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No namewrote:
I'm leaving a few words here just to say Hello ;-) I'm an old friend of Hugh (Mr.Danford) from Norway and got this link from him. I hadn't heard from or spoken to Hugh for years when I tried to look him up on the internet and the first thing I found was commitee hearing. Didn't find his adress at that time, but now I'm in contact with him again. I think what he has done is a noble and courageous thing to do.
All the best to you and your work towards a safer sky. 
Respectfully,
Trond
Jan. 8

DHC2 Widow's space

Quest for Justice and Change in Canadian Civil Aviation
May 15

US Aviation Safety Under Scrutiny: Canada is No Better

Watching the news unfold about the fatal Colgan Air crash in Buffalo this past February, I cannot help but be reminded that all the issues they are discussing are reflected here in the Canadian aviation industry.  Issues of fatigue, pay and training have been long-standing here as well, and only worsened by the world financial crisis.  Knowing that air taxis, feeder airlines and other small aircraft operations will always be the place to get the hours required to move up the “food chain”, one would think that the FAA and TCCA would pay more attention to these sectors. 

My sincere hope is that Canada’s government will learn from the US experience, and insist upon a (quasi-) judicial inquiry into our own system of aviation safety oversight.

 

Updated: 05/15/09 10:59 AM

SPECIAL REPORT: INVESTIGATING FLIGHT 3407

How did complacency turn into catastrophe?

By Michael Beebe and Jerry Zremski

NEWS STAFF REPORTERS

WASHINGTON — Federal investigators wrapped up three days of federal hearings Thursday into the crash of Continental Connection Flight 3407, without answering the question of how the final 30 seconds of the flight went from complacency to catastrophe, as one National Transportation Safety Board member put it.

How did a seemingly normal flight suddenly lose so much speed — from 182 knots to 130 knots — that it caused the air-craft’s stall-warning alarm to sound? And why did the pilots both take actions that experts say only worsened the problem and caused the plane to crash Feb. 12 in Clarence Center, killing 50 people?

Mark V. Rosenker, the acting NTSB chairman, pledged to the families and other loved ones who attended the hearings, or watched on the Internet or in simulcasts in Buffalo and Newark, N. J., where the flight originated, that his agency will find the answers.

“We are going to find out what happened here,” Rosenker said at the end of the hearings, “and I can assure you this will be a comprehensive report, with determination of probable cause, and recommendations will follow that, if implemented, will prevent this from happening again.”

Rosenker’s agency has investigated past fatal accidents, found the cause and made recommendations, only to see the Federal Aviation Administration delay or study them further.

He and fellow panel members grilled the final three witnesses, all FAA executives, about those past recommendations that safety board members say have been ignored.

Rosenker is confident that it won’t happen this time.

He said a Senate hearing into the cause of the crash will take place June 10, the new nominee to head the FAA will face confirmation hearings, and the FAA’s charter is coming up in Congress for renewal. New York’s congressional delegation has pledged to tie all of that into the Flight 3407 investigation.

“I’m optimistic,” Rosenker said. “I think we will get a series of changes because of this public hearing, and the attention we have received in the last three days.”

It was unwanted attention for Colgan Air, the regional carrier that operated Flight 3407; the Airline Pilots Association, the pilots union that just won a contract to represent Colgan pilots six weeks before the crash; and the regional airline industry.

Much of America learned for the first time that regional carriers now make up half of the nation’s airline flights.

Passengers aboard Flight 3407 bought their tickets from Continental Airlines, without knowing that Continental subcontracts the flights to Colgan Air, which is owned by Pinnacle Airlines.

The hearings brought out the low pay scales for regional airlines. Flight 3407’s first officer, Rebecca L. Shaw, Colgan executives testified at the hearings, was paid only $16,000 a year, and at one time had to take a second job at a coffee shop. Colgan later said its average pay for a first officer is $24,000.

How could Shaw, 24, who commuted from her home in Washington State, afford to rent an apartment in Newark on that salary, board member Kathyrn O’Leary Higgins asked.

She obviously couldn’t. To start off her shift, Shaw commuted from Seattle to Memphis, Tenn., on a FedEx red-eye flight, slept for four hours in a pilots lounge, and then caught a flight to Newark on the day of her flight to Buffalo, where it is believed she slept in the crew room.

Fatigue management, a key problem in an industry with 16-hour duty days, took up a large part of the hearings.

Flight 3407’s pilot, Capt. Marvin Renslow, 47, who came to flying as a second career, had to take a job stocking shelves in a Tampa, Fla., supermarket before he got hired at Colgan.

Renslow commuted from Tampa, and there is no record that he had an apartment or that he rented hotel rooms in Newark. It’s unknown where he slept on the night before the flight to Buffalo, but he had logged onto the computer in the Newark crew room at 3 a. m.

Colgan has stressed throughout the hearings that it has an excellent safety record and that its pilots are trained as well as any of the major air carriers.

“We want to know what happened as much as anyone else does and remain committed to do everything we can to prevent future accidents,” Colgan spokesman Joe F. Williams said at the hearing’s close.

“We are totally committed to safety and are determined to work closely with our industry colleagues and regulators to reinforce this primary industry objective.”

It was another rough day of testimony for Colgan and its Flight 3407 pilots Thursday as board member Deborah A. P. Hersman, who seemed to ask the most telling questions during the hearings, questioned a NASA scientist who studies pilot distractions.

“I think the crew went from complacency to catastrophe in 20 seconds,” Hersman said. “It seems like they were discombobulated.”

She said co-pilot Shaw put the airplane’s flaps up, which experts said was the wrong thing to do.

Renslow yoked the control back, causing the nose of the Bombardier Dash 8 Q400 twin-engine turboprop plane to pitch up, instead of putting the nose down to recover from the stall, she said.

“The room’s on fire at this point,” she said to Dr. Robert Key Dismukes of NASA’s Ames Research Center. Wouldn’t it make sense, she said, for aircraft manufacturers to install warnings that the aircraft is losing that much speed that quickly before the “stick shaker” alarm goes off?

“It would be sort of like a fire alarm,” she said. “The stick shaker is more like being in a room on fire.”

Dismukes, who spoke at length about what causes pilots to lose attentiveness, agreed with Hersman that for all the other warnings and chimes in a cockpit, this seems like one that makes sense.

Dismukes told the panel that he has spent 20 years studying such issues as pilot attention and holds pilot licenses from gliders to the 737, so he could appreciate their problems more and experience them firsthand.

The NASA exert also was surprised by the actions of Renslow and Shaw when the stick shaker went off, signaling that the plane was on the verge of a stall because insufficient air was flowing over its wings.

Dismukes said the only way for pilots to react to such emergencies was continual comprehensive training so that when it happens, they can automatically know what to do. Otherwise, he said, it’s like having to consult a book, not doing what needs to be done immediately.

He agreed with questioners who wondered whether stall training for pilots should be done the way it is now. Currently, pilots know they are going to encounter a stall in the simulator, and the element of surprise is gone.

Dismukes also agreed that having pilots encounter stalls when flying on autopilot would much better mimic the sudden terror that Renslow and Shaw experienced when the alarm went off as they approached Buffalo Niagara International Airport.

“Surprise and stress are problematic,” Dismukes said. “Even experienced pilots flail around.”

Dismukes said the pilot and co-pilot of Flight 3407 could have fallen victim to “automation complacency” — that is, putting so much faith in the autopilot that they were not paying enough attention.

“You’re a step removed from physical control of the aircraft,” Dismukes said.

Noting that the period just before landing is “one of the busiest periods in general” for flight crews, Dismukes noted that a lot was happening all at once as Flight 3407 descended toward Buffalo. The control tower was contacting the cockpit just as Renslow and Shaw were preparing for landing, adding one more distraction.

Meanwhile, the plane lost 50 knots of speed in 20 seconds — and the crew did not notice that the plane had decelerated to a dangerous level.

The plane’s stall-warning system activated when it fell to a speed of 130 knots. Sources with knowledge of the Q400 said that when flying a relatively full load in icy conditions, pilots generally would not want to slow the aircraft to much below 140 knots.

