Source: http://www.tsb-bst.gc.ca/eng/recommandations-recommendations/aviation/1995/rec_a9511.asp
Timestamp: 2018-01-22 20:08:03
Document Index: 279132488

Matched Legal Cases: ['art 703', 'art 704', 'art 705', 'art 703', 'art 704', 'arts 722']

Recommendation A95-11 - Transportation Safety Board of Canada
Recommendation A95-11
Reassessment of response to Aviation Safety Recommendation A95-11
Guidelines for crew resource management and pilot decision-making training
The aircraft, a Convair 580, was on a flight from Vancouver to Tofino, British Columbia, with 4 crew members and 47 passengers on board. When the aircraft landed at Tofino, it touched down about midway down the 5000-foot runway. The aircraft ran off the end of the runway and came to rest 150 feet past the runway end. There were no injuries; however, the aircraft sustained substantial damage.
Board Recommendation A95-11 (May 1995)
In May 1995, the Transportation Safety Board of Canada (TSB) made two Aviation Safety Recommendations as a result of the investigation into a runway excursion of a Canair Cargo Convair 580 at the Tofino Airport, British Columbia. The recommendations were related to crew resource management (CRM) and pilot decision-making (PDM) skills.
Poor CRM/PDM in small air carrier operations has been a matter of concern to the TSB for some time. In 1990, the Board had recommended that the Department of Transport devise and implement a means of regularly evaluating the practical decision-making skills of commercially employed pilots engaged in small air carrier operations (A90-86, issued 17 December 1990). Transport Canada (TC)'s response to that recommendation was assessed as Unsatisfactory.
In the Tofino occurrence, the company had not provided its crews with a course in CRM or PDM, nor was such training required by regulations. The TSB identified eight other recent occurrences that were linked to poor PDM/CRM. It was noted that, while some larger air carriers can develop the necessary training on their own, other operators will require direction in setting up meaningful training programs.
Transport Canada's response to Recommendation A95-11 (July 1995)
Crew resource management (CRM) and decision-making training will be mandated for all air operators who are required to adhere to the Airline Operations regulations. A standard has been developed and forms part of the Commercial Air Services Standard (CASS) incorporated by reference by the Canadian Aviation Regulations (CARs). The CARs will appear in the Canada Gazette, Part I during the summer of 1995 and be promulgated later in the year. The CASS will allow initial CRM training to be conducted separately for pilots and cabin safety personnel; however, recurrent training will be conducted annually in a joint training environment. In addition, guidance material has been developed to support the regulation and standard.
Board assessment of the response to Recommendation A95-11 (no date on the document)
The intent of the recommendations was to provide ... all aircrew involved in commercial aviation ... with the proper tools and skills needed to reduce the likelihood of inappropriate decisions in the day-to-day commercial flying environment. TC's response states that crew resource management (CRM) and pilot decision-making (PDM) training will be mandated for “... all air operators who are required to adhere to the Airline Operations regulations”( i.e., the large air carriers coming under the new Canadian Air Regulation (CAR) 705).
In attempting to clarify the intended scope of TC's action, informal correspondence between TC and TSB staff confirmed that Air Taxi (CAR Subpart 703) and Commuter Operators (CAR Subpart 704) will not be required to provide their crews with CRM or PDM training or evaluation. Furthermore, a TSB staff review of the guidance material developed for the CAR Subpart 705 operators revealed that this material would likely not be sufficient in detail to assist the smaller CAR Subpart 703 and Subpart 704 operators.
TC's action is aimed only at those operators that have the resources to establish proper CRM/PDM training and, in all likelihood, already have done so. With this limited extent of the TC action, the shortcomings in CRM and PDM training for the crews of smaller operators will continue.
Therefore, the response to Recommendation A95-11 is assessed as Unsatisfactory.
Board reassessment of the response to Recommendation A95-11 (March 2005)
The extent of Transport Canada action to date is directed at large air operators; hence, the shortcomings in crew resource management (CRM) and pilot decision-making (PDM) training for crews of smaller operations will continue. The TSB acknowledges that, while the action taken to date does address one aspect of the deficiency, it does not substantially eliminate it for all operators and aircrew.
Therefore, the assessment of the response to Recommendation A95-11 is Satisfactory in Part.
Furthermore, given that the safety deficiency addressed by Recommendation A95-11 (as well as that by A95-12) is very similar to that being addressed by the more recent Recommendation A00-06 (i.e., lack of guidelines and standards for PDM training for all pilots involved in commercial air operations), it is appropriate to follow the progress on PDM safety issue through Recommendation A00-06.
As such, further action is unwarranted on this recommendation, and the status of Recommendation A95-11 is now Inactive.
Board review of Recommendation A95-11 deficiency file status (April 2014)
The Board requested that Recommendation A95-11 be reviewed to determine if the Deficiency File Status was appropriate. After an initial evaluation, it was determined that the safety deficiency addressed by recommendations A95-11 and A95-12 is addressed by the more recent recommendations A00-06 and A09-02.
It is therefore appropriate to follow the progress on crew resource management (CRM) and pilot decision-making (PDM) safety issues through recommendations A00-06 and A09-02.
Therefore, the assessment of the response to Recommendation A95-11 remains Satisfactory in Part.
Transport Canada's response to Recommendation A95-11 (January 2015)
Board reassessment of the response to Recommendation A95-11 (March 2015)
Until all regulatory changes proposed by Transport Canada are enacted, the deficiency identified in Recommendation A95-11 will continue to exist. However, the proposed regulatory changes, if fully implemented, will substantially reduce or eliminate the risks associated with the safety deficiency identified in Recommendation A95-11.
Transport Canada's response to Recommendation A95-11 (November 2015)
(Includes recommendations A95-12, A00-06, A07-03, and A09-02.)
Board reassessment of the response to Recommendation A95-11 (March 2016)
Transport Canada appears to be making meaningful progress. However, the action has not been sufficiently advanced to reduce the risks to transportation safety. Until the proposed crew resource management (CRM) standards are fully implemented, the safety deficiency will continue to exist.
Therefore, the assessment of the response to Recommendation A95-11 is changed to Satisfactory Intent.
Transport Canada's response to Recommendation A95-11 (January 2017)
TSB reassessment of Transport Canada's response to Recommendation A95-11 (March 2017)
TC's latest response suggests that its revised Notice of Proposed Amendment (NPA 2014-021) addresses the deficiency identified in Recommendation A95-11. The NPA states that TC's current framework for CRM training does not reflect many contemporary CRM training concepts. The NPA's objective is to integrate such concepts into commercial aviation crew training programs. Additionally, the proposed amendments will see a broader application of these updated CRM training requirements to include Commercial Air Service Standards (CASS) Subparts 722, 723, 724 and 725.
The Board is pleased that the intent of NPA 2014-021 is to update CRM training standards across all CASS, including Aerial Work operations, which were not included in the original recommendation. Consequently, if fully implemented, the proposed changes should serve to mitigate the risks identified in Recommendation A95-11.
However, until the new CRM Standards are fully implemented, the risks associated with the safety deficiency identified in Recommendation A95-11 will continue to exist.
Therefore, the response to Recommendation A95-11 is assessed as Satisfactory Intent.
The TSB will continue to monitor the progress of TC's proposed regulatory amendments to mitigate the risks associated with the safety deficiency identified in Recommendation A95-11, and will reassess the deficiency on an annual basis or when otherwise warranted.