Best Practices in Controller-Pilot Communications


by Joel Morley, Operational Safety and Human Factors Specialist, NAV CANADA

As an aviation professional, you learned the fundamentals of proper radio communication early on in your training. As a fledgling pilot, air traffic controller or flight service specialist, you wrote exams on the phonetic alphabet and the meaning of certain key words and phrases, while your instructors tried to instill good practices in communicating over the radio.

And as you progressed in your career, you were regularly tested, and during those times you did things the way you were taught. Between tests, however, in the real world, things are often done a little differently...

Direct controller-pilot communications are a critical link in the safe, expeditious flow of air traffic. To provide separation, it is imperative that controllers and pilots have the same understanding of the trajectory the aircraft will follow.

Built-in checks

This is why controller-pilot communications contain built-in checks to ensure understanding, including standard phraseology and required readbacks of clearances and instructions.

Controller-Pilot Communication Loop

Take a moment to consider how frequently practices differ from the ideal we learned early in our careers, when it comes to controller-pilot communications.

How often do we hear non-standard phraseology, readbacks that are "close-enough," incomplete call signs being used, or no call signs at all?

The simple answer is quite frequently.

One study completed in the United States found that over 40percent of controller communications and 59percent of pilot communication contained at least one communication error!

Typical errors

These errors included the incorrect grouping of numbers, omitting elements of a message, substituting words or phrases, transposing elements of a message, excessively long messages, partial readbacks, trouble speaking, and difficulties with pronunciation1.

A significant portion of communications are non-standard. Put another way, these non-standard communications are not taking full advantage of all the checks in place within the air transportation system.

This represents a considerable drift from the way the system was designed to function to the way it actually functions.

Why we drift

Sidney Dekker describes the reasons for drift within a system and the possible impact2. We drift because we depart slowly from the ideal, and we get away with it.

It is a quiet day and there is not a lot of traffic so, as a pilot, you drop your call sign when reading back a clearance. The controller knows your voice anyway, and nothing happens...Others may notice the non-standard phraseology, but they don't say anything.

As a controller, you notice and you are frustrated by it, but you either don't have the time, or don't take the time, to insist on a full readback. You figure there is no point, because if you took the time to correct every pilot using poor phraseology, you wouldn't have time to do anything else!

Or, perhaps you are the flying pilot listening to your colleague on the other side of the cockpit. You know it is not quite right, but you don't say anything because you don't want to look uptight, and everybody does that when it is quiet. There is no adverse consequence, and nobody seems put out by it, so we continue the practice and we continue to get away with it.

One of the reasons we continue to get away with it is that the system is robust to such errors. There are multiple checks in place to catch errors, and these checks work well most of the time, so most of the time the errors are inconsequential.

In fact, one European study found the rate of communication problems leading to a reported occurrence was quite low, with an estimated 2.44communication-related occurrences per million instructions or clearances delivered3. In other words, not doing things "by the book" when it comes to communication carries no real consequence.

From drift to problem

There will, however, come a time when we won't get away with it. As Sidney Dekker points out, drift slowly erodes defences, reducing the effectiveness of the checks that are in place to maintain safety, and thus increasing risk.

What if that clearance you read back without including your call sign wasn't for you? What if you responded to it simply because you were nearing top of descent and you were expecting it? And what if, as a controller, you didn't notice that it was not the right voice accepting the clearance?

As part of our ongoing safety management activity, NAV CANADA investigates more than 300operating irregularities4 each year. These investigations are clearly indicating that communication errors are a problem that requires our attention.

Almost one-third of operating irregularities investigated by NAV CANADA in 2005, had communication error as a contributing factor. And almost one-third of these communication problems were related to readback/ hearback errors on the part of the controller or the pilot.

Although the occurrences investigated by NAV CANADA did not result in loss of life, their potential should not be underestimated. Communication errors have been shown to contribute to the types of occurrences that carry the greatest risk to aviation safety, including altitude busts, runway incursions, and losses of separation.