“I don’t see any evidence that he [Renslow] understood the situation he was in,” Dismukes said.

Dismukes noted that responding to a stall is much different in real life than it is for pilots training in a simulator.

Pilots have about 3 seconds to respond correctly to the stick shaker, which is far easier for pilots who are expecting a mock stall in training.

“If you’re expecting a stall, 3 seconds is plenty,” Dismukes said. “If you’re not expecting it, the response would be highly variable. Some [pilots] would respond correctly in 3 seconds. A lot would not.”

But safety board member Higgins noted that an earlier stall warning — an illuminated red barber pole — came on but went unnoticed.

“There was a warning,” she said. “It just was not recognized.”

 

 

 

 

 

May 11

Press Release: Air Safety Problems Exposed Online

FOR IMMEDIATE RELEASE

MAY 11, 2009

CANADA

 

Air Safety Problems Exposed Online

 

During Question Period on April 23, the Honorable Rob Merrifield, Secretary of State for Transport, rejected the claims of the NDP Transport Critic, Dennis Bevington, that Canada is not meeting international standards for aviation safety.  Perhaps Mr. Merrifield has been duped by bureaucrats in the same manner as the Canadian travelling public.

 

In addition to evidence provided during extensive Committee hearings held in 2007 over a controversial Bill to amend the Aeronautics Act, further proof was recently aired in a landmark Round Table discussion on Air Safety held at Parliament Hill and hosted by Mr. Bevington.

 

The organizers have now created a new website, www.safeskies.ca, which allows media and members of the public to experience the Round Table: to see and hear the revelations made by pilots, industry insiders, whistleblowers and accident victims.

 

Canadians need to know that despite lessons learned from aviation accidents and related problems in the rail industry, Transport Canada has abandoned them and left their lives in the hands of those responsible for profit margins – a dangerous strategy which is likely to have tragic consequences.”, claims the SafeSkies website.

 

“International Civil Aviation Organization (ICAO) says you absolutely have to retain your traditional oversight and the fact of the matter is, Transport Canada is simply not doing that and has no intention of doing it” states Greg Holbrook, National Chair of the Canadian Federal Pilots Association (CFPA), during his presentation.

 

Apparently the Canadian Public is travelling under a false sense of security.  The major airlines have already been empowered to regulate themselves, and are operating without scrutiny from Transport Canada.  A similar situation in the US resulted in national disaster, thousands of cancelled flights and huge public outcry.  Business aircraft have been governing themselves since 2003 – though enabling regulations were not actually passed until 2005.  Transport Canada’s own audit in 2007 revealed this has created a system plagued with troubling holes.  Air Taxi and Commuter aircraft in Canada have not yet been enabled by regulations to govern themselves, yet Transport Canada is no longer overseeing this major sector of aviation either. 

 

Other Round Table presentations highlighted the systemic problems within Transport Canada, and the known failures which have caused multiple deaths and destroyed lives.

 

An alliance of individuals and industry representatives is now being formed with its prime focus to seek resolution to these issues, hold Transport Canada accountable to the public, and restore Canadian’s faith in air safety.  For information about future developments on these topics, check back with www.safeskies.ca and subscribe to the newsletter.

                      

 

Prepared by

Kirsten Stevens and Kirsten Brazier

 

Advocates for Air Safety

April 25

Majority of Canadian Aircraft Using Outmoded Emerg. Beacons

Majority of aircraft in Canada using outmoded emergency beacons

Alison Auld, THE CANADIAN PRESS

25/04/2009 3:40 PM | Comments (0)

HALIFAX, N.S. - The majority of commercial and private aircraft in Canada are flying with emergency locator beacons that use an outmoded satellite frequency, effectively silencing a lifeline that tells searchers where a plane is if it crashes or needs help.

The international satellite system that monitors the transmitters used to listen to beacons on two frequencies - the digital 406 megahertz and analog 121.5 megahertz beacons.

But as of Feb. 1, it began listening to only the digital emergency frequency.

As a result, the older analog beacons no longer alert search and rescue authorities, leaving the 75 to 85 per cent of helicopters and fixed wing aircraft that haven't made the switch in Canada virtually in the dark if they have an emergency.

"When an accident or a serious incident occurs, that's when they really act like a crew's lifeline to survival," said Carole Smith of the National Search and Rescue Secretariat, a branch of National Defence.

However, Smith says the international satellite system, and Canadian search and rescue centres, are now only listening for the newer beacons.

"Only those digital beacons that operate on a frequency of 406 megahertz will continue to be monitored," she said.

The beacon sends out a signal to the Cospas-Sarsat satellite system alerting authorities that an incident has occurred, automatically sending a location through to rescue authorities to guide them to the crash.

The devices, which can be activated manually or automatically under the force of impact, are mandated for use by Transport Canada on everything from a Cessna to a Boeing 737 and higher.

But the switch to the 406 megahertz frequency is still voluntary while the federal department drafts regulations.

Smith says the 406 digital beacon is an improvement over the older analog version because it provides ground search and rescue officials with more precise co-ordinates of a plane in distress and gives detailed information about the aircraft.

Not adapting a transmitter to use the 406 megahertz beacon means it could take far longer to determine the location of a downed plane.

Last month, a light aircraft still equipped with an analog beacon and affiliated with a training school went down near Fredericton.

Notification of the crash only came from another plane passing overhead and the location co-ordinates were far from where the small aircraft actually went down.

"It did take considerably longer than if that aircraft had a 406 megahertz beacon on board," Smith said. "(With 406 megahertz) search and rescue would have known within minutes that there was a distress and which particular aircraft was in distress."

But owners and operators have been slow to change over, saying there are fundamental, age-old problems with the transmitters that are simply being passed on with the new frequency.

John Davidson of the Civil Air Search and Rescue Association said the emergency locator transmitters have a central design flaw that means they often don't go off.

It has a one-directional gravity switch that won't get activated if it isn't hit at a certain angle when a plane crashes.

"All of the installation factors are still a problem from the original 121.5 system," he said from Winnipeg. "None of the equipment has changed other than to change the frequency and that's the rub - all of the problem sets from the original system are still there."

Critics contend the new system has its own set of deficiencies and will cost up to $4,000 to install.

The new digital system will take about 50 seconds longer to alert search officials of an emergency, in which time an aircraft can sink, turn upside down or catch fire, all of which would prevent a signal from getting out.

The system is mandatory in several countries, but it will likely be years before Canada forces aviators to make the switch.

Draft regulations have been published in the Canada Gazette and are being reviewed, but the government is expected to grant a two-year implementation period once the regulations are brought in.

"We're currently reviewing feedback from stakeholders, looking at all technologies and working on finalizing regulations," said Maryse Durette, a spokeswoman with Transport Canada.

Davidson, whose group represents about 3,500 volunteers involved in search and rescue, said he wants regulators to consider other technologies before mandating the emergency locator transmitters, or ELTs, on the 406 megahertz frequency.

"The industry is saying, 'Why don't we fix it, why don't we get newer technologies out there that monitor airplanes,"' he said. "There are too many dangers of the ELT not working properly."

 
 
April 23

Self-policing by Airlines Stirs Concerns

Self-policing by airlines stirs concerns
Apr 22, 2009 04:30 AM
 
Bruce Campion-Smith

OTTAWA – Ottawa's push to let air carriers police the safety of their own operations marks a "dismantling" of regulatory oversight in this country and is a disaster in the making, a Parliament Hill forum has heard.

In sometimes moving testimony, pilots, union officials and relatives of air crash victims yesterday gave a damning condemnation of Transport Canada's ongoing move to shift responsibility for safety onto the airlines and air taxi operators.

While federal officials have claimed it will add a layer of scrutiny, it comes as Transport Canada is cutting back its own audits and inspections of aviation companies, the forum was told.

"This is a plan about making it look good ... in fact, the actual activities and actions of oversight will not occur," said Greg Holbrook, national chair of the Canadian Federal Pilots Association, whose ranks include pilot inspectors with Transport Canada.

