Havilland DHC-6-300 Twin Otter C-FWLQ - Davis Inlet, Nfld.
(as presented in the TSB Report)
After the accident, Transport Canada (TC) conducted a regulatory audit of the operator and increased the frequency of in-flight checks and general inspection of the Goose Bay operation.
Safety Action Required
(as presented in the TSB Report)
Regulatory Safety Oversight
This occurrence investigation uncovered several serious deficiencies in the conduct of the mission. These deficiencies could be symptomatic of a broader and ongoing disregard for regulations and company standard operating procedures (SOPs). Indicators of the deficiencies are as follows: the presence of poor company loading practices at Goose Bay; inadequate company supervision of the Goose Bay operation; non-adherence to aircraft SOPs; and deliberate operation of the aircraft below the minimum descent altitude (MDA) when adequate visual references for landing were not present. These deviations from normal practices were present in day-to-day operations.
The TSB has observed similar deficiencies in the conduct of business in other organizations, as demonstrated by the occurrences referenced in Appendix A--Supporting Documentation to Section 4.2. Common findings relating to regulatory oversight in these accidents, in general terms, were as follows:
descent below MDA without adequate visual references;
non-adherence to SOPs;
operating under visual flight rules when in instrument meteorological conditions;
operating the aircraft in an overweight condition; and
- inadequate company supervision of operations or maintenance.
Generally, these accidents have been with smaller commercial operators or during operations in remote areas where oversight is difficult. In these operations, there were clear indications that a culture was allowed to exist in which crews and operators operated outside the safety regulations, with catastrophic consequences.
It is recognized that effective safety oversight of smaller or remote operations is a challenging task. Notwithstanding this challenge, the level of acceptable risk should not be greater for passengers and crews who fly on aircraft operated by smaller operators or who operate in or into remote areas, simply because oversight is difficult. It is also recognized that there have been initiatives undertaken by TC to reduce the level of risk in these operations. However, these and other accidents indicate that more needs to be done. It appears that the traditional methods of inspection, audit, general oversight, and regulatory penalties have had limited success in fostering appropriate safety cultures in some companies and individuals; consequently, unsafe conditions continue to exist and unsafe acts are still being committed.
These serious accidents indicate that some operators and crews have disregarded safety regulations and, consequently, put passengers and themselves at an unnecessary and unacceptably high level of risk. In these accidents, findings indicate that, in certain areas of commercial operations, the safety oversight efforts of TC have been somewhat ineffective. Therefore, the Board recommends that:
The Department of Transport undertake a review of its safety oversight methodology, resources, and practices, particularly as they relate to smaller operators and those operators who fly in or into remote areas, to ensure that air operators and crews consistently operate within the safety regulations. (A01-01)
Transport Canada's Response:
Transport Canada is continually reviewing its safety oversight program methodology, resources and practices to meet the challenge of providing effective safety oversight to all areas of the aviation industry in Canada, including the provision of air service to and within remote regions of the country.
Continuous review and improvement of programs and activities is a long established operating principle of Transport Canada. Recent examples include:
The promulgation of the Canadian Aviation Regulations to replace the Air NavigationOrders in October 1996;
The Safety of Air Taxi Operations (SATOPS) Task Force launched in 1996 producing a final report in May 1998;
Flight 2005: A Civil Aviation Safety Framework for Canada published in December 1999; and
A comprehensive external review of the Civil Aviation safety oversight program completed in July 2001.
Canadian Aviation Regulations (CARs)
The introduction of CARs improved significantly the regulatory framework for small operators. The Canadian Aviation Regulation Advisory Council (CARAC) process incorporates a consultative approach to rulemaking and this feature has improved compliance by producing rules and regulations which are easier to understand and therefore easier for operators to follow. When the operators are actively engaged in the rule-making process they are less likely to ignore the regulations and standards and more likely to develop safe operating practices.
The Safety of Air Taxi Operations (SATOPS)
In January 1996, the Safety of Air Taxi Operations (SATOPS) Task Force was established to examine the operational attitudes and practices prevalent in Air Taxi Operations and to recommend ways to reduce the number of accidents in this sector of the aviation industry.
The final SATOPS report dated May 28, 1998 included 71 recommendations that Transport Canada and the industry have worked to implement.
The majority of accidents cited in the TSB supporting documentation occurred before the SATOPS recommendations were put in place. The number of accidents, on an annual basis, in the air taxi sector has been diminishing steadily, and significantly, since 1998. For instance, the number accidents involving fixed-wing small commercial operators (CAR 703 and 704) dropped from 94 in 1998 to 63 in the year 2000. This would indicate that implementing the SATOPS Task Force recommendations is having the intended effect.
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