be more small airports with actual weather reporting, more RNAV approaches especially LPV.

[Diadem]

There might actually be something to be learned from CVRs. Take, for example, JustCurious's accident, in which they had a CVR but it wasn't working. The TSB couldn't come to any real conclusions about how they ended up on the mountainside without that data. Without knowing what the pilots were actually doing leading up to the accident they could tell if it was simple pilot error or whether there was, say, a waypoint with incorrect coordinates. If the latter happened in Canada, with a bunch of aircraft flying towards a point that their GPSs think is somewhere it's not supposed to be, that's a huge safety issue that can easily be rectified. We can't know whether there's useful information on the CVR until after an accident happens, but we can guarantee that there won't be any if one isn't installed.