The federal government has been introducing "safety management system," to sectors of the aviation industry, a process that lets individual firms rather than federal inspectors oversee their operations.

New Air Safety System Doesn't Meet Standards

New airline safety system doesn't meet standards: Pilots

 

 
By Sarah Schmidt, Canwest News Service
April 22, 2009 
 

OTTAWA — Transport Canada pilots charged with inspecting the safety practices of airline operators said on Wednesday that Canada is no longer meeting international aviation standards because the government has downloaded responsibility for safety oversight to airlines.

Greg Holbrook, chairman of the federal pilots association, made the assessment when he got behind a call from the New Democrats for an investigation into Transport Canada's implementation of its new inspection model called Safety Management System (SMS).

An international first in civil aviation, SMS requires airlines to develop and oversee its own system of safety checks.

Holbrook said Transport Canada inspectors are no longer conducting traditional audits and inspections to make sure airlines are meeting all regulatory requirements, putting Canada offside with the requirements of the United Nation's International Civil Aviation Organization (ICAO), to which Canada has agreed to conform as a contracting state.

"ICAO does not advocate the allowance of audits and inspections to be eliminated from the program and let operators check things themselves. They require clearly a balanced approach. It's quite clear to us that this is not happening here in Canada," said Holbrook.

Standing alongside NDP transport critic Dennis Bevington and international trade critic Peter Julian at a news conference on Parliament Hill, Holbrook said Transport Canada inspectors only "examine the air operator's safety management system to see if their system meets the requirements. It will not check for regulatory compliance."

This causes pilot inspectors "great concern" because they're only doing "one tenet of what is required by international aviation standards. Transport Canada is doing half the program and trying to present it as an additional layer, which it clearly is not," said Holbrook.

"We would request that the parliamentarians advocate a real sober second think of this whole initiative that seems to be proceeding at a juggernaut pace."

Transport Canada spokesman Patrick Charette says it's "incorrect to say that safety management systems remove government oversight. Rather, they are a proactive tool to complement our inspection regime."

Charette said "SMS targets 'root causes' to prevent problems before they happen," and that it instils more accountability and a culture of safety throughout the industry. "The fact is inspections continue as do our efforts to ensure the highest possible levels of safety for Canadians," he added.

The transition to SMS, which has already resulted in the elimination of Transport Canada's national and regional auditing programs in civil aviation, has been fully implemented at Canada's large airlines. Its full transition across all sectors of civil aviation is expected to be complete in 2010.

After instituting SMS for rail transportation in 2001, the Liberal government at the time, under the stewardship of Transport Minister David Collenette, expanded the oversight system to civil aviation, to be phased in over time.

Bevington said now is the time to put on the brakes and investigate federal civil aviation practices.

"There's a disaster in the making, and I don't want to alarm people, the flying pubic, but all of us, whether we fly in air taxis, charter aircraft, or whether we deal with scheduled air carriers, want to ensure that the best possible systems are in place to protect our safety and the safety of our loved ones. This is not happening, and in fact, it's degrading everyday," said the NDP's transportation critic.

The Canada Safety Council and Canadians for Accountability were also on hand to bolster the case for a public probe, along with Kirsten Stevens of Campbell River, B.C; her husband was one of four loggers who died after their float plane crashed off Vancouver Island in February 2005.

Ian Bron, spokesman for Canadians for Accountability and the former chief of aviation security regulations at Transport Canada, said SMS fails the "accountability test," pointing to transparency problems and concerns over whistleblower protection.

Bron said Transport Canada is not equipped to "lead a new and untested initiative in which it expects a completely different code of conduct from the airline industry. We believe if SMS does go forward, more lives will be lost to preventable accidents."

Emile Therien of the Canada Safety Council added, "aviation safety in this country is a disaster in the making."

Auditor General Sheila Fraser last year criticized the implementation of SMS in her audit of Transport Canada's oversight of air-transportation safety.

In planning for the transition and shifting resources from traditional oversight activities in its civil aviation branch, Fraser found the department did not document risks, such as the impact of the transition on oversight of safety. Transport Canada also failed to identify how many inspectors and engineers it needs during and after the transition, Fraser found.

© Copyright (c) The Calgary Herald
 
March 16

Ottawa Faces Scrutiny Over Air Safety Regulations

Ottawa faces scrutiny over air safety regulations

Updated Sun. Mar. 15 2009 10:31 PM ET

CTV.ca News Staff

A prominent public official warns that new guidelines for airlines could erode safety procedures and lead to a major domestic aviation disaster in the near future.

Virgil Moshansky, the retired judge who probed the deadly 1989 Dryden air crash, said the so-called safety management system (SMS) guidelines minimize federal inspections and essentially let the airline industry regulate itself.

"We're leaving it up to the airlines, the air carriers themselves, to set their own safety protocols and to enforce them ... on themselves," said Moshansky.

"It's like a traffic cop saying to a motorist, 'If you speed -- let me know, and I will send you a ticket.'"

The comments come as the Transportation Safety Board probes a deadly helicopter crash last week off the coast of Newfoundland which killed 17 people.

In short, Moshansky said that SMS allegedly results in fewer federal inspectors keeping watch over Canada's airlines and an overall deterioration of safety standards in the skies.

In 1989, Moshansky's probe into the Dryden air crash blamed the crash partly on safety deregulation and a paucity of federal inspectors.

Two decades later, Moshansky said that safety standards in the commercial Canadian aviation industry are actually worse than they were before the Dryden tragedy.

"Very serious airline captains and senior maintenance engineers (and) aviation experts are trumpeting the fact that we are in a very serious crisis," he said.

Meanwhile, Ottawa maintains that SMS will in fact improve standards and make airline travel in Canada safer.

In an email to CTV News, Transport Minister John Baird said that SMS "does not remove government oversight and inspections -- rather, it adds another layer of responsibility on the part of the operator."

However, many remain unconvinced of the plan's efficacy.

"Go and ask certain pilots at Air Canada what they think of it, and they will tell you they think it stinks," said Emile Therien of the Canada Safety Council.

With reports from CTV's Graham Richardson


With video: http://watch.ctv.ca/news/Redirect/?ClipId=150337  

Does the FAA’s oversight of US carriers have a broken link?

Safety chain
By Mary Kirby 
Flightglobal.com

Is a broken link in the FAA's oversight of US carriers becoming apparent as the agency implements a new system? Does the FAA rely too much on the industry?

Over the past decade there has been a paradigm shift in the way the US Federal Aviation Administration conducts oversight of airlines. In 1998 the agency launched its data-driven, risk-based Air Transportation Oversight System (ATOS) with the 10 largest carriers in service at the time. As of December 2007, all Part 121 operators have been brought under the system, which has a five-year implementation schedule.

But while many government and industry stakeholders see ATOS as an improvement over the FAA's past safety oversight protocol, cracks in the system are emerging. This was underscored last year by the highly publicised breakdown in the FAA's oversight of Southwest Airlines, which resulted in several congressional hearings that highlighted weaknesses in ATOS. Some top legislators feared that the FAA had succumbed to excessively "cosy" relationships with carriers.

Those fears have not been fully quelled. Following the hearings, an independent review team tasked by the transportation secretary with studying the FAA's approach to safety, found that ATOS "still needs further attention for it to live up to its promise".

Additionally, the House of Representatives, in its latest mark-up of FAA reauthorisation legislation, directs the FAA to increase the number of aviation safety inspectors, create an independent "Aviation Safety Whistleblower Investigation Office" and mandate a two-year "post-service" cooling-off period after inspectors leave the FAA.

If the legislation is passed, principal supervisory inspectors would be rotated between airline oversight offices every five years and monthly reviews of the ATOS database would be required "to ensure that trends in regulatory compliance are identified and appropriate corrective actions taken".

The Department of Transportation's watchdog, the Office of the Inspector General, is also conducting audits to, among other things, examine the FAA's implementation of ATOS.

Courtney Scott, public and legislative affairs specialist for the OIG office of legal, legislative and external affairs, says the OIG is "not in a position to discuss what we may or may not be finding or when we plan to issue a report".

