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Canadians Issue a ‘Watchlist’ of Needed Safety Improvements

Fri, Mar 19, 2010 — David Evans

Articles, Featured

Canadian safety officials have launched a program similar to one in the U.S. that has been unsuccessful. Since recommendations issued by the Transportation Safety Board (TSB) of Canada are exhortative – not required to be implemented – elevating some of the more important of them to a high-profile list is not likely to be any more successful than the U.S. National Transportation Safety Board (NTSB) and its “Most Wanted” itemization.

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Now both safety agencies are in the position of vainly publicizing, cajoling and embarrassing regulatory bodies into taking belated action. In the U.S., the Federal Aviation Administration (FAA) has proven itself beyond embarrassment over NTSB “Most Wanted” recommendations that languish for years before lapsing into partial, incomplete or delayed action, if not rejected outright. (See Aviation Safety Journal, “Time to Revamp ‘Most Wanted’ System’)

The TSB is calling its system the “Watchlist,” which is described as identifying “the safety issues investigated by the TSB that pose the greatest risk to Canadians.” Like the NTSB’s “Most Wanted” list, it covers all modes of transportation (marine, pipeline, railway, etc.); this discussion will focus on aviation items and desired initiatives common to all modes of transportation.

Like the NTSB, the TSB is clearly frustrated at the slow pace with which its recommendations are implemented:

“In each case, actions taken to date are inadequate and concrete steps must be taken on the part of industry and the regulator to eliminate these risks.”

To combat the glacial pace of correction, the TSB has issued the “Watchlist” to put the heat on the regulator, which in this case is Transport Canada (TC), the equivalent of the FAA.

The TSB’s “Watchlist” covers five issues, as opposed to seven items on the NTSB’s “Most Wanted” list. The NTSB color codes recommendations red, yellow, green depending on the FAA’s timeliness in responding. One gathers that all the TSB items would be coded yellow or red, for slow to nil progress. Many of the TSB’s recommendations go to the FAA, as well as to TC. There is a high degree of issue overlap:

A Comparison of the TSB “Watchlist” to the NTSB’s “Most Wanted”
Item On TSB List On NTSB List
Improve oversight of pilot proficiency   X
Improve transportation recorders X X
Improve the safety of emergency medical services (EMS) flights   X
Improve runway safety X and X (two TSB issue areas) X
Reduce dangers to aircraft flying in icing conditions   X
Improve crew resource management   X
Reduce accidents and incidents caused by human fatigue in the aviation industry   X
Implement safety management systems (SMS) X  
Reduce CFIT (controlled flight into terrain or water) accidents X  

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The TSB chairman and members of the board outlined the rationale for each issue items.

Herewith, extracts of two individuals’ remarks in announcing 16 March the new “Watchlist” program, which was launched on the 20th anniversary of the TSB’s founding.

Wendy Tadros, TSB Chairman:

“It will take a concerted effort by industry and government to tackle these tough issues. The Transportation Safety Board’s Watchlist is a blueprint leading the way forward …

“Time and again, our investigators arrive at the scene of an accident and find the same old safety issues – issues that pose the greatest threat to Canadians. These are the issues on our Watchlist …

“Today we are calling for change. It is time for industry and Ottawa [the government] to step up and tackle these critical safety issues. For the Transportation Safety Board, there is no higher priority …”

Kathy Fox, TSB Member:

“Let me talk about the critical issues in aviation safety. The likelihood of a collision on runways at Canada’s airports is low. However, should two aircraft collide, or an aircraft collide with a vehicle – the consequences could be catastrophic. This is why this issue is on our Watchlist.

“Airports are complex environments where aircraft and ground vehicles must coexists in a confined area. Too often, over 3,800 times since 1999, there have been conflicts, or ‘runway incursions.’ By focusing on improved procedures and enhanced collision warning systems, we think the risk of these incursions at Canada’s busy airports can be lowered.

“Moving to another area, in low visibility or at night, pilots may lose track of exactly where they are in relation to the ground or water. The risk is greatest for smaller planes venturing into remote wilderness or into mountainous terrain as they do not have ground proximity warning systems.

