Small aircraft operators making ‘gradual drift’ toward unsafe flying, says TSB

[W5]

https://www.nationalnewswatch.com/2019/ ... cXlqDNKiUk

OTTAWA — Small aircraft operators in Canada have fallen into a trap of accepting too many safety risks — and it has to stop before more people are killed or injured, the Transportation Safety Board warned Thursday.

TSB senior investigator Glen Whitney said so-called air-taxi operators — companies that carry fewer than 10 passengers in fixed-wing aircraft and helicopters, often in remote areas — don't flagrantly break regulations as a general rule.

But over time, many have become complacent about the safe operation of their aircraft as they come under pressure to cut costs, Whitney said as the board released its findings from an investigation of the industry launched in May 2015 that looked back on 15 years of data.

"I'm not talking about flagrant rule violations," Whitney told an Ottawa news conference. "I'm talking about a gradual drift that occurs over time with every successful, though not necessarily safe, flight."

The board analyzed more than 700 incidents that occurred between 2000 and 2014, involving aircraft used to ferry small numbers of passengers; everything from helicopters used by utilities to fixed-wing turbo-prop airplanes that service some of the most isolated regions of the country.

Over the years, investigators have released 22 recommendations to Transport Canada on how safety can be improved on such aircraft, including implementing seat belts with chest harnesses and ensuring the availability of safety belts designed for children.

Just last month the safety watchdog called for clearer regulations around seatbelts as a result of its investigation of a 2017 crash in eastern Ontario that killed four men who were in a Hydro One helicopter.

The TSB issued four new recommendations Thursday, including a call on Transport Canada to educate pilots and service operators about the risks of accepting unsafe practices.

All too often, aircraft operators facing economic challenges put pressure on pilots to fly under unsafe conditions, such as flying overweight, or with minimal fuel reserves, or by delaying scheduled maintenance, said TSB chair Kathy Fox.

"Although these vital air links have helped build Canada and sustain its population, air-taxi operations are at higher risk," said Fox.

"The air-taxi sector continues to have more accidents and more fatalities than all other sectors of commercial aviation combined."

The TSB also called on industry associations to share tools and data that can be used to implement best safety practices.

Investigators found a wide array of safety standards have been adopted by air-taxi operators across the country with some going above and beyond current safety regulations while others comply with the bare minimum regulations.

Transport Canada should review the gaps in safety standards to ensure they are up to date, the board said.

It also called on the government to require all commercial operators to report aircraft data, such as the number of hours flown, to better calculate accident rates and ensure that current safety strategies are working.

Transport Canada has 90 days to respond to the TSB's recommendations.

This report by The Canadian Press was first published Nov. 7, 2019.



Terry Pedwell, The Canadian Press

[ReserveTank]

Until enforcement goes up to places like YXL every day and stands on these operators' heads, nothing will change for the better. And we know that won't happen.

[pelmet]

I found this statement very interesting and while I realize that this TSB concern is directed toward 'small' operators, they have inadvertently brought up an important point that I would like to discuss about larger operators.

"All too often, aircraft operators facing economic challenges put pressure on pilots to fly under unsafe conditions, such as flying overweight, or with minimal fuel reserves, or by delaying scheduled maintenance" said TSB chair Kathy Fox.

We have seen a dramatic decrease in the number of airliner accidents in the last decade or so. 15 years ago, there were predictions that we would average one serious airline accident per week but instead, it is far, far less.

But there are still many close calls. With the dramatic decrease in accidents due to icing, microbursts and CFIT, the focus has turned to runway excursions which frequently happen in poor weather. Of course, the important question is....why. Why is it that pilots are repeatedly landing in heavy rain and running off the runway. Why don't they just wait it out.

I think that it is due to the regulators allowing the airlines to fly with the minimum fuel that the regulations currently allow. Just a few months ago, after a long flight to an airport with a good weather forecast of no precipitation, we arrived with thunderstorms in the area and minimum fuel. The alternate......the second airport for the city about 15 miles away. Now you have a situation where there are likely a bunch of us with minimum fuel all hoping that the rain adjacent to the airport doesn't get worse. It all worked out, but what if conditions get much worse. One can say, "well why don't you just take more fuel". But we may have to bump payload for a flight to a destination with a very good forecast.

I suspect that a lot of the incidents we read about where a pilot made a decision to attempt a landing where part of the equation in that decision was the pressure of minimal fuel reserves. I think that it is time that the TSB and their fellow safety boards examine the rules about legal fuel reserves which in my opinion are unsafe. How about a final reserve of 45 minutes making pilots more comfortable about diverting to their alternate. One can say that it is just excess worrying but when situations start happening due to weather events, there can easily be delays resulting in one landing with less than 30 minutes of fuel om the fuel gauges(which are not always reliable), an extremely uncomfortable situation which I believe has led some pilots to stick with the destination instead of diverting to the alternate.

We could have 45 minutes of reserve fuel required but a requirement to declare a fuel emergency remaining at 30 minutes giving some margin between the two.

[Beefitarian]

I suspect they are referring to pilots going with bare minimum fuel that probably is already below current legal reserves in order to reduce weight.

They don't get discovered unless they run out.

[valleyboy]

It's always been an issue with small aircraft design and trying to operate an aircraft legally when the manufacturer puts too many seats and manipulate gross weights to keep an aircraft in a certain class. Cut throat business also adds to it and skimping on fuel to try and keep legal sets up a paradox that defies logic. What is needed is a proper designed aircraft that will take a load and meet all regulations. Cabin class twins should not be allowed nor should possibly single engine IFR. Radical statements, I know but what are we willing to do for safety. Why is busting minimums such a big no no amongst pilots yet the same will blast off with so little fuel that any unexpected unforeseen issues can ruin the whole day and possibly lives.