It should also be remembered that the worst accident in the history of aviation, in terms of loss of life, resulted from the use of non-standard phraseology, when two 747scollided on a runway in Tenerife in1977.


All of this leads to three conclusions:

  1. Communication errors are common in aviation. There is drift.
  2. Few of these errors are consequential. The system is robust to these errors.
  3. Communication errors have the potential for significant consequences. There isrisk.

So, what is being done to address this risk?

Working Group

To address this issue, NAV CANADA is forming the Air Traffic Services-Pilot Communications Working Group.

Made up of representatives from across the aviation industry, the Working Group will identify means to raise awareness of the potential impact of communication errors on safety.

The output of the Working Group will be materials designed to raise awareness of the importance of employing best practices in controller-pilot communications.

This issue is not unique to Canada, and other countries have recognized this problem as well. Similar working groups have already been formed in the UK and Europe, and have produced some interesting material on communication errors.

The following Web site has more information:

There are some simple steps we can all take to begin addressing this issue:

  1. Examine your own communication practices. Are you using standard phraseology? Are you providing full readbacks to clearances and instructions, including your call sign? Are you keeping the controller fully informed of your intentions?
  2. Insist on best practices from others in your cockpit and your company. Help stop the drift by saying something when you see non-standard communication practices.

We all know how to communicate properly on the radio. We learned early on in our careers. We need to make sure we are doing things right!

If you would like more information about the Air Traffic Services-Pilot Communications Working Group, or would like your organization to be involved, please contact Joel Morley at NAV CANADA by e-mail at

Disruptive Passenger Behaviour-Creating a Safer Environment

by Erin Johnson, Cabin Safety Project Officer, Cabin Safety Standards, Standards, Civil Aviation, Transport Canada

Have you ever been on a flight that was disrupted by an irate, intoxicated, or stressed-out passenger? If so, you were most likely bothered by the increase in noise and commotion that ensued. Perhaps you even experienced a sense of fear and anxiety from the disruption. Not only do unruly passengers create an annoyance for fellow passengers, they are also a serious threat to the safety and security of the entire aircraft operation. Unruly passengers hinder crew members' ability to carry out their duties, maintain order, and provide for the safety of other passengers, other crew members, and the aircraft itself. This, in short, is the aviation safety concern that arises from disruptive passenger behaviour.


In the mid-1990s, media headlines drew public attention to several incidents involving unruly passenger behaviour. The Air Transport Association of Canada (ATAC) raised concerns about the increase in unruly passenger incidents. ATAC also drew attention to the fact that there was a lack of regulatory provisions to aid crew members in responding to situations where passengers exhibited unruly or harmful behaviour.

Following this, in 1998, a Prohibition Against Interference with Crew Members Working Group was formed, which included members representing a variety of expertise. The mandate of the Working Group was to define instances of abusive and unruly passenger behaviour, determine the need for a zero-tolerance policy for unruly passengers, and recommend an effective strategy to reduce the number of incidents of interference with crew members. Upon completion of their mandate, the Working Group filed a final report containing 11 recommendations, all of which were accepted by the Canadian Aviation Regulation Advisory Council (CARAC).

Following the events of September11, 2001, the Public Safety Act, 2002, was enacted by the Parliament of Canada, which brought about amendments to the Aeronautics Act. These amendments facilitate action against unruly passengers and make it an offence to engage in any behaviour that endangers the safety or security of a flight, or persons on board, by interfering with crew members or persons following crew members' instructions.

The public and air operators-sharing the responsibility

The two main areas of focus of the Working Group's recommendations included raising the travelling public's awareness and amending the Canadian Aviation Regulations (CARs) with respect to unruly passenger behaviour. A public awareness campaign to inform the travelling public of the dangers of interference with crew members was launched in June1999, and continues to be in place today. Posters, brochures, and ticket stuffers-identifying which behaviours would not be tolerated on board an aircraft, and possible consequences to those behaviours-are posted at airports and distributed to travellers.