CRACKS IN THE ARMOUR

However, at least one former FAA inspector - who is not linked to the Southwest case - intends to alert regulators to what he believes is a serious misapplication of ATOS, specifically regarding the Safety Attribute Inspection (SAI) data collection tool.

Unlike the Element Performance Inspection (EPI) portion of ATOS, which is designed to inspect the operational performance of a particular airline function, SAI is intended to focus on the design and documentation of various air carrier programmes.

Once completed, the inspector enters the results of both EPI and SAI inspections in the ATOS database, which is used by the agency for predictive analysis in hopes of preventing future incidents and accidents.

"The SAIs cover 106 air carrier programmes, resulting in approximately 10,000 inspection entries. Some of the SAIs have 200-300 pages of questions and they are so specific that the inspector must have an in-depth familiarity with the carrier's programme. Each SAI inspection question must be answered by 'yes' or 'no' and be followed by a specific manual reference(s) from one or more of the air carrier's manuals," explains Ladd Lewis, who spent 20 years at the FAA, including almost five years for the ATOS Program Office.

Now head of a consulting company specialising in regulatory and safety programme support for small airlines, Lewis claims some FAA offices have begun to shift the responsibility of SAI completion on to the carriers.

He likens the practice to the following scenario. "Remember the recent peanut factory fiasco, where salmonella was discovered? Imagine the public's outrage if it was the practice of the Department of Agriculture to send the inspection forms to the factory, have them fill them out and send them back, and then the department would load that information into their computer."

Lewis says that when he retired from the FAA and became a contractor, he was astounded "at the response I got from the FAA when I pointed out that their guidance said the SAIs are not a list of questions to be given to the carriers to respond to.

"And yet, they are," he claims, "and if the carrier questions it, they [local FAA offices] tell the carriers it will delay the programme, such as adding a new aircraft or flight programme, etc. Therefore, carriers do not want to speak out against the process."

Lewis is not alone in his concerns. The Professional Aviation Safety Specialists (PASS) union, which represents 11,000 FAA and Department of Defense employees, has made known its fear that the FAA has allowed ATOS to be used as a way to shift the burden of oversight from the agency to the industry.

"I think ATOS is a useful tool for an inspector, and then he or she can prioritise their duties in accordance with the data they analyse. The problem is that it is being used to essentially replace inspectors. The agency has relied on the industry for data to put into ATOS, and if the data is coming from the people you oversee, it's going to be hard to find too many faults," says PASS president Tom Brantley.

In short, says Brantley, the FAA "is relying too much on the industry to police itself".

When asked if some offices are shifting the burden of ATOS responsibility to airlines, the FAA says: "The burden of carrying out ATOS functions falls entirely on FAA inspectors, unless air carriers voluntarily agree to participate in certain types of ATOS inspections. ATOS is designed to provide an independent assessment of a carrier's compliance with the regulations and of its capacity to operate safely."

The FAA says data provided by an airline during a collaboratively conducted design assessment "must be validated by FAA inspectors" before entering the ATOS database.

It also says carriers are not required to use ATOS data collection tools to provide information when they apply to expand their scope. "Such use of ATOS data collection tools is voluntary. An air carrier that feels threatened, unfairly treated, or who objects to ATOS in general, is encouraged to use FAA's Consistency and Standardization Initiative to elevate its complaint to higher levels in the FAA."

Former FAA associate administrator for aviation safety Nicholas Sabatini further emphasises the point. He says: "What has got to be understood is this - it is the air carrier's responsibility to comply with the regulations and to always be able to demonstrate compliance. In a safety system, what gives FAA great confidence in the air carrier is knowing that we have a certified entity that is proactive in their safety risk management."

He adds: "Air carriers must have in place their own auditing system. So it should not be a burden on them. They are expected to ascertain system performance. They should be using the same tools the FAA uses."

A BETTER SHIELD

Before development of ATOS, the FAA used a less comprehensive reporting format known as the Program Tracking and Reporting System (PTRS) to report inspection findings.

A former long-time FAA inspector, Gary Perkins, now heads the Aviation Safety Oversight Group, one of several consulting firms qualified by the FAA to assist carrier applicants in preparing for Part 121 certification. He believes ATOS is invaluable in assisting carriers with the start-up process.

"I was there [at the FAA] during a time when we certificated airlines and all we expected them to do was to have compliance with the regulations in their manuals. But you've got to understand that a lot of that compliance was purely policy. It didn't tell people how to do the job, it was just policy, and even the biggest airlines had that policy. From 1980 until 1998 [when ATOS was introduced], you could still find new airlines starting up with old Braniff and Pan Am manuals," says Perkins.

Perkins questions why a carrier would see ATOS as a burden. "You should be self-auditing already. The burden you are seeing is that they do not want to go back and look at systems that were not set up well to see if they can identify latent failures that are risk items."

Bill Bottoms, executive vice-president and one of the principals at aviation consultancy Team SAI, agrees with Perkins. "ATOS is the creation of a system safety approach. That is what it's called and what it is. It forces the operator to look at the interfaces that take place throughout all aspects of their operation and make sure those interfaces are compatible and complementary and, as such, lead to the most optimum safe environment for the carrier.

"With that said, the intent of pushing the carrier toward more ATOS standards is to push them deep into their systems to make their safety process a compatible system. So I think that placing the burden of compliance on the carrier, and the burden of satisfying the requirements, is indeed appropriate."

Lewis agrees carriers have an obligation to conduct their operations within the regulations, and that includes auditing their own processes and developing their own changes. But, he says: "The FAA has a statutory obligation to conduct inspections to insure the carrier is doing that and not use carrier-furnished inspection data to meet this obligation."

He warns: "Unless the FAA takes back their SAI inspection responsibility, they may find themselves explaining to Congress why it's such a good idea to have the air carrier furnish inspection data."

A breakdown in the FAA's oversight of Southwest Airlines resulted in congressional hearings.

March 06

About-face at Transport Canada on safety issue

About-face at Transport Canada on safety issue

No agreements on confidentiality
 
By FRANCOIS SHALOM,
The Gazette

March 6, 2009
 

Transport Canada officials reversed course this week on a controversial aviation safety issue. The department now says no Canadian airline asked Transport Canada aircraft inspectors to sign confidentiality agreements about potential safety problems "in the last several years."

This contradicts a statement by Transport Canada spokesperson Maryse Durette, who said in an email to a Canwest News Services reporter last week that "Transport Canada has only recently been made aware of such requests being made and that agreements may have been signed (by TC inspectors). We have clarified with (airlines) where the agreements were requested that they are not required."

"Of course, no such (confidentiality) request would be acceptable," Chris Day, press attaché to Transport Minister John Baird, said in a telephone interview this week.

Asked about the discrepancy in a series of brief discussions, Durette said simply: "when I wrote to (Canwest), the information I had was current." She would not expand on that statement or say what had changed in the intervening time.

The issue is particularly sensitive, coming in the middle of the implementation over several years of a new safety management system (SMS) for the Canadian airline industry.

There's even a dispute as to whether the new system itself is a de facto form of deregulation or a reinforcement of safety procedures benefiting the travelling public.

Day said that the SMS is "an added layer of protection" for flyers. But the Union of Canadian Transportation Employees, which represents Transport Canada inspectors, notes that one of the provisions of the system calls for airlines to conduct safety inspection of their aircraft themselves rather than by inspectors, as has been the case traditionally.

UCTE national vice-president Kerry Williams disputed Day's assertion. "It is definitely not an additional layer of safety, it's a totally unproven system. It's based on what the airlines tell the regulator about their own operations."

Day countered that the airlines are bound by exacting regulations and stringent reporting standards.

"Given a choice between commercial and safety considerations, we will always opt for safety," Day said.

But Williams compared aviation regulations with the recent listeria outbreak in the food business, saying that Canadians would be shocked to find out that flying safety procedures are conducted by the airlines rather than by the national regulator.

