Transport Committee on April 4th, 2017

[Kathleen Fox]

I was not aware that in 2012 they had removed the oversight of business aviation. In fact, the TSB made a recommendation back around 2009 following an accident that occurred in 2007 that indicated that the Canadian Business Aviation Association, which was at that time responsible for safety management oversight of that sector of the industry, had not been effective at doing that, so Transport Canada, in fact, took back responsibility for oversight for audits and inspection for that segment of the industry. We were briefed by Transport Canada officials that their intent was to—and this goes back to August 2016—reduce or redirect resources away from planned oversight of that segment of the industry, which has a very good safety record compared to other segments of the aviation industry, in favour of redirecting their resources to higher priority or higher risk areas that they'd identified. But we were not aware that they had stopped surveillance.

[Gagan Sikand, Liberal, Mississauga—Streetsville, ON]

Again, thank you for being brief because I'm sharing my time.

Along those lines, given the relatively small number of accidents involving large commercial carriers in Canada, should discussions of aviation safety issues focus on regulations in other sectors?

[Kathleen Fox]

If we look at the number of fatal accidents, most of them occur in the smaller, air taxi sector and that's one of the reasons we launched our safety study into that sector back in 2015. Larger companies, the scheduled carriers, have more infrastructure, more support, more expertise, and they've implemented fairly elaborate safety management systems. However, we believe that smaller operators can also benefit from the same principles and that they should be extended to all commercial operators.

[The Chair, Liberal, Judy Sgro]

Thank you.

Go ahead, Mr. Hardie.

[Ken Hardie, Liberal, Fleetwood—Port Kells, BC]

Thank you, Madam Chair, and thank you for being here today.

There's a strong sense of déjà vu because, of course, we had the rail safety study as well. I guess the question that comes up is about the ability of the large and rather well-heeled operations to have very robust safety management systems versus the smaller operators. Rail or air, it seems to be about the same story. Is the safety management system platform or approach or model really performing as expected, so people can be assured that these companies are doing the right things in the right ways?

[Kathleen Fox]

Our investigations have certainly identified weaknesses in safety management in some operators, large and small. However, we also know that strict compliance with minimum regulations isn't, in and of itself, sufficient to ensure safety or reduce risk. Safety management systems incorporate certain principles, such as the commitment of senior management, having policies with respect to safety, having processes by which companies can manage their safety risks, and having ways to internally report safety issues that need to be addressed. We believe that those principles are adaptable and scalable to smaller operators and that they can go even further than strict compliance with regulations, in terms of helping companies manage safety.

[Ken Hardie, Liberal, Fleetwood—Port Kells, BC]

We have records here that show that in 2009-10 and again in 2014-15 that there were cuts in Transport Canada by the previous government and up to about 100 positions were eliminated. Did this raise concerns with your organization with respect to Transport Canada's ability to do its job?

[Kathleen Fox]

We look at investigations, and we do look at Transport Canada oversight and what role, if any, it played in those investigations. What we've identified are issues with the way oversight was carried out. Transport Canada didn't identify situations of non-compliance with regulations, or they did identify non-compliance but were ineffective at bringing the company back into safe operation, or they were simply looking at SMS from the perspective of compliance with the regulations, rather than whether it was effective.

In the investigations we've done to date, we haven't identified a lack of resources as contributing to that. It's really been about the training that the inspectors receive and about where they place their emphasis when they're doing investigations. That's why we've called in our safety watch-list for a balanced approach to audits and inspections for compliance, as well as assessments of safety management systems for effectiveness.

[Ken Hardie, Liberal, Fleetwood—Port Kells, BC]

The Canadian Federal Pilots Association is concerned that many of their inspectors haven't been able to keep their pilots' licences current. They seem to be relying more on simulators, as opposed to people on the ground, to check the capabilities of pilots. Again, has this shown up on your radar screen?

[Kathleen Fox]

It has not.

[The Chair, Liberal, Judy Sgro]

Thank you.

Next, we have Mr. Aubin.

[Robert Aubin, NDP, Trois-Rivières, QC]

Thank you, Madam Chair.