Cessna 206, collision with hilltop near Shawinigan, QC

Cessna 206, collision with hilltop near Shawinigan, QC

“In Canada, between 2000 and 2009, an unsuspecting crew flew a perfectly good plane into the ground 129 times [an average of once a month]. These cases account for just 5% of accidents but nearly 25% of all fatalities! In our Watchlist, we urge wider adoption of ground proximity warning systems for smaller Canadian aircraft …

Sikorsky S-76, collision with terrain, Temagami, ON

Sikorsky S-76, collision with terrain, Temagami, ON

“Aircraft running off the end of runways is a problem worldwide. The latest figures from the Flight Safety Foundation reveal that almost 30% of aircraft accidents between 1995 and 2008 were runway overruns. And at home, we have a vivid reminder of the Air France aircraft at Toronto’s Pearson Airport in 2005.

Runway overrun, Air France A340, Toronto, ON

Runway overrun, Air France A340, Toronto, ON

“When this happens – and it will happen again – the TSB needs to know that passengers will be safe. Sometimes all that is required is to lengthen the safety areas at the end of runways. Where geography will not allow it, solutions may be found in engineered systems and structures designed to quickly and safely stop an airplane.

“The Watchlist contains two issues common to the marine, rail and aviation industries. The first is Safety Management Systems, a powerful, internationally recognized management tool to help organizations find trouble before trouble finds them. They help companies foresee what might go wrong so they can take pre-emptive action.

“The Transportation Safety Board has emphasized the advantages of Safety Management Systems. However, in some of our investigations, we have found there is a lack of regulatory oversight or that key industry segments are not required to have a systemic approach to managing safety. [Note, TC requires SMS at Canada’s airlines. The NTSB is frustrated that in the U.S. the FAA has opted for the airlines to adopt SMS on a voluntary basis, which has resulted in highly patchwork implementation. As a result of the FAA’s voluntary application, the U.S. has filed a “difference” with the International Civil Aviation Organization, which requires SMS.]

“In the aviation industry, we note with satisfaction that Canada leads the world in requiring its commercial carriers to have a Safety Management System. By and large, Safety Management Systems appear to be working well with our large carriers. The challenge to come will be the rest of the aviation industry – Canada’s air taxis, helicopter operations, commuter airlines and flight training schools.

Touchdown short of runway, Bombardier Global 5000, Fox Harbor, NS

Touchdown short of runway, Bombardier Global 5000, Fox Harbor, NS

“Transport Canada will need to closely monitor the industry to ensure all are on board and that there is a smooth transition … The Board will be watching this issue very closely. Madam Chair?”

Chairman Tadros:

“The last issue on our Watchlist is about the tools the TSB needs to deliver, for the benefit of Canadians. As Churchill once said, ‘…give us the tools and we will finish the job.’

“The tool we most need is objective data to provide a clear picture of what happened. Following any accident, investigators have a long list of questions, starting with ‘what happened,’ and ‘why.’ A prime source for information are the onboard recorders – an airplane’s black box, a locomotive’s event recorder, or a ship’s voyage data recorders.

“These contain engine and equipment settings, navigation details, voice recordings, and computer data to quickly pinpoint what happened.

“In Canada, we have a real patchwork of requirements. In some industries, there simply are no recorders. In others, data is recorded but not voice. Some recorders are required to be crash and fire resistant and others are not …

“The aviation industry has enjoyed the benefits of voice and data recordings for approximately 50 years. However, critical information is sometimes lost. The Transportation Safety Board has made repeated recommendations to extend all cockpit voice recordings to two hours from the current 30 minutes.

“While there has been some industry movement, a final regulatory change in Canada has yet to be made. Global efforts are required to build better recorders, to enhance the quality and duration of their recordings, and to ensure they keep recording when the power supply fails. As we embark on the next 20 years, this issue is fundamental to advancing transportation safety. I think you’ll agree that this patchwork makes little sense. That’s why this issue concludes our Watchlist.”

As an exercise, note the number of times Tadros and Fox use the word “patchwork.” There are laments about the “lack of regulatory oversight” and the need for “change.” Virtually the same expressions were uttered by NTSB officials at the recent “Most Wanted” hearing. One would think senior U.S. and Canadian government officials would demand that the FAA and TC implement the recommendations.


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