An Ounce of Prevention: Developing a Safety Case

by Cliff Marshall, Civil Aviation Safety Inspector, Technical and National Programs, Standards, Civil Aviation, Transport Canada

When it comes to managing risks associated with an operational change, the adage “an ounce of prevention” is certainly appropriate. A safety case acts as a proactive prevention tool. Safety cases are developed when a major change occurs in your organization. They help the organization anticipate hazards that can result from operational change, and help ensure the successful management of risk during that change. This allows your organization to demonstrate to all stakeholders how you have managed the associated risks. A safety case is developed in much the same way as a business case.

Some common examples requiring the use of a safety case are:

  • when a major operational change is planned;
  • when a major organizational change is planned;
  • when key personnel change;
  • when a new route structure is contemplated;
  • when a new aircraft is introduced into the fleet;
  • when a new airport is being considered for use;
  • when a new control tower or terminal or other facility is contemplated; or
  • when an extension or resurfacing of an existing runway is planned.

Building the safety case involves identifying the hazards associated with major change. Consideration should be given to hazards arising as a result of a change in management, facilities, routes, or operating equipment. Once the hazards have been identified, an assessment of the related risks and a plan for managing these risks should be developed.

When we talk about safety cases, two key words, hazard and risk, should be clearly understood:

  • hazard: a source of potential harm or a situation with a potential to cause loss.
  • risk: the chance of injury or loss measured as the probability and severity of an adverse effect on health, property, the environment, or other things of value.

It is management’s responsibility to manage the risk associated with a project. Since all projects involve some degree of risk, a safety case is necessary to define and document procedures that will be used to manage risk throughout the life of a project. Therefore, it follows that by recognizing potential problems, organizations can develop options to manage risk to an acceptable level using the four methods of controlling risk: transfer the risk, eliminate the risk, accept the risk and mitigate the impact of the risk.

The procedures used to manage risks are documented in the safety case, and then executed throughout the life of a project. Risk management is the process of thinking systematically about all potential undesirable outcomes before they happen and determining procedures that will minimize their likelihood and impact if they were to occur.

There are four stages to risk management planning:

  • Risk Identification: “What could go wrong?”
  • Risk Quantification: “How likely is it to happen and how bad would it be if it did happen?”
  • Risk Response: “How do we prevent or reduce the effect of that happening, or is it an acceptable risk?”
  • Risk Monitoring and Control Assessment: “How do we know if our plan is working?”

A safety case should also specify who is responsible for managing the different areas of risk, how risks will be tracked through the project life cycle, and how monitoring risk control effectiveness will be addressed.

Project size also has an effect on the safety case. Large projects normally require more detailed risk planning than smaller projects due to the volume and complexity of potential risks. Quite often, this requires developing and analyzing alternative risk control strategies and evaluation criteria.

In summary, a safety case helps you increase your chances of success by assessing risk occurrence and defining clear strategies, techniques, and control mechanisms to deal with risk and move forward with your planned change.

Eyes Wide Open: Operating VMC in Class C and D Airspace

Canadian Owners and Pilots Association (COPA)

by Jeff MacDonald, Director, Operations Planning and Programs, NAV CANADA

Recent discussion in safety forums and with the pilot community have revealed a lack of understanding of NAV CANADA services in Class C and D airspace under Visual Meteorological Conditions (VMC), for both IFR and VFR aircraft. This article aims to clarify this, as well as address both ATC and pilot responsibilities.

The following paragraphs describe the terminology and specifically the collision risk management methods available today.

See and Avoid: The oldest risk mitigation strategy, it provides the foundation for the Rules of the Air. It is applicable to any situation where the individual flight operators:

  • are responsible for their own collision avoidance;
  • can detect emerging conflicts; and,
  • can negotiate and apply solutions based on an established rule structure.

The effectiveness of this strategy declines as traffic levels, airspace compression, aircraft mix, and speeds increase. When augmented by traffic alerting or emerging sense and avoid systems, however, it is still a valid risk mitigation strategy.

Traffic Information: Information issued by Air Traffic Services (ATS) to pilots regarding other known or observed traffic that may be in such proximity to their position or intended route as to warrant their attention.

Conflict Resolution: The resolution of potential conflicts between IFR/VFR and VFR/VFR aircraft that are radar-identified and in communication with ATC (Transport Canada Aeronautical Information Manual [TC AIM] RAC 2.8.3). Conflict resolution or visual separation implies a collaborative environment between pilot and controller. The ultimate responsibility for collision avoidance rests with the pilot; however, in certain types of airspace and under particular conditions, ATC is responsible for detecting conflicts, providing traffic information, and suggesting avoidance actions.