"Who in the heck knew they weren't inspecting our meat?" Williams asked. "We commissioned a survey by Praxicus - Stephen Harper's polling firm - which polled 800 people across the country between Jan. 2 and 5, and 80 per cent were against airlines being the sole inspector of airplanes. Most Canadians don't know this is happening."

WestJet Airlines spokes-person Richard Bartrem did not return calls. Air Canada spokesperson Isabelle Arthur said: "(SMS) is an industry-wide initiative" and referred questions to the umbrella group representing Canada's commercial carriers, the National Airlines Council of Canada. NACC spokesperson Brigitte Hébert did not return more than a dozen calls seeking comments and explanations.

But one U.S. aviation safety consultant said that airlines asking government inspectors to sign confidentiality agreements is unheard of in the U.S. - and dangerous.

"The job of the regulator is not to work with the airlines, their job is to ensure public safety," said Jeffrey Roy, an aviation safety consultant in Longmont, Colo. He added that in his 21 years as an inspector for the U.S. Federal Aviation Administration, "I was never asked to sign such an agreement and I never encountered anyone who was."

In fact, Roy says that asking for confidentiality smacks of the backsliding in safety standards that occurred in the U.S. airline industry as deregulation was in vogue, and sternly warned against following this example.

"Last year, we had the Southwest and American (Airlines) and other situations, where incidents came to light showing that (FAA) inspectors had become far too cozy with the airlines. The FAA was not getting enough information out to the public and were letting things slide. That coziness is what you want to prevent."

Christine Collins, president of the UTCE, questioned Transport Canada's credibility on this issue, "saying one thing one week and another the next."

While the department still has nominal oversight responsibility, she said that "there is total confusion in practical terms. Are inspectors inspecting or they box-tickers, just there to (rubberstamp the inspection) checklists filled in by the airlines?"

Proposed amendments to legislation last year would have imposed a total ban on air safety reports, but the amendments died along with the tabled legislation when last year's federal election was called.

fshalom@thegazette.canwest.com

© Copyright (c) The Montreal Gazette

The Montreal Gazette

February 24

Confidentiality agreements requested by some airlines before inspections

 
 
By Sarah Schmidt, Canwest News ServiceFebruary 24, 2009 4:02 PM
 
 
Transport Canada confirmed Tuesday that some of the companies approached government inspectors to sign confidentiality agreements to ensure they do not disclose any details of their safety records as part of the SMS assessment process.
 

Transport Canada confirmed Tuesday that some of the companies approached government inspectors to sign confidentiality agreements to ensure they do not disclose any details of their safety records as part of the SMS assessment process.

Photograph by: Todd Korol, Reuters

OTTAWA — Some of Canada's large commercial airlines required government inspectors to sign confidentiality agreements to comb over company documents to assess a controversial new oversight system, Canwest News Service has learned.

Over the coming year, inspectors will be conducting in-depth assessments of the safety management systems (SMS) at Canada's large airlines, including Air Canada, WestJet, Air Transat, Porter Airlines and Skyservice, among others. The new safety system — a first in civil aviation — puts more onus on airlines in managing safety risks in their operations, and is now fully phased in at Canada's large commercial carriers.

Transport Canada confirmed Tuesday that some of the companies approached government inspectors to sign confidentiality agreements to ensure they do not disclose any details of their safety records as part of the SMS assessment process.

"Transport Canada has only recently been made aware of such requests being made and that agreements may have been signed," a departmental spokesperson said in a statement.

The department declined to name the airlines. It also refused to say how many confidentiality agreements have been signed, but a departmental source familiar with the process said the agreements were the "first order of business" in at least some instances.

Transport Canada would only say it has "clarified with the operator where the agreements were requested that they are not required." The department declined to elaborate.

News of the confidentiality agreements come a year after the Canadian Newspaper Association and Canadian Union of Public Employees complained about proposed amendments to the aeronautics and access to information acts that would have resulted in a sweeping ban on the release of company reports of air safety problems.

The legislation died last fall when the federal election was called.

David Gollop, senior vice-president of policy at the newspaper association, says confidentiality agreements are the latest tool used by commercial airlines to shield them from public scrutiny.

"There is a very strong feeling in the airline industry that the public needs to be protected from information that might cause panic or disquiet or prejudice the competitive advantage of one operator or another."

The problem is Transport Canada "is on side with this idea that such information should remain secret," said Gollop.

"Why would a regulator that is empowered by the people of Canada to have some sort of oversight make that oversight conditional on the prerequisites of the airline industry? That I just don't understand."

"We're not authorities on air safety. All we care about is the public should be informed about what goes on in the sky. All of us are passengers and you can see by the crash in Buffalo, we live under these things."

Air Canada and WestJet referred all questions about confidentiality agreements to the National Airlines Council of Canada, a newly created lobby group representing the country's four largest airlines — Air Canada, Air Canada Jazz, Air Transat and WestJet.

The council's director, Brigitte Hebert, declined to say which members required confidentiality agreements, but said the principle of confidentiality is important to promote transparency with the regulator.

"By definition, and as was always the case in the past with regard to safety management, SMS implementation is based on co-operation and it entails the greatest transparency between the carrier and Transport Canada. At the same time, it is a key tenet of the system that the specifics of the SMS process of any particular carrier are not to become public, in order to encourage transparency and foster safety. The system is — and has always been — based on trust, transparency and confidentiality," she said in a statement.

Richard Balnis, a researcher at CUPE, which represents about 8,000 flight attendants at some of the country's largest carriers, including Air Canada, CanJet and First Air, said the council is engaged in "classic doublespeak."

"What it means is unbridled secrecy to hide their safety problems from their workers and the travelling public who have the right to make an informed choice about the airlines they select," Balnis said.

The transition to SMS, which already has resulted in the elimination of Transport Canada's national and regional auditing programs in civil aviation, is expected to be complete in 2010 for all sectors of civil aviation.

The transition has not been smooth, according to the Auditor General Sheila Fraser's critique last year of Transport Canada's oversight of air-transportation safety.

In planning for the transition and shifting resources from traditional oversight activities in its civil aviation branch, Fraser found the department did not document risks, such as the impact of the transition on oversight of safety. Transport Canada also failed to identify how many inspectors and engineers it needs during and after the transition, Fraser found.

DOT, FAA sued in bid to force air safety changes

DOT, FAA sued in bid to force air safety changes

By DAVID PORTER – 24 minutes ago

NEWARK, N.J. (AP) — Airline safety advocates filed a lawsuit Tuesday to force the U.S. Department of Transportation to adopt long-standing safety recommendations in the wake of a deadly plane crash in New York earlier this month.

The complaint, brought by Gail Dunham, executive director of the National Air Disaster Alliance/Foundation, was filed in U.S. District Court in Washington, D.C., and names Department of Transportation Secretary Ray H. LaHood and Lynne A. Osmus, acting administrator for the Federal Aviation Administration.

Dunham's group says the government is moving too slowly on improving air safety.

The lawsuit seeks to force the government to approve safety measures recommended by the National Transportation Safety Board as far back as the mid-1990s.

The suit accuses the DOT and FAA of continuing to "shirk their duties to the traveling public" by not doing so.

The DOT oversees the FAA, which has the power to put new safety measures in place. The NTSB is an independent investigative body.

Listed in the lawsuit are recommendations made in 1996 that focus on aircraft performance in icing conditions, spurred by the 1994 crash of an American Eagle flight in Roselawn, Ind., that killed 68 people.

Icing has been cited by NTSB investigators as a factor in the crash of Continental Connection Flight 3407 — a twin turboprop similar to the American Eagle plane — in Clarence, N.Y., on Feb. 12, in which all 49 people on board and one person on the ground were killed. The investigation is expected to take a year or more to determine the cause of the crash.

Dunham was traveling and unavailable Tuesday, but representatives of the group provided details of the lawsuit at a news conference near Newark Liberty International Airport, where Flight 3407 originated.

"We know from experience that holding government accountable and putting the light of sunshine of public disclosure on these pending measures is perhaps the best — and in some cases the only — way to get the necessary changes that we need," said attorney and former DOT Inspector General Mary Schiavo, a frequent critic of the FAA who is representing Dunham.