Poster "Interference with crew members is NOT tolerated" (TP13382) /

Ticket stuffer
Ticket stuffer "Interference on board an aircraft will not be tolerated" (TP13378)

Inaddition to the awareness campaign, new regulations were drafted and published in the Canada Gazette, PartI, in May2007. The new regulations and their accompanying standards are intended to address a need for provisions in the CARs that will enhance the ability of air operators, private operators, and their employees to deal with passengers who are unruly. The regulations target the problem of unruly or disruptive passenger behaviour, or what is often referred to as "air rage." They are directed at those passengers who indicate by their words or actions that they may behave in a manner that may create an unpremeditated hazard, rather than at those individuals who board, or attempt to board, an aircraft with the deliberate goal of destruction.

Zero tolerance

The regulations will introduce a definition of "interference with a crew member." This phrase will be interpreted as any action or statement, set out in the four levels listed below, by a person on board, or about to board, an aircraft that distracts or prevents a crew member from the performance of their assigned safety responsibilities.

The four levels of interference with crew members have been identified and are harmonized with levels used by other countries, such as the United States. They range in seriousness from a minor incident (level1) to an incident causing a threat to safety (level4). Examples of interference with crew members include unacceptable language, obscene or lewd behaviour, threats, tampering with emergency or safety equipment, attempting to enter the flight deck, and use of weapons. Essentially, it is any behaviour that in its nature hinders the work of crew members and poses a possible threat to the safety of a flight and the travelling public.

All such incidents of interference with crew members will require intervention by the affected operational personnel; however, the response will be different depending on the level. It will also be mandatory for all unruly passenger incidents, except those categorized as level1, to be reported to the air operator. For level1 incidents, a report may be submitted voluntarily.

An ounce of prevention is worth a pound of cure...

The new regulations focus on prevention through the establishment of clear and precise procedures.

Accordingly, air operators will be required to establish procedures in their operations and flight attendant manuals to assist employees in dealing with occurrences of unruly behaviour, and to ensure that occurrences of such behaviour are reported to the air operator.

Another new regulation will make it a requirement for operational personnel to be trained on their responsibilities and the company's procedures in both their initial and annual training. Such procedures should include ways to avoid situations where passengers may become unruly, and provide all employees with the means and knowledge necessary to respond appropriately to such situations. By recognizing signs that could lead to a possible incident of interference, employees will be better apt to diffuse it before it escalates. By reacting promptly, incidents of greater safety threat will be lessened.

The regulations will provide both travellers and crew members with better resources and recourse, should an incident occur. They are not intended to ban passengers for life, but rather to offer crew members a safe workplace, and passengers safe transport to their destination.

Finally, with the new regulations, reporting will become mandatory, and statistics will be required to be submitted to Transport Canada every six months. These statistics will provide the necessary information to track trends and determine if the number of incidents has increased or decreased.

A safer environment for passengers and crew members

With the launch of the awareness campaign and the proposed new regulations in the CARs, Transport Canada continues to work towards providing both passengers and cabin crew members with a safe and hazard-free environment by eliminating potential hazards associated with unruly passenger behaviour.

The SAC Column-Book Report: Blink

by Dan Cook, Soaring Association of Canada (SAC)

The SAC submitted the following book report for publication in the Aviation Safety Letter (ASL). One of the issues the SAC has been wrestling with in gliding flight safety has been why some pilots react and others don't. In addition, the quality of the pilot's response in high-stress situations varies greatly. This is often labelled as pilot error in subsequent occurrence reports, but the nagging question is, why? The book Blink discusses potential reasons, and it is why Dan Cook wrote the report. I personally find it applicable to all pilots, not only to the gliding community. -Ed.