Separation: The spacing between aircraft, altitude, or tracks. A separation minimum is a statement of the least allowable amount of lateral, longitudinal, or vertical separation to be applied by ATC between aircraft and between aircraft and obstacles. Separation standards are published in CARs, Standard 821- Canadian Domestic Air Traffic Control Separation.

Runway Separation: The separation of aircraft operating on the runway.

Using the preceding definitions, the required ATC services for each class of airspace, in accordance with CAR 801.02, are summarized below.

Table 1 – Required ATC Services – ATS Airspace

ATC Service Required (CAR 801.02)
A VFR Not Permitted VFR Not Permitted
  • Separation
  • Separation
  • Separation
  • Separation
  • Conflict resolution (upon request)
  • Runway Separation
  • Traffic Information
  • Conflict resolution
  • Runway Separation
  • Traffic Information
  • Separation
  • Runway Separation
  • Traffic Information
  • Runway Separation
  • Traffic Information
  • Runway Separation
  • Traffic Information
  • Separation
  • Runway Separation
  • Traffic Information
E No specified VFR service No specified VFR service
  • Separation
F ATC services as specified ATC services as specified ATC services as specified
G No Specified ATC Service No Specified ATC Service No Specified ATC Service

NAV CANADA also provides service in Class D airspace beyond what is required under CAR 801.02, as follows (TC AIM RAC 2.8.4):

Equipment and workload permitting, conflict resolution will be provided between VFR and IFR aircraft, and upon request between VFR aircraft.

So, how do pilots operating in Class D airspace know whether conflict resolution will be provided? The simple answer is, they don’t, because the service depends on workload and equipment. Pilots are therefore urged to remain vigilant under VMC conditions.

Other important facts to remember when operating in Class C and D airspace
are (TC AIM RAC 2.83 and 2.84):

  • Both IFR and VFR flights are permitted in Class C and D airspace;
  • an ATC clearance is required to enter Class C airspace;
  • two-way communication must be established with ATC before entering Class D airspace; and,
  • a continuous listening watch on the assigned ATC frequency must be maintained by the flight crew while in Class C and D airspace.

The aircraft must be equipped with both:

  1. radio equipment capable of two-way communication with the appropriate ATC unit; and,
  2. a transponder and automatic pressure altitude reporting equipment (for all Class C and D airspace that is designated transponder-required).

In summary, it is important to understand what ATC services are provided in each airspace classification. While NAV CANADA may provide conflict resolution and traffic information in Class C and D airspace, the ultimate responsibility for collision avoidance under VMC rests with the pilot.

We're Watching and Planning

by Civil Aviation Contingency Operations (CACO) Division, National Operations Branch, Civil Aviation, Transport Canada

Did you know that Transport Canada Civil Aviation (TCCA) monitors the National Civil Air Transportation System (NCATS) 24/7? This function is the responsibility of the Civil Aviation Contingency Operations (CACO) Division of the National Operations Branch in Ottawa. CACO is the Civil Aviation focal point for all emergency preparedness activities, operational communications with NAV CANADA concerning incident and occurrence reports, and has national responsibilities for coordinating operational response, contingency planning, exercises and training.

So, what does this mean? CACO manages and operates an Aviation Operations Centre and provides a 24/7 operational response capability. CACO is responsible for monitoring and tracking aviation-related accidents, incidents and high profile events, including aviation security incidents, for the purpose of keeping senior managers apprised of operations in the NCATS and, where applicable, triggering operational responses and activations of the Transport Canada Situation Centre (TCSC) in Ottawa and Regional Transport Canada Situation Centres (RTCSC).

Why is monitoring and tracking necessary? It is the first step in the process of identifying potential hazards in the NCATS. For example, if multiple incidents are reported involving the same air operator, airport, air traffic services unit or aircraft, there may be a potential danger to the public requiring intervention by Transport Canada (TC), using the regulatory tools available to its inspectors.

