"We found that accidents in this sector of aviation boil down to two underlying factors: the acceptance of unsafe practices and the inadequate management of operational hazards," said Kathy Fox, Chair of the TSB. "And although overall, commercial aviation in Canada has shown improved safety performance over the past 10 years, air-taxi operations remain at higher risk."
Air-taxi operations in Canada involve aircraft (excluding jets) and helicopters that, by regulation, carry fewer than 10 passengers. These aircraft provide a wide variety of services throughout Canada, often in remote environments with less infrastructure than is available at large airports, and where access to basic weather information and the latest technology may be limited. "It is this unique operating context-the diversity of both operations and environment-that exposes air-taxi companies to very different risks," said Fox.
Air-taxi operators must balance several competing pressures, each with its own consequences, in order to deliver a service, stay safe, and remain economically viable. "When one of or more of these pressures is not adequately managed," said investigator-in-charge Glen Whitney, "it doesn't always lead to an accident, but it almost always leads to a reduced safety margin."
To address this problem, and raise the bar on air-taxi safety, the TSB recommends that operators, their clients, and Transport Canada (TC) work together to eliminate the acceptance of unsafe practices and to promote both proactive safety management and a positive safety culture. The TSB also recommends that TC close known safety gaps in the regulations, and require all commercial operators to collect data on hours flown and aircraft movements by type of operation, in order to measure whether risk mitigation measures are effective.
Moving forward, the TSB will follow up on this investigation by communicating its results to TC, air-taxi operators, their clients and passengers, and industry associations. The TSB will also reach out to these stakeholders to help them understand their role and responsibility in creating a culture where unsafe practices are unacceptable and operational hazards are adequately managed.
See the investigation page