Book Report:

Malcolm Gladwell
Little, Brown and Company, Time Warner Book Group, New York, NY, 2005

Malcolm Gladwell is a staff writer for The New Yorker magazine, and formerly a business and science reporter at the Washington Post.

The book Blink explains how unconscious thinking can have an impact on our decision-making process in the "blink of an eye." It shows why some people make brilliant snap decisions, while others make less successful ones. The book is recommended reading for pilots if they want to help themselves understand human factors in how we make decisions under pressure.

The author speaks about "adaptive unconscious" decision making, and states, "we make very quick judgments based on very little information. The adaptive unconscious does an excellent job of sizing up the world, warning people of danger, setting goals, and initiating action in a sophisticated and efficient manner." In flight, we use the frontal lobe of our brain to analyze and make decisions, but we are often making many more rapid decisions that we are not consciously aware of. Gladwell states, "our unconscious is a powerful force. But it is fallible. It's not a case that our internal computer always shines through, instantly decoding the truth of a situation." He further explains that it is possible to learn when we can use this ability and when we should be careful.

Gladwell points out that we use a process called "thin slicing," which is in our adaptive unconscious to make snap decisions accurately. He gives examples of many experts who can look at certain criteria and make accurate, fast decisions. He points out that the quick decision is often more accurate, since a detailed study often leads to other factors or doubts clouding the issue. He states, "thin slicing refers to the ability of our unconscious to find patterns in situations and behavior based on very narrow slices of experience," and, "the truth is that our unconscious is really good at this, to the point where thin slicing often delivers a better answer than more deliberate and exhaustive ways of thinking."

Gladwell explains that we often function (most of the time for some) on a kind of autopilot. We believe we are making rational decisions, but we are often using thin slicing and the previous associations we have made. Poor decision making is often identified in human factors following an aviation accident.

He discusses the issues of training for development of the cognitive subconscious for decision making. He states, "I think two important lessons are here. The first is that truly successful decision making relies on a balance between deliberate and instinctive thinking....Deliberate thinking is a wonderful tool when we have the luxury of time, and the fruits of that type of analysis can set the stage for rapid cognition. The second lesson is that in good decision making, frugality matters." Here, Gladwell explains that "the most complicated problems have identifiable underlying patterns, and when identifying these patterns less is more....To be a successful decision maker, we have to edit." This editing would have to be done unconsciously for thin-slicing decision making.

What does this mean for us as trainers of student pilots who are learning to make decisions that will have to be made quickly in the future? One could argue, based on Gladwell's book, that to be effective we need to do some analysis to try to identify the underlying patterns that are important in a situation. We may not be able to accurately identify all the criteria for a thin-slice decision for the many aviation situations that might constitute an emergency. Gladwell explains that creating scenarios as close to real life as possible, which would safely allow the student to experience what should be done, could unconsciously develop thin-slicing criteria for snap decision making. In aviation instruction, scenario-based training (SBT) can help develop these useful criteria in our student's unconscious.

The last area the author touched on that I believe is important to us as pilots was the physiology of acute stress. Gladwell writes about how acute stress and the adrenaline we produce can affect our thinking. He writes that "Dave Grossman, a former army lieutenant colonel and author of On Killing, argues that the optimal state of ‘arousal'-the range in which stress improves performance-is when our heart rate is between 115 and 145 beats per minute (bpm). After 145 bpm, bad things begin to happen. Complex motor skills start to break down." This is where many of us feel as though things are happening in slow motion. He continues with, "doing something with one hand and not the other becomes very difficult....At 175bpm, we begin to see an absolute breakdown of cognitive processing....The fore brain shuts down, and the mid brain takes over. Vision then becomes even more restricted." At this point some of us experience tunnel vision, "behavior can become aggressive. At heart rates above 175 bpm the body considers physiological control a non-essential activity. Blood is withdrawn from our outer muscle layer, and concentrated in the core muscle mass. This is to reduce bleeding in case of injury. But that leaves us clumsy and helpless." He describes people having had difficulty dialing 9-1-1 or moving away from an approaching vehicle. You will recall the discussion earlier on the brain injury in the frontal lobe. Here they describe the fore brain shutting down at 175 bpm, which has similar symptoms to the "ventromedial" patient experiencing a lack of ability to make a decision and take action. Sometimes we call it pilot error, but we are victims of our own biology.