NAV CANADA is CACO’s primary source of information on aviation incidents; however, information can be received from the Royal Canadian Mounted Police (RCMP), local law enforcement agencies, the Transportation Safety Board (TSB), an air operator, pilot or member of the public. Aviation and security incidents that do not require immediate intervention or are not extremely time sensitive can be reported to CACO online:

In practical terms, a response to an accident or incident would be as follows:

CACO receives a call from NAV CANADA advising of an in-flight emergency involving an air operator: the pilot has advised Air Traffic Control that the landing gear is not indicating down and locked. The pilot has declared an emergency and has requested that airport rescue fire fighters be on standby. The gear collapses on landing. There are no injuries. CACO’s role in this situation would be to gather as much preliminary information as possible and immediately advise the region where the incident took place, the Transport Canada Marketing and Communications Group, Civil Aviation management and external partners such as the TSB. CACO would then monitor the situation and provide updates as required.

Incidents that are more complex require a large, coordinated response by Headquarters and the region(s) and may necessitate the activation of the main TCSC in Ottawa and those in each affected region. Upon triggering an activation, CACO would assume the role of Director of the TCSC, coordinate the gathering of information and brief senior management. Using the TCSC allows CACO to focus on the response to an event and coordinate with stakeholders, while permitting normal daily operations to continue in the Aviation Operations Centre. Examples of previous activations by CACO include: September 11, 2001, the SwissAir 111 crash at Peggy’s Cove, the Air France 358 crash at Toronto Pearson, the Y2K (Year 2000) transition, the 2010 Icelandic volcanic eruption, and H1N1 Influenza.

Halifax Airport around 3:30 pm on 9/11
CACO was activated to assist in the recovery of airliners affected by the events of September 11, 2001. This photo shows Halifax Airport around 3:30 pm on 9/11.

In order to respond to incidents efficiently and effectively, plans and procedures must be developed in advance, they need to be validated through exercises and maintained. In fact, the Emergency Management Act requires the Minister of Transport to do exactly this for risks identified within or related to his area of responsibility. Within TCCA, CACO has been delegated the responsibility of developing, maintaining and implementing contingency plans for use by personnel at Headquarters and in the regions. CACO also provides input, from a Civil Aviation perspective, regarding other departments’ plans and participates in multi-modal, multi-departmental and international exercises that help confirm plans, procedures, communication and cooperation between stakeholders. All this contributes to CACO’s state of readiness and enables it to respond to accidents, incidents and other major events that occur within Canada or affect Canadian interests.

Additionally, CACO partners with TC Intelligence in order to maintain current situational awareness on threats to aviation safety and security. It has state of the art facilities and equipment that enable secure communications with other government departments, agencies and/or stakeholders, and the ability to monitor and track aircraft.

In dealing with potential aviation threats, or to prepare for major events such as the Vancouver 2010 Olympics or the G8/G20 Summits, CACO routinely exercises scenarios with the Department of National Defence, RCMP, TC Aviation Security, NAV CANADA, Canadian North America Aerospace Defense Command, U.S. Homeland Security and the U.S. Federal Aviation Administration.

To carry out the many and varied duties, the staff of CACO undergo extensive, structured, on-the-job training in addition to TC mandatory courses. CACO staff have been delegated a Ministerial Authority which, in part, allows them to restrict airspace, divert or detain aircraft or to authorize a person to give an interception signal or an instruction to land, if such authorization is in the public interest and is not likely to affect aviation safety.

That’s CACO in a nutshell; however, did you know that CACO also:

  • Provides support to NASA shuttle launches and the 5 Canadian East Coast emergency landing sites?
  • Coordinates the authorization of over-flight and technical landing permits for foreign air operators after hours?
  • Distributes Emergency Airworthiness Directives after hours?
  • Coordinates activities related to space launches or space junk re-entry?
  • Represents Canada on the NATO Civil Aviation Planning Committee and provides guidance and input to the NATO Transportation Group – Aviation working groups?
  • Provides Technical Advisors to the ICAO Cooperative Arrangement for the Prevention of the Spread of Communicable Disease Through Air Travel (CAPSCA) Program?
  • Acts as the emergency point of contact for Canadian Coast Guard and Transport Canada aircraft?
  • Acts as emergency point of contact should Civil Aviation Inspectors become incapacitated while travelling on government business?
  • Contributes to the government-wide coordination of activities for VIP visits such as Queen Elizabeth, or President Obama?

In undertaking all of the above, CACO is doing its bit to contribute to an Aviation Safety Program in which the public can have a high level of confidence and to the continued improvement of aviation safety in Canada.