Laura Brown, a spokeswoman for the FAA, did not immediately respond to a request for comment Tuesday. In an interview with The Associated Press last week, Brown noted that the agency has issued more than 100 safety directives since 1994 requiring specific actions related to icing for existing aircraft.

The NTSB blamed the 1994 American Eagle crash partly on ice accumulated on the plane's wings, and recommended in 1996 that testing requirements for flight certification of all turboprop planes be adjusted to include the specific kind of icing conditions in the Roselawn crash.

The board also recommended that turboprop planes already in use when the testing requirements were in place should be retested and, if necessary, redesigned. But more than 12 years later, those recommendations remain on a "most wanted list" kept by the NTSB of issues it says the FAA has dragged its feet on.

Since the American Eagle crash, the NTSB has partly blamed the FAA's inaction on icing issues for the crash of a turboprop operated by Comair in Monroe, Mich., in 1997 that killed 29 people and a 2005 crash of a Cessna Citation business jet in Pueblo, Colo., in which eight people died.

"We don't know what caused the crash of Continental Connection 3407, but certainly we can say that the NTSB has been recommending that they pass these lessons learned on to operators as they go along," said Don McCune Jr., a retired airline pilot and attorney for a South Carolina-based aviation law firm.

Dunham's lawsuit also seeks to force the FAA to take action on runway safety recommendations that the NTSB has made, such as installing "moving map" displays in all cockpits to alert pilots if another plane is attempting a takeoff from the wrong runway.

The FAA has undertaken several initiatives in recent years to boost runway safety, but a General Accounting Office report last fall rated the risk of runway collisions "still high."

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February 21

Kirsten Stevens: Aviation Safety Advocate (Part 1)

 

Quote

Talking about YouTube - Kirsten Stevens: Aviation Safety Advocate (Part 1)
  
February 11

FAA Whistleblower Office Proposed - Will Transport Canada Take the Hint?

The US House Transportation and Infrastructure Committee will hold a hearing today on the proposed creation of a Whistleblower Office to investigate complaints from both FAA and private sector employees.
 
One cannot help but hope that when the Canadian Bill C-7, An Act to Amend the Aeronautics Act and to make Consequential Amendments to Other Acts, is re-introduced in Parliament, that a hint will be taken from what is happening down south.  Canadian calls for a Whistleblower amendment need to be heard.
 
FAA whistleblower office proposed in House bill
By REBECCA NEAL
February 10, 2009


A House bill to reauthorize the Federal Aviation Administration calls for the creation of a whistleblower office to encourage reports of unsafe practices.

The four-year reauthorization bill, introduced Monday, would create an independent Aviation Safety Whistleblower Investigation Office within FAA. The office would receive safety complaints and information from FAA and private-sector employees, investigate the complaints and recommend action to FAA.


In 2008, two FAA employee whistleblowers who reported maintenance problems at Southwest Airlines told the House Transportation and Infrastructure Committee that supervisors ignored their complaints for years and that their jobs were threatened.

HR 915, the 2009 FAA Reauthorization Act, requires FAA to clarify to airlinesthat the agency’s customers are airline passengers, not the airlines or related companies. And FAA must notify airlines and other companies it regulates that they do not have the right to choose which FAA employees will conduct their inspections, sometimes a problem in the past.


In addition, the bill requires FAA inspectors who leave the agency take a two-year “cooling off” period before returning to lobby or represent companies they used to inspect.

The bill would authorize about $70 billion for fiscal 2009 through 2012, including:

• $38.9 billion for FAA operations.
• $16.2 billion for the airport improvement program.
• $13.4 billion for FAA facilities and equipment.
• $1.3 billion for research, engineering and development.

The bill includes funding to speed up implementation of the Next Generation Air Transportation System, a system to modernize air traffic control and relieve congestion in the skies.

FAA’s authorization was scheduled to expire in September 2007, but a series of extensions kept the agency running. The current extension expires at the end of March.

HR 915 is virtually identical to a previous version of the bill, HR 2881, introduced in 2007. That bill passed the House but stalled in the Senate.

Rep. James Oberstar, D-Minn., chairman of the House Transportation and Infrastructure Committee, said in a statement that he’s hopeful the bill will pass.
“We have a new president and a new Congress,” he said. “This time we’ll get the job done.”

The bill is sponsored by Oberstar and Jerry Costello, D-Ill., chairman of the subcommittee on aviation.

The subcommittee will hold a hearing on the bill Wednesday.
FAA whistleblower office proposed in House bill - Federal news, government operations, agency management, pay & benefits - FederalTimes.com
December 05

Corporate "Non-punitive" Whistleblower Programs?

On December 5th, 2008, USA Today reported “Three Airlines Drop Self-Reporting Safety Program”.  As unions charge “that the airlines have gone back on their word and unfairly punished pilots who voluntarily disclosed problems”, this does not bode well for the Aviation Safety Action Program (ASAP). 

 

In 1977, the Washington based Institute for Policy Studies launched the Government Accountability Project (GAP) in an effort to support individuals who come forward, risking their jobs and careers, by challenging wrongdoings for the benefit of public safety.  The following is an excerpt from “The Whistleblower’s Survival Guide:  Courage Without Martyrdom”, first printed in 1997.

 

“Structurally, corporate voluntary disclosure programs are vulnerable to the now-familiar conflict of interest inherent when an institution is responsible for disclosing its own misconduct.  To illustrate, the investigations often are conducted by attorneys whose professional duty is to the client corporation – rather than to the public.  The same attorney who interviews whistleblowers and serves as a liaison between the corporation and the government during a voluntary disclosure may later act as counsel for the defense in the event of enforcement action.

 

As a result, voluntary disclosure programs have failed to serve as an effective substitute for external oversight, and too often serve as a shield for liability.”

 

In Canada, this program is an integral part of “Safety Management Systems”, and it is working its way into Transport Canada’s regulatory framework.  Despite many years worth of research, government is not recognizing that inadequate protection from repercussions force whistleblowers into silence.

 

“The GAP has identified six basic principles that we believe are needed for any meaningful system of whistleblower protection and corporate and government accountability.  Whistleblowers must:

 

1.        Have a legal right to protection against discrimination for challenging illegality or violations of the public trust through lawful disclosures, without having to obtain advance permission, as well as the same protection for refusing to violate the law;

2.       Have access to courts in which the decisionmakers have judicial independence from the political process, and be entitled to a jury trial;

3.       Have remedies that hold individual harassers personally liable and subject to discipline, so that an employer or supervisor has something to lose by retaliating;

4.       Gain access to legal shields for following government or professional codes of ethics;

5.       Have the ability to go on the attack against lawlessness by restoring citizen standing to challenge fraud and enforce the law; and

6.       Restore substantive and procedural due process rights for all violations of constitutional rights, even when the government asserts a conflict with national security.”

 

When will the regulators – both national and international – wake up?  For the safety of our communities, our very lives, we must protect those who seek only to protect us.

December 01

Canadian flyers could face safety risk: insiders

Canadian flyers could face safety risk: insiders

Sarah Schmidt, Canwest News Service
Published: Monday, December 01, 2008


OTTAWA - Industry insiders are concerned with a "number of aspects" of airline oversight in Canada and are worried the government's inability to recruit and retain qualified inspectors is "placing the safety of the flying public at risk," a new survey has found.

And many outside experts have concerns with Transport Canada's move to a self-policing model of oversight, where department inspectors assess company protocols to manage safety risks in their operations instead of doing direct inspections of aircraft, records and personnel. The transition to safety management systems (SMS), which already has resulted in the elimination of Transport Canada's national and regional auditing programs, is expected to be complete in 2010.

Linda Duxbury of Carleton University's Sprott School of Business canvassed the opinion of seven "highly qualified" experts who have worked for many years in the industry but have never worked for Transport Canada.

The interviews were done as part of a larger survey of 276 pilots working as inspectors at Transport Canada and the Transportation Safety Board of Canada, commissioned by the Canadian Federal Pilots Association.