I want to thank the witnesses for being here.

I'll address the fatigue issue. I was somewhat taken aback by your opening remarks, when you said that “one issue that is not on our watchlist, but is a current topic of discussion between Transport Canada and the aviation industry, is pilot fatigue.” You then said that you still take this factor into account when you need to analyze an accident.

Following an accident that requires an investigation, how do you approach the fatigue issue? Do you approach it by only checking the pilot's log of flying hours? How do you approach the issue?

[Kathleen Fox]

Following an accident, we always look at a number of factors to see whether fatigue could have played a role in the incident. For example, we look at the time of day when the incident occurred. During some parts of the day, such as the late afternoon or middle of the night, there's a normal decline in physiological performance caused by fatigue. We look at how many hours the crew or pilot were up, how many hours they worked, when they went to sleep and how long they slept. We look back up to 72 hours to see whether fatigue was present. Even if fatigue was present, that doesn't necessarily mean it contributed to the accident. We look at the two factors, but we do so in a very scientific way.

[Robert Aubin, NDP, Trois-Rivières, QC]

I imagine the time difference is also taken into account in the scientific calculation when assessing fatigue. Some long-haul flights are now able to fly for 16 hours, and that's on top of the time difference.

[Kathleen Fox]

Yes. We can take into account that the flight was long.

[Robert Aubin, NDP, Trois-Rivières, QC]

In the cases you've investigated in recent years, has fatigue been identified as a significant or new factor that explains the increasing number of accidents or incidents?

[Kathleen Fox]

Since 2000, fatigue has played a role in about 20 accidents or incidents we've investigated, and 15 of those events involved the crew and pilots. A number of those events involved private airplanes. In the commercial sector, fatigue or fatigue management has played a role in five or six cases, and that's out of many investigations. However, in the rail transportation sector, we found that the fatigue factor has contributed in a higher proportion to incidents and accidents. That's why we included the fatigue factor on our watchlist for freight trains and not for air transportation.

[Robert Aubin, NDP, Trois-Rivières, QC]

You seemed to say that it was difficult to obtain evidence to assess the fatigue issue in aviation safety. What methods should we implement to obtain evidence that would help you better assess the fatigue factor?

[Kathleen Fox]

In our investigations, we ask questions. We try to find a number of sources of data to show, for example, how many hours the crew worked and slept. Part of this is subjective. If a pilot is asked how many hours he slept two nights ago, it won't always be easy for him to remember. We're somewhat limited by this, but we still manage to analyze whether fatigue was a factor.

[Robert Aubin, NDP, Trois-Rivières, QC]

Do you think we should establish a type of logbook, like the one truck drivers have, for example, to track the pilots' hours of work and sleep?

[Kathleen Fox]

A regulation already requires flying hours to be logged. In the commercial sector, the number of hours is already capped. The companies are required to keep logs to show they comply with the regulations.

[Robert Aubin, NDP, Trois-Rivières, QC]

I wanted to know whether you find this sufficient or whether the number of hours of sleep the day before the flight should also be taken into account.

[Kathleen Fox]

I'll ask Mr. Sarazin to answer you.

[Yanick Sarazin, Manager, Standards and Quality Assurance, Air Investigations, Transportation Safety Board of Canada]

When an incident or accident is investigated, the investigators have tools developed by the TSB to find or distinguish facts related to either the reasons for or the risk associated with fatigue. First, the investigators look at the past 72 hours, as Ms. Fox mentioned. After, if they have indications, they'll use these tools to look more specifically at different areas, such as whether the ocean was crossed the right way or the wrong way or whether the flight came from Europe. At the TSB, we also have human factor specialists.

If fatigue is identified by the investigators' tools, we conduct a more in-depth study using our specialists' report on the human factors. This gives us a good sense of the direction to take the final report, but it's also useful in terms of the data, because we keep all the data. Whenever we identify a fact that may be related to fatigue, we keep the fact in mind.

[Robert Aubin, NDP, Trois-Rivières, QC]

Thank you.