In summary, the author states that "our unconscious thinking is, in one critical respect, no different from our conscious thinking: in both, we are able to develop our rapid decision making with training and experience." I believe this is a good human factors book to read and add to your pilot library. It will give all pilots and flight instructors food for thought; an insight into how they perform and how training may be improved.

Doing the Right Thing

by Armin Shafai, Flight Operations Specialist, Mesa Airlines

During a recent visit to the Phoenix, Ariz., airport ramp, I had the opportunity to observe a pilot conducting a pre-flight walk around. Two things gravely concerned me as I watched. First, the pilot was holding a cup of coffee in his hand, and second, he was applying the concept of walk around literally-a casual stroll around the aircraft.

If this had been a check ride, I am confident that this pilot would have failed on the spot; and yet, here he was, preparing to pilot a regional jet aircraft on a revenue flight. Even worse is that I'm sure others were also watching-possibly even a few of his passengers! Now, what kind of confidence does that instill?

So here is my question: as pilots, why do so many of us become complacent and lose the edge in our approach to safety or the application of procedures-or put another way, fail to do the right things consistently, 100percent of the time? I'm sure that at one point in his training days, this pilot was shown that a proper walk around involves carrying a checklist, and perhaps a flashlight, in one hand while actively checking the condition and serviceability of the aircraft.

Let's think of it this way, would we ever see a surgeon sauntering into the operating room minutes before an operation, holding a cup of coffee to see the patient before starting the operation? If surgeons-highly skilled and trained professionals-fail to observe the basic precautions prior to an operation, they may risk causing injury or possible death to their patient. If pilots-highly skilled and trained professionals-fail to notice low tire pressure during the walk around, they could risk damaging the aircraft or causing injury or death not only to themselves, but to the rest of the crew and passengers.

For some pilots, it seems that each move up the aviation career ladder signifies that standards can be relaxed and a different approach can be adopted towards following polices and procedures, and in the application of safety. However, the challenge then becomes overcoming this change in attitude or mindset, considering that nobody forces them to cut corners during the walk around, take off without a current weather briefing, or ignore a known or suspected discrepancy prior to takeoff. In a sense, this change in attitude is a form of self-induced barrier towards doing things the right way.

One reason for this change in attitude could be the belief that, "now that we've made it in the ‘big leagues,' we no longer need to do the things we used to do during our training days." Perhaps we adopt this attitude because we no longer need to demonstrate to someone (instructor, flight test examiner) that we are proficient in these skills. Perhaps since we are no longer assessed on performing these minor-yet important-tasks, we give less importance to completing them consistently and effectively. Another self-induced barrier could be the perception that others will view us as too "by the book" or "going overboard." Would we criticize our doctor or surgeon for that?

Here is where the often over-used word "professionalism" comes into play. In my opinion, professionals are those who apply their knowledge and skills in striving to do the right thing consistently, every time. We cannot take a course in "professionalism" to gain this attribute. Like any other skill, professionalism must be learned, practiced, maintained and built upon; if not, it will erode with time. The good news is that our "professionalism" teachers are all around us. We should simply look around, and while observing our peers doing their job, ask ourselves who performs their job correctly and consistently all the time, and who gets by with performing the minimum required tasks, or uses shortcuts all the time? Now, whom should we emulate?

Walk around
The pilot was applying the concept of walk around literally-a casual stroll around the aircraft.