The view of these industry insiders is "representative of those working in the industry as a whole," the survey states. This included people currently employed at Air Canada, West-Jet and Zoom Airlines after working at smaller regional airlines, and working in a variety of roles, including a captain on 737s and A330s and trainers.

"One of the main concerns of the industry pilots that we interviewed was the government's ability to recruit and retain inspectors qualified to ensure the safety of the flying public."

According to the survey, Transport Canada can expect an exodus of its most experienced inspectors in the next seven years.

 
http://www.nationalpost.com/news/canada/story.html?id=1015511
November 30

Air-safety agencies need to co-operate

Air-safety agencies need to co-operate

 

 
November 30, 2008
 
 

Canadians like to think of our air transport services, large and small, as safe and dependable. So it was disturbing to learn, from a Canwest News Service story this month, that the federal government has failed to implement fully half of the air-safety recommendations made by the Transportation Safety Board over the past 10 years.

The story broke after a pair of small-plane crashes just 10 days apart brought Canadians' attention to air safety. Somehow the crew and the three passengers all escaped alive after a med-evac plane crashed in northern Manitoba last Sunday, but seven died and only one survived when an old Grumman Goose crashed on a British Columbia island Nov. 16.

Most people think of "aviation safety" in terms of jetliners, and Canadians can be proud of the safety record of our major airlines. But thousands of smaller aircraft serve the remote and frontier regions of this vast country, and provide pleasure flying and practical commuting nearer the major population centres, as well. Thousands of Canadians put their faith in those kinds of aviation daily. The vast majority of these flights end happily. But everyone involved has a duty to make sure that the highest safety standards are established - and enforced.

That's why it's hard to understand why there's such a gap between what the TSB proposes and what Transport Canada imposes on aircraft operators. Transport Canada has satisfied the board in only 26 of the 53 recommendations made over the past decade. In the other cases, the TSB says, the transport department has not done enough to "substantially reduce or eliminate the safety deficiency."

Take for example a 2006 crash of a single-engine Cessna in commercial service in B.C. The pilot and two passengers died in the crash outside Port Alberni; five other passengers survived. A coroner's report noted that in the U.S., that aircraft would have been forbidden to fly across such terrain, because it lacked a terrain-awareness system. Canada's TSB had previously proposed just such a requirement for this country, and in 2005 Transport Canada had approved the idea but "implementation and compliance have been delayed," the TSB noted with terse bureaucratic blandness. Somebody is going to have to explain why.

The TSB also notes that 10 years after Swissair Flight 111 crashed off the Nova Scotia coast, 18 of the TSB's subsequent 23 recommendations were still "active" this fall. One of these, for example, would require new tests to measure the flammability of insulation materials. The fire that brought down Swissair spread through flammable insulation materials. Again, Transport Canada owes us an explanation of this delay.

Well, what should be the relationship between the TSB and Transport Canada over these issues? There may be reasons not to proceed with TSB suggestions, but if so we're certainly ready to hear them. We believe that many Canadians would feel a lot better about general aviation if the relationship between the two agencies, and the progress of specific safety-related proposals through the bureaucracy, were more open and transparent.

© Copyright (c) The Montreal Gazette
 
November 26

Transport Canada unit restricts media interviews

Transport Canada unit restricts media interviews

Sarah Schmidt ,  Canwest News Service

Published: Wednesday, November 26, 2008

OTTAWA - Facing a barrage of media scrutiny about the state of air transportation safety, the head of Transport Canada's civil aviation unit has told inspectors not to speak to reporters or to the public without clearance so there are no surprises for the new minister of transportation.

The internal correspondence, obtained by Canwest News Service, outlines a push to move to a "zero-surprise environment" to "build confidence" with the newly appointed minister, John Baird.

"(N)o one does interviews with the media unless . . . appropriate approvals are in place," Merlin Preuss, the director general of civil aviation, told staff last week. Technical answers to "ad hoc" technical questions from members of the public also must be vetted, he said.

"We cannot be speaking anywhere where our responses can get into the media without prior approval to speak in accordance with approved lines."

This effort to be "out in front of issues that we anticipate will be attention-getters" came after published reports highlighted some safety gaps in Transport Canada's oversight of air transportation.

Two plane crashes in the span of seven days, involving small aircraft also recently provided focus to the issue of how well Transport Canada's transition to a new self-policing oversight system in civil aviation is proceeding.

Under safety management systems, the department assesses the protocols of companies to manage safety risks in their operations instead of doing direct inspections of aircraft, records and personnel. The transition, which already has resulted in the elimination of Transport Canada's national auditing and regional auditing programs, is expected to be complete in 2010.

Greg Holbrook says the information clampdown is so sweeping it means inspectors can't do their jobs without fear of reprisals.

"When you use language like 'ad hoc' questions, how far does that go? The day-to-day business of our members is answering technical questions with the public and industry," said the national chair of the Canadian Federal Pilots Association, which represents pilot inspectors at Transport Canada.

"What's driving this? Does this government really want to have that close a control on what inspectors do on a daily basis to try and protect safety on behalf of the travelling public? I'm surprised that protecting safety is now a political issue."

© Canwest News Service 2008
 
November 24

Federal government not meeting air-safety recommendations: Analysis

Federal government not meeting air-safety recommendations: Analysis
 
Sarah Schmidt
Canwest News Service

Monday, November 24, 2008

OTTAWA - The federal government has failed to fully implement half the recommendations in the last decade from the Transportation Safety Board (TSB) to fix safety gaps in Canada's air transportation system, according to an analysis by Canwest News Service.

Transport Canada has fully satisfied the board in 26 of the 53 recommendations. In the remaining cases, the government has not taken adequate action to "substantially reduce or eliminate the safety deficiency" for air travellers.

Of the 27 delinquent files, the board has determined Transport Canada's response to be "unsatisfactory" in two cases, because the board has received "inadequate explanations to convince it that the risks are not worth pursuing." Both are in response to recommendations related to the Swiss Air crash off the coast of Nova Scotia in 1998 that killed 229 people.

In 10 cases, Transport Canada has committed to fix the safety deficiencies flagged by the board as far back as March 1999, but has yet to do so. On average, the board warned the government of these deficiencies 76 months ago.

The remaining 15 files remain deficient, because the steps Transport Canada has taken to date will improve safety, but not substantially reduce or eliminate the safety deficiency. The board provided the department with these recommendations, on average, 70 months ago.

The analysis does not include any recommendations made since August 2006, because Transport Canada's responses are not yet publicly available, but some address a long-standing problem previously flagged by the TSB.

Post-impact fires involving small aircraft in otherwise survivable accidents are a "well-known safety concern," the board noted in a safety-issues report dated Aug. 29. 2006, but a "cost-benefit analysis negated the proposed safety measures."

Canwest's analysis of Transport Canada's responses to air-safety recommendations comes as investigators probe two crashes in the span of seven days.

Board investigators were sent Sunday to northern Manitoba after a fire in the cockpit of a small commuter aircraft forced a crash landing. The crew and three passengers on the medevac escaped before the plane exploded.

The board is also investigating a fatal crash off B.C.'s Sunshine Coast on Nov. 16. The crash of a charter aircraft operated by Pacific Coastal Airlines killed the pilot and six passengers when the vintage, amphibious Grumman Goose carrying workers to a hydroelectric project crashed on a small island; one passenger survived.

It was the second crash fatal crash this year for the Vancouver-based airline. On Aug. 3, another Grumman Goose crashed into a mountainside on Vancouver Island, killing the pilot and four passengers; there were two survivors.

The most recent Pacific Coastal crash came just a week after the B.C. coroner's office highlighted Transport Canada's failure to implement a key safety recommendation of the board dating back years.

The B.C. coroner's office probed the deaths of a pilot and two passengers, including a three-year-old boy, after a single-engine Cessna commercial aircraft operated by Sonicblue Airways lost power on a flight from Tofino to Vancouver on Jan. 21, 2006, and crashed near a logging road near Port Alberni. Five passengers survived.

