July 23, 2015

TSB Chair Discusses Accident Investigation Evolution

During Thursday morning’s keynote speech at the ALPA Air Safety Forum, Kathy Fox, chair of the Transportation Safety Board (TSB) of Canada, discussed the board’s “Watch List” of safety concerns and the manner in which aircraft accident investigations have evolved to better determine the causes of events.

Of the various TSB Watch List priorities, three items address aviation: 

1. The risk of approach-and-landing accidents, with special attention given to unstable approaches.
2. The risk of runway collisions. (There is approximately one runway incursion a day in Canada, although “most of these are benign,” said Fox.)
3. Safety management and regulatory oversight—more specifically, ensuring that airlines implement formal, effect safety-management processes.

Fox observed that over time the focus of accident investigations has shifted from mechanical failures to crew decision-making and human factors concerns. She discussed a 2011 First Air B-737 accident near Resolute, Nunavut, and a 2012 Perimeter Aviation Metroliner accident near Sanikiluaq, Nunavut, to examine contributing factors and why crews involved in accidents make the decisions they do. 

“At the TSB we are very careful not to assign blame or fault because pointing fingers and blaming people doesn’t do anything to prevent the next accident,” said Fox. “Understanding the operating context does. Identifying the underlying safety issues does.

Fox then described an incident involving a Sunwing B-737 involved in a morning takeoff from Toronto Pearson International in 2011 in which the crew successfully managed an erroneous stall warning, an operational condition later addressed in a Boeing advisory. Sunwing delayed reporting the incident because those responsible didn’t see the value. Fox acknowledged that at night or in poor weather, the outcome of this event could have been significantly different and that information describing what happened could prevent another incident or accident.

In closing, the TSB chair suggested that greater access to cockpit voice recordings, in a nonpunitive environment with appropriate protections against misuse, would greatly contribute to the board’s ability “to better understand what and why events occur.” She added that greater access to these recordings would need to be legislated to properly protect those involved, but that providing this additional information would improve Canadian aviation’s safety culture.

Founded in 1931, ALPA is the largest airline pilot union in the world and represents over 52,000 pilots at 31 U.S. and Canadian airlines. Visit the ALPA website at www.alpa.org or follow us on Twitter @WeAreALPA.

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