Professionalism-when incorporated as part of our core competencies-becomes the primary driving force in overcoming the self-induced barriers towards complacency. In wanting to be a professional, we will want to do the right thing consistently, every time. The best part is that it moves with us from job to job and is recognizable by all, so whether we remain in our current position, or plan on moving on to bigger and faster aircraft, professionalism becomes our most notable and visible attribute. One of the by-products of doing things the right way all the time (professionalism) is consistency. When we become consistent, we almost eliminate surprises, or-put differently-we reduce or eliminate the "error" element when paired with the word "human."

As our notable attribute, others who fly with us will recognize this consistency and approach to doing the job right, every time. It will encourage others to emulate this attribute, or it will let them know they can't cut corners or skimp over policy or procedures, thereby jeopardizing safety.

The author may be contacted via e-mail at

COPA Corner-Ramp Rash (Hangar Rash)

Canadian Owners and Pilots Association (COPA)

by John Quarterman, Manager, Member Assistance and Programs, Canadian Owners and Pilots Association (COPA)

Accidents and incidents are tracked across the aviation system by Transport Canada (TC), NAV CANADA, and of course, the Transportation Safety Board of Canada (TSB). But who tracks ramp and hangar rash? Most of us who have been around aviation long enough know about it, have seen the results, and may even have been responsible for it.

Ramp or hangar rash is that mysterious set of dents that appear on aircraft after ice storms (caused by too-zealous line staff who don't necessarily understand that broomsticks and shovels are not the way to de-ice aircraft). Hangar rash is also the dents in the wings, rudders, and tail caused by aircraft being stacked closely together in hangars, overlaid like a jigsaw puzzle, where the only person who can untangle them is the one who put them together so intricately in the first place.

Student-pilots jockeying their aircraft around the gas pumps is another source of ramp rash. Trying to move an aircraft around the fuel pumps, without contacting the ones crowded in behind it, can be a task that goes beyond the skills of most mortal humans. All in all, it sometimes seems as though parking control on airport and flight-school ramps is the thing we do worst in general aviation.

All of the above begs the question: why don't we do better?

Well, it seems that the major problem comes from the lack of planning in ramp layouts, and pilot and groundstaff training in ramp movements. We, in the pilot population, have all been trained to taxi, communicate, fly, land, take off, deal with emergencies, and even deal with a forced landing, but we haven't been trained to run a ramp properly. In the ground-staff contingent, all too often, the training comes on the job and from learning the hard way by breaking aircraft.

So what are the statistics? There really aren't any because the regulations don't specify any reporting unless the aircraft is under its own power. Damage caused by pushing or pulling other aircraft into an aircraft is not reported, and neither is hitting poles, fences, hangar doors, etc., with an aircraft. Even when the aircraft is under its own power, the need to report only comes if some major damage affecting airworthiness takes place. We can also surmise that in some cases major damage goes unreported-how much and what percentage is unknown.

The fact that this kind of damage goes unreported does not mean that there isn't a problem. The aircraft maintenance engineer (AME) at a particular flight school that has about 10aircraft was asked recently, "what is your estimated cost of ramp rash every year?" The reply was stunning: "About $20,000."

For a flight school with razor-thin operating margins, this amount was way beyond "affordable."

So what to do?

Well, one answer is efficient ramp organization. It should be possible to refuel an aircraft after a flight without having to move three other aircraft. Some careful planning, good signage, and ramp painting clearly indicating which way to go, as well as good training for all the pilots and ground personnel are all ways to minimize the potential for damage. Placement of the aircraft refuelling area is, of course, critical!

Aircraft in the hangar for winter pre-heat should have a clear way to move in and out of the hangar space, minimizing the unnecessary movement of other aircraft.

Another answer is co-operation. Having enough people to move aircraft in and out of the ramp area, placing personnel so that the aircraft being moved is wellmonitored for clearance around the wings and tail, and getting that extra set of eyes to watch and supervise the whole process can help prevent an expensive mistake.

The last answer is attitude. Being aware and careful can prevent expensive ramp rash.