More information on CACO is available on the following Web site:

St. Clair McColl: 2011 Transport Canada Aviation Safety Award Recipient

St. Clair McColl of Salt Spring Island, B.C., has become the twenty-third recipient of the Transport Canada Aviation Safety Award. Brian Jean, then Parliament Secretary to the Minister of Transport, Infrastructure and Community, presented the award to Mr. McColl on February 23, 2011, during a reception to celebrate the third annual National Aviation Day.

"I would like to congratulate Mr. McColl for his tremendous contribution to aviation safety and for being such an excellent role model to other aviation professionals and those considering a future career in this field." said Mr. Jean while presenting Mr. McColl with the award.

Mr. Brian Jean presenting the Transport Canada Aviation Safety Award to Mr. St. Clair McColl
Mr. Brian Jean (left) presenting the award to
Mr. St. Clair McColl on February 23, 2011.

The selection committee unanimously selected Mr. McColl as this year's winner for his commitment to excellence in aviation safety in Canada. The founder of Saltspring Air, Mr. McColl has been a pilot and an air operator owner on the British Columbia coast for over 30 years, offering safe transportation to thousands of passengers to a wide variety of locations under all conditions imaginable.

In his earlier years, St. Clair realized the need for safety and the constant vigilance required to mitigate one's exposure to hazards. He felt a compelling drive to keep the safety of his flight foremost in his operations. It should come as no surprise that he insists that all his pilots be trained in Underwater Egress and that he constantly upgrades his training programs to ensure his flight crew not only meets the standards, but also exceeds them. McColl has acquired a team of dedicated partners and employees who embrace his mantra: "If it's not safe, we aren't flying. If it's not fun, we are not interested."

In the fall of 2009, a tragic accident involving another operator prompted McColl's to become the first operator in North America to outfit his entire fleet of de Havilland Beaver floatplanes with emergency push out windows, which provide an alternate exit to the main cabin doors in case of an emergency. When asked about this decision, McColl replied, "It just made common sense. If I need to be the first to install these windows in order to get the rest of industry on board then so be it." This process involved expense and down time for each aircraft, but that did not deter him from making safety his top priority.

As someone who demonstrates industry leadership and who prides himself on his company's safety record, it should come as no surprise that Mr. McColl was recently elected vice-president of the newly formed Floatplane Operators Association.

More recently, St. Clair developed his own "Pre-Boarding Safety Video", which he hopes the rest of the industry will use to adopt their own.

Those who know McColl know him not only as a leader, but also as a hero. During what began as a routine flight, St. Clair rescued a father and son from the frigid waters of the Strait of Georgia after a sharp-eyed passenger noticed a capsized boat and notified McColl. Despite choppy seas, McColl successfully landed the de Havilland Beaver and, using a rope he was able to pull them close enough to his aircraft so they could jump aboard. In 2007, the Lifesaving Society of British Columbia honoured McColl and his two passengers for the rescue.

A leader and a hero, St. Clair is undoubtedly worthy of this award and the excellent reputation he enjoys in the industry is well deserved. To quote St. Clair: "The pursuit and dream of flying is constantly kept alive and supported by ALL of us. Therefore before we entertain our dreams, we must first attend to our primary goal: the safety of flight."

To date, St. Clair has not rested. He spends countless hours at work, as his wife and three sons can attest to. He continues to passionately pursue his dream of "running his own airline."

The Transport Canada Aviation Safety Award recognizes persons, groups, companies, organizations, agencies or departments that have contributed, in an exceptional way, to aviation safety in Canada. Visit Aviation Safety Award to learn more about this prestigious award or to find out how to submit a nomination.

In 2009, February 23 was designated as National Aviation Day in Canada. This occasion highlights the federal government's role in the safety and security of all Canadians and celebrates the successes of the aviation industry in Canada. The Canada Aviation and Space Museum hosted a career day for students. Transport Canada joined industry and education leaders to showcase the many aviation career opportunities.

"This day is about inspiring our youth to pursue rewarding careers in aviation and highlighting the progress we've made toward safe, efficient and sustainable aviation in Canada," said the Honourable Chuck Strahl, then Minister of Transport, Infrastructure and Communities. "The men and women in the Canadian aviation sector keep Canadian skies safe for travellers, giving us a safety record that is the envy of the world." 

