It was evident in the industry consultation sessions that Air Taxi management, pilots and AMEs were interested in obtaining more information and education on decision making and human factors issues. A safety-minded company's management is committed to safe operating practices and provides its employees with the tools, encouragement, and support required. Air Taxi management is not always aware of what services or training Transport Canada System Safety has to offer and the System Safety branch is not always aware of changes in air operator personnel. Commercial and Business Aviation inspectors interview prospective Chief Pilots and Operations Managers prior to their acceptance to that position by Transport Canada. These new managers should be made aware of human factors courses and other training that is available.

SR 27 - Recommend Transport Canada provide the Chief Pilot and Operations Manager on initial appointment to that position with information about courses and training materials available from System Safety (e.g. Decision Making/Human Factors, Company Aviation Safety Officer course, etc.)

SR 28 - Recommend Transport Canada encourage Air Taxi operator management to attend the Company Aviation Safety Officer (CASO) course.

IA 28 - Recommend Air Taxi operator management attend the CASO course and implement the principles learned in the course in their company.

The Canadian Aviation Regulations do not require a safety program for Air Taxi operations, although many companies have established an in-house safety program. These programs are not necessarily formalized in the operations manual but normally consist of having safety meetings from time to time, posting company bulletins about safety, open communication between operating personnel and management, open discussion of problems experienced in day-to-day operations and most importantly, management's insistence on safe operating practices. Some of the benefits of operating incident- and accident-free are lower maintenance costs, lower insurance rates, less down time for aircraft, more productive pilots, continued good reputation with clients, and increased motivation and positive attitude of employees.

SR 29 - Recommend Transport Canada promote the benefits of having a company safety program to Air Taxi operator management and review the requirement for Air Taxi operators to have a company safety program.

IA 29 - Recommend Air Taxi operators establish a company safety program that is fully supported by management.

When an accident occurs, often the pilot is the only one held accountable. While the pilot may be at fault for having made a poor decision or series of decisions that led to the accident, other questions have to be asked... Were there any systemic problems in the company? What was management's role in the accident? What did management do to prevent the accident? What is management doing to prevent a recurrence? Management must be accountable for the safety of the day-to-day operations. When management is held responsible for an accident, they will become more proactive in promoting safe operating practices.

SR 30 - Recommend the Transportation Safety Board evaluate the management factors that contributed to the accident during the accident investigation.

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