As for the flight school I mentioned, it now has a carefully-planned and painted circular refuelling movement pattern instituted on its ramp; movement and handling of aircraft is much safer and damage is much more unlikely. This has apparently resulted in fewer incidents of ramp and hangar rash, all of which means more money for other uses.

Notes on abnormal occurrences

Pilots are advised that ramp or hangar rash should always be followed by inspection by a competent person, usually an AME.

Canadian Aviation Regulations (CARs): (see:

605.88 (1)No person shall conduct a take-off in an aircraft that has been subjected to any abnormal occurrence unless the aircraft has been inspected for damage in accordance with Appendix G of the Aircraft Equipment and Maintenance Standards.

(2)Where the inspection referred to in subsection (1) does not involve disassembly, it may be performed by the pilot-in-command.

CARs Standard 625, Appendix G-Inspection after Abnormal Occurrences spells out what occurrences MUST be followed by an inspection, and what must be inspected (see:

For more information on COPA, visit

Transport Canada Civil Aviation: An Update on the Reorganization

by Derek Howes, Program Manager, Business Planning and Quality Assurance, Program Management, National Operations, Civil Aviation, Transport Canada

The implementation of safety management systems (SMS) has brought, and will continue to bring, significant changes to the way in which the holders of Canadian operations certificates perceive and manage safety. SMS is moving Canadian aviation companies from an environment that focuses on safety within the individual, technical facets of a company (operations, maintenance, air traffic control, etc.), to one where a company manages safety at a systemic and organizational level.

While regulatory compliance and excellence within the various technical areas within a company remain fundamental components of any company's approach to safety, elements, such as recognizing the impacts of organizational inter-relationships between various areas of the company, proactive hazard identification and risk analysis, and active monitoring/quality management processes, will all contribute to a systemic approach to safety within the Canadian aviation system. Such an approach holds significant promise for improving the Canadian aviation system's already excellent safety record.

Place de Ville Tower C

Transport Canada's Headquarters:
Place de Ville, Tower C, in Ottawa, ON

But what about Transport Canada Civil Aviation (TCCA) itself? Throughout its history of regulating and overseeing the Canadian civil aviation system, TCCA's structure has very much paralleled that of industry, with organizations based on specific and technical aspects of the industry- aircraft operations, maintenance activities, manufacturing and engineering, air traffic services (ATS), etc. With the requirement for industry to implement SMS, and with the requirements of our own internal Integrated Management System (IMS), TCCA has to ensure that it has the capacity and the culture to work at the same systemic level that we are demanding of industry.

As part of this, TCCA undertook a review of its organizational structure and is now in the process of making transitional steps toward that new organization through the National Organization Transition Implementation Project (NOTIP). While NOTIP is charged with the overall reorganization of TCCA, this article examines the concepts of oversight of and services provided to the aviation industry. Over the course of the past year, several transitional organizational steps have been taken in these activity areas, both at regional levels and at Headquarters. While these transitional organizations will definitely be subject to change as the broader organization rolls out, an understanding of two of the major criteria underpinning these steps will give the reader a broader view of the TCCA oversight role in 2010 and beyond.

Multidisciplinary teams

As indicated above, TCCA has traditionally been organized along functional and technical lines. Under this organizational structure, companies involved in more than one facet of the aviation industry would be audited and inspected ("overseen") by various Transport Canada groups. For example, a national airline with a maintenance organization would be overseen by separate, Headquartersbased groups involved with air operations and cabin safety, while at the same time being overseen by regionally-based maintenance, aviation occupational safety and health, and dangerous goods groups.

As one of the foundational criteria for the TCCA reorganization, we are moving to multidisciplinary teams-integrated groups of personnel charged with all aspects of oversight for the particular company involved.

Such changes have been reflected in the creation of a National Operations Branch in Headquarters (charged with the oversight of nationally-based airlines and air navigation service providers), and in the creation of a Combined Operations Group in some Regions (tasked with oversight of regionally-based companies).