Snowbirds' Canadair CT-114 Tutor

On February 23, 2011, the Canada Aviation and Space Museum unveiled the Snowbirds’ Canadair CT-114 Tutor to celebrate the official inauguration of their new wing. In the glassed-in entrance of the museum, the Tutor dangles upside down from the exposed trusses of the ceiling—a suitable way to showcase an aircraft that’s renowned worldwide for its skyward acrobatics.

Snowbirds’ Canadair CT-114 Tutor

Ballistic Recovery Systems: What First Responders Need to Know

This article is based on Transportation Safety Board of Canada (TSB) Final Report A10O0101, and on Aerodrome Safety Circular ASC 2006-28, Ballistic Recovery Systems Info For First Responders.

On May 25, 2010, a Cirrus SR20 aircraft departed from the Toronto Buttonville Municipal Airport on a flight to the Burlington Airpark in Ontario. Shortly after takeoff from Runway 15, the pilot reported a problem and initiated a left turn to return to the airport. It is estimated that the aircraft did not reach an altitude of more than 500 ft above ground level (AGL). The aircraft’s bank angle increased and its nose dropped suddenly. The aircraft entered a spin and crashed on the roof of a nearby building. A post-crash fire broke out shortly after impact and consumed most of the aircraft. The two occupants were fatally injured. Fire and emergency services arrived within 10 minutes.

As a result of the accident investigation, the TSB determined that the number 3 cylinder head failed due to fatigue and separated from the cylinder during takeoff, resulting in reduced power from the engine. This article focuses on the risk posed by an undeployed airframe-mounted ballistic emergency parachute system in aircraft wreckage.

The Cirrus SR20 aircraft is equipped with an airframe-mounted emergency parachute system, which had not been deployed in this occurrence. The Cirrus Airframe Parachute System (CAPS) is designed to lower the aircraft and its passengers to the ground in the event of a life-threatening emergency. Approximately 15 minutes after impact, there was an explosion as the rocket from the CAPS ignited from the heat of the fire. Still partially tethered to the airframe by stainless steel cables, the rocket ricocheted across the roof before breaking free of the cables and landing in the street approximately 165 ft from the crash site.

Picture of the accident scene when the ballistic parachute system deployed from within the aircraft wreckage.
Picture of the accident scene when the ballistic parachute system
deployed from within the aircraft wreckage.

In its final report, the TSB made the following finding:

“The Cirrus Airframe Parachute System activated post impact as a result of the post-crash fire and the rocket projectile landed in the street. Unless first responders are aware that some aircraft may be equipped with ballistic projectiles, and are trained in how best to deal with them, they will be placed at risk if there is ignition.”

Back in 2006, Transport Canada (TC) published Aerodrome Safety Circular ASC 2006-028 on this issue. In the interest of making this information better known, we are reprinting the information found in ASC 2006-028 below, as well as some current links. This advisory circular can also be found on the Transport Canada Web site at:

The following is based on Aerodrome Safety Circular (ASC) 2006-028. (Note: links have been updated and may change over time.)

Aircraft Rescue and Fire Fighting (ARFF) safety information on rocket-deployed aircraft emergency parachute systems.

This circular is to provide information for the ARFF to respond safely to incidents or accidents involving aircraft equipped with rocket-deployed aircraft recovery parachutes.

Following the crash of a small aircraft equipped with a rocket-deployed recovery parachute that had not been deployed, the emergency responders reported that some of the existing warning labels did not provide sufficient information on safety precautions for handling such systems when responding to an emergency. The U.S. National Transportation Safety Board (NTSB) issued a safety recommendation to provide emergency responders with training and information on such systems.

To this date, only a small number of these systems are in use in Canada. However, as the use of these systems received significant interest in the U.S., their use in Canada is expected to grow. It is important for airport operators to obtain and disseminate information regarding rocket-deployed emergency parachutes to the on-site and off-site responding agencies to allow them to introduce pertinent information in their site-specific ARFF training and emergency response plan procedures.

The following Web sites include information that is currently available on rocket-deployed parachute systems:

Awareness and training information should be provided to emergency responders. They must first identify the presence of an un-deployed emergency rocket-deployed parachute system and then de-activate it to render it harmless.

The information and pictures provided in the document published by the manufacturer, Ballistic Recovery Systems (BRS), entitled BRS Ballistic Parachutes: Information for Emergency Personnel, available at the BRS Web site, should be used as reference for the development of response procedures to maximize the safety of emergency responders.

For additional information, please contact the Aerodromes and Air Navigation Services Division, Standards Branch, at 613 990-2201, or by e-mail at

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