[Capt. Underpants]

I think that it is due to the regulators allowing the airlines to fly with the minimum fuel that the regulations currently allow.

The issue isn’t in what they are “allowing”. Regulators can’t just make stuff up, they can only enforce what the regulations require. If this really is a thing - which is debatable - it’s in the regulations themselves.

I’ve seen the data from a detailed analysis of fuel burns over a year long period for flights where extra fuel was taken without the concurrence of the dispatcher. In the vast majority of cases, the extra fuel was still on board at the destination, but the additional fuel burn averaged between 2.5 and 4 percent of that extra weight - depending on the fleet. There were no minimum fuel or fuel emergency declarations made during those flights. The same analysis looked at flights where the flight planned fuel was carried. In virtually all of those flights, the arrival fuel at destination was more than the flight planned value.

The only accident I recall where the TSB should have looked deeper into fuel on board was the Air France A340 overrun at YYZ. It was mentioned, but only casually. But for me, the most glaring miss in that investigation was their failure to make recommendations regarding the decision to continue an approach when a massive thunderstorm was located in the missed approach path and clearly visible to the crew on their weather radar. Pilots do this all the time - they race the incoming weather to the airport without considering the “what ifs” of a go-around into really nasty weather.

[ayseven]

Twas always thus. Be vigilant, be safe and be thankful every time you land safely. Then debrief yourself on how you might have done it better.

[pelmet]

I think that it is due to the regulators allowing the airlines to fly with the minimum fuel that the regulations currently allow.

The issue isn’t in what they are “allowing”. Regulators can’t just make stuff up, they can only enforce what the regulations require. If this really is a thing - which is debatable - it’s in the regulations themselves.

The regulators make as well as enforce the regulations. Therefore regs can be changed. A lot of regulations have influence from commercial carriers including fuel and rest requirements. We have certainly seen recent influence on the latter. No doubt the carriers were influential in the former. I personally believe it has resulted in decision making leading to some of the many overruns we have seen around the world. But something like this is extremely difficult to prove.

[pelmet]

I think that it is due to the regulators allowing the airlines to fly with the minimum fuel that the regulations currently allow.

The only accident I recall where the TSB should have looked deeper into fuel on board was the Air France A340 overrun at YYZ. It was mentioned, but only casually. But for me, the most glaring miss in that investigation was their failure to make recommendations regarding the decision to continue an approach when a massive thunderstorm was located in the missed approach path and clearly visible to the crew on their weather radar.

Thanks,

Just to add a little bit, there was heavy thunderstorm activity on final approach as well.

[PilotDAR]

Until enforcement goes up to places like YXL every day and stands on these operators' heads, nothing will change for the better.

That's an unfortunate perspective. Personally, I don't need TC Enforcement staff lurking around the corner to prompt me to assure that my flying is safe and compliant, I simply plan to fly safely and with compliance because it's a good idea! If a pilot does not understand the limitations of the aircraft, or the applicable regulations, the pilot should inquire, this is not complicated stuff! If the pilot chooses to fly not safely, well, I guess that's another issue, we'll hope Enforcement catches them before gravity does.

when the manufacturer puts too many seats and manipulate gross weights to keep an aircraft in a certain class. ........... What is needed is a proper designed aircraft that will take a load and meet all regulations.

The certified airplanes all meet the design requirement for useful load and fuel capacity. FAR 23.25: 170 pounds per seat; all seats occupied, and one half hour of fuel, and minimum crew and full tanks. If a manufacturer chooses to exceed these requirements, super, but if the requirements are met, it's up to the pilot to understand and work within them.

Yeah, the normalization of deviance can catch a pilot or an operator, and it's up to all of us to remind ourselves to guard against it. Are there pilots out there who are literally waiting to be caught by Enforcement? I guess I'm happy to fly in my own little world!

[AirFrame]

FAR 23.25: 170 pounds per seat;

An excellent example of a regulation that needs updating. It's been a long time since 170 lbs was the average passenger. Certainly in North America if not elsewhere as well.

[TailwheelPilot]

Full seats and 30 minutes fuel (VFR reserve) is not all that useful either...

[goingnowherefast]

Yeah, the normalization of deviance can catch a pilot or an operator, and it's up to all of us to remind ourselves to guard against it. Are there pilots out there who are literally waiting to be caught by Enforcement? I guess I'm happy to fly in my own little world!

Bingo! And yes, there are operators where Enforcement could show up and catch something big on 75% of the flights departing. There are bosses who enforce a culture of bending and breaking rules for more profit. Then give pseudo punishments to pilots who don't skirt the rules. No pay raise, bad reference, no upgrade, given the shitty flights at 2am, deny vacation/time off. Stuff that's near impossible to prove.

It ties into the dramatic decrease in experience too. A 1000hr captain should really be the FO and in much need of mentoring. They are much more likely to listen to the asshole boss who says " a little overweight is okay". Same statement with icing, minimums, fuel, maintenance, etc.

[digits_]

It ties into the dramatic decrease in experience too. A 1000hr captain should really be the FO and in much need of mentoring. They are much more likely to listen to the asshole boss who says " a little overweight is okay". Same statement with icing, minimums, fuel, maintenance, etc.

On the other hand, having 10 other jobs available if you get fired for turning down unsafe flights, makes aviation safer.

I doubt even the more asshole pushing boss would push a 1000h captain as much as his 6000 hour captains 10 years ago.