Such a multidisciplinary team brings a more systematic focus to the oversight of that company; TCCA is more clearly able to see the linkages between all components of the company and the broader challenges and risks facing that organization.


One of the other basic criteria established for the reorganization is the idea of accountability. In a concept closely related to multidisciplinary teams, TCCA intends to have "accountable managers" or "enterprise managers" assigned to specific companies. Under such a concept, companies will be able to deal with one Transport Canada enterprise manager for "one-stop-shopping" in areas such as certification, on-going Transport Canada oversight, etc. As indicated in the above section on multidisciplinary teams, Transport Canada responsibilities are currently split amongst a number of groups-often between Headquarters and Regions.

Such enterprise teams and enterprise managers have been established in Headquarters as part of the formation of the transitional National Operations Branch. Major national airlines have been assigned to specific enterprise team leaders (ETL). In turn, each ETL has a multidisciplinary team to support Transport Canada activities with that company. Similarly, an accountable manager, along with a team of diverse experts, is responsible for Transport Canada's work with Canadian air navigation service providers.

While such specific implementations of enterprise management and enterprise teams will no doubt undergo refinement and change as TCCA's reorganization is fully realized, clear benefits are immediately apparent- companies receive one-stop service through one accountable point of contact. At the same time, from Transport Canada's point of view, these teams facilitate the systemic focus on the overall company.


While there are clear benefits associated with the two above organizational criteria, there are also certain implications that must be examined and planned for.

Work standardization

One of the major benefits in the existing TCCA organization was the grouping of similar functional experts. By having functional experts (pilots, aircraft maintenance engineers [AME], etc.) working together, work standardization was facilitated. An inspector had immediate access to a pool of other experts with the same technical skills. Subject matter expert (SME) managers were in place to ensure standard approaches in that functional area. All of this facilitated common work practices throughout the organization. With cross-functional or multidisciplinary teams, such support mechanisms are not "built-in," and work standardization is more difficult to achieve. This challenge has been recognized and will be addressed as the reorganization rolls out.

System level intelligence

While the enterprise model facilitates the gathering of system intelligence and the identification of hazards at a company level, there is a need to integrate this information at an overall, "civil aviation" system level.

Similarly to the response to work standardization, a "safety intelligence" function has been identified as a fundamental component of the new TCCA organization. Teams of personnel, with appropriate analytical and risk analysis background, will be put together in both Headquarters and Regions, with a mandate to provide the risk information needed to formulate the longer-term, strategic direction for TCCA and the short-term annual plans.

Program management

Two issues were identified-work standardization across multiple enterprise teams, and the need to gather and analyze the "safety intelligence" point to a broader need for strong and effective horizontal co-ordination amongst the various enterprise teams. In response to this need, the TCCA reorganization has identified the need for a strong "program management" component in each of the Regions and the Headquarters branches.


In implementing Flight 2010, SMS, and IMS, TCCA is in the midst of a significant culture change-from a technically-focused, transactional-based model of oversight and regulation to a model that, while maintaining touch with the technical aspects of the aviation industry, focuses on overall companies and on the overall civil aviation system.

The transitional steps taken to implement enterprise managers, enterprise teams, and put in place strong crossfunctional program management functions, are the first steps in that cultural change.

We look forward to the rest of the journey!

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Dekker, S.W.A. (2004) "Why we need new accident models." Journal of Human Factors and Aerospace Safety, 4(1), 1-18. Ashgate Publishing.
Van Es, G. (2004). Air-Ground Communication Safety Study: An Analysis of Pilot-Controller Occurrences. Brussels: Eurocontrol.
An ATS OPERATING IRREGULARITY is defined as: a situation which occurs when air traffic services are being provided and when a preliminary investigation indicates that safety may have been jeopardized, less than minimum separation may have existed, or both.
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