The coroner's report noted that regulations in the United States would not have allowed the aircraft to fly in this area unless it was equipped with a terrain-awareness and warning system. Canada had no such requirement, even though the report noted the safety board had previously recommended the installation of those systems.

Transport Canada approved these equipment requirements in 2005, "however, implementation and compliance have been delayed," the coroner's report stated.

In its January 2008 report, the TSB determined that the lack of equipment enabling the pilot to locate and identify high terrain was one of the contributing factors to the Sonicblue crash.

Department spokesman Patrick Charette said Monday a new terrain-awareness proposal will be ready for industry to review next spring, and, once the new rules come into force, aircraft will have two years to comply.

In cases where files are stalled, Charette said some of the TSB recommendations refer to areas of jurisdiction not exclusive to Transport Canada. And others require changes to aircraft design, which cannot be done without further study, he said.

None of this washes well with Jonathan Huggett, whose 25-year-old son, Edward, died in the pilot's chair of the Sonicblue aircraft.

"Had my son had the terrain-awareness and warning system, it would have said, 'You're too close to the ground, you've got to get out of here.' Had he all the right gear, it was probably a survivable incident," Huggett said in an interview.

Kirsten Stevens points to other examples of unfulfilled safety recommendations.

Her husband, David, was one of five occupants who survived impact and escaped from their float plane, but later died after it crashed on waters near , on Feb. 28, 2005.

Her husband's body was the only one found; autopsy results showed he died of drowning and suffered from extreme hypothermia.

While the TSB did not investigate this crash, the board's analysis of another fatal float plane crash seven months later involving a drowning death highlighted a recommendation in 1994 to require occupants to wear life-jackets while taking off or landing, but noted Transport Canada believed this "provides no tangible and quantifiable safety improvement."

The Nov. 11, 2006, report also cited an aviation safety advisory to Transport Canada dated March 2000, "regarding its concerns regarding the apparent lack of progress among seaplane operators to address the issue of underwater escape."

Another Transport Canada float-plane safety review launched after a series of crashes in 2005 resulted in more recommendations in 2006, but they have not been enacted. The review was "inconclusive," according to internal Transport Canada correspondence dated May 23, 2008.

And senior managers in the civil aviation unit "agreed that, in the absence of a clear way forward, this file would be put on hold in deference to other civil aviation priorities," states the document, released to Stevens under Access to Information.  

"There are so many recommendations and they're not acted on, and people are still dying," said Stevens.

But Charette pointed to fully implemented recommendations, including a new requirement for cockpit voice recorders to have a capacity of at least two hours, up from 30 minutes, and new rules governing runway approaches in poor visibility.

The investigation system

The Transportation Safety Board does not investigate all accidents, but, when it does, Transport Canada must respond within 90 days to any recommendations. The board uses four categories to assess the department's responses - fully satisfactory, satisfactory intent, satisfactory in part and unsatisfactory.

Fully satisfactory: if action taken by Transport Canada will "substantially reduce or eliminate the safety deficiency."

Satisfactory intent: if the planned action when fully implemented will substantially reduce or eliminate the safety deficiency. "However, for the present, the action has not been sufficiently advanced to reduce the risks to transportation safety."

Satisfactory in part: if the planned action or the action taken to date will reduce, but not substantially reduce or eliminate, the deficiency. In these cases, the board continues to follow up to review options to further mitigate risks.

Unsatisfactory: if no action has been taken or proposed that will reduce or eliminate the deficiency. "In the board's view, the safety deficiency will continue to put persons, property or the environment at risk."

In most cases, there is a back-and-forth between the TSB and Transport Canada until the board is either satisfied or concludes the department has no intention of fully implementing the recommendation. In both cases, the file then becomes inactive. Other cases remain active files with a "deficiency" label.

© Canwest News Service 2008
 
November 22

Lives Could Have Already Been Saved

SMALL-PLANE CRASHES

'Lives could have already been saved'

What caused Sunday's deadly crash in B.C.? One of the first assumptions is pilot error - but there could have been more to it than that

ROBERT MATAS

rmatas@globeandmail.com

November 22, 2008

VANCOUVER -- Hugh Danford believes he knows what was in the mind of the pilot of the amphibious Grumman Goose plane as he took off from Vancouver airport on his last flight with the fog rolling in last Sunday morning.

The pilot left in bad weather, got into worse and kept going. The plane crashed less than 20 minutes later, plowing through tree tops and slamming into a hillside on nearby Thormanby Island. The pilot and six passengers were killed. One bewildered passenger survived with severe burns.

Peter McLeod, 53, an Australian, had been with Pacific Coastal Airlines for only nine months. But he had been flying on the West Coast for four years and had more than 13,000 hours on his record. On his final trip, he was taking construction workers to a remote hydroelectric project in the Toba Valley on British Columbia's Sunshine Coast.

Mr. Danford, 61, has about 30 years of experience as a pilot. After beginning his career in Northern Manitoba, he flew small bush planes extensively in Antarctica and the oil fields of northern Africa. He believes Mr. McLeod would have been aware of the risks posed by the weather. Even though the airport cleared the flight for take-off, the pilot would realize the fog could be much worse just around the corner.

"You're flying - they call it 'special VFR [visual flight rules],' " Mr. Danford said, referring to rules that allow pilots of small planes to navigate by looking out the window rather than relying on instruments.

"You're scud-running and you feel safe because you are in a boat, really, a flying boat," Mr. Danford said in an interview from his home in Ottawa. "And you always have that in the back of your mind - I can put this down anywhere. It floats."

Everyone wonders what that guy was thinking when he took off in the fog, Mr. Danford said.

"Well, he was thinking what we all thought when we all lucked out. I figured I had nine lives and then some. That's the kind of flying it is."

But don't jump to conclusions when attributing blame, he quickly added. Look at why the pilot did what he did.

Recalling his experience in Northern Manitoba, Mr. Danford said pilots who fly in marginal circumstances are often under pressure to take the flight. "It was, if you don't take it, the other guy will. And if you do that too often, you don't have a job," Mr. Hanford said.

Looking at only the pilot, the weather or the condition of the aging plane cannot make sense of the accident. "The cause of the accident is no regulatory supervision," Mr. Danford said. No one was watching to ensure that safety regulations were followed, he said.

A week after the crash, investigators from the Transportation Safety Board of Canada have begun looking for answers. TSB spokesman Bill Yearwood said yesterday that investigators took photographs and collected items from the wreckage scene before the RCMP, the coroner and the media went through the site. They are interviewing people while events are fresh in their minds and gathering documents.

The TSB decides whether to dig deep into the cause of an accident only when the initial review indicates that something new can be learned. The Grumman Goose crash was one of those accidents requiring an exhaustive review, Mr. Yearwood said.

A public report of the investigation, possibly with recommendations for changes to improve safety, will be issued once the team discovers "the ultimate source" of the accident, he said. Investigators will also consider whether lack of enforcement of Transport Canada regulations was an issue.

Last weekend's crash evoked troublesome memories for Kirsten Stevens. The TSB decided not to investigate the fatal accident that killed her husband Dave and four others on Feb. 28, 2005. Authorities listed the crash for statistical purposes, but did not pursue what happened.

Ms. Stevens and the families of others killed in the accident could not accept the TSB's response. Ms. Stevens said she believes a closer look at accidents would save lives. "There are recommendations that should have come out of our accident, and if those recommendations had by now been issued, there is a good chance that lives could have already been saved," she said.

Mr. Stevens was on a DeHavilland Beaver float plane with three other passengers when the pilot took off in stormy weather from Campbell River on Vancouver Island. The plane disappeared. Three days later, Mr. Stevens's body washed ashore, but the float plane, the pilot and other passengers have never been found.

The official search for the plane and its passengers stretched into April, 2005. The families of the missing passengers were under the impression that officials had dismissed the accident as the result of bad weather and possible pilot error.

Undeterred by the TSB's refusal to issue a formal report, the families continued the search with the help of friends, neighbours and businesses and located the wreckage in the summer of 2005. They retrieved the fuselage, but not the engine. To the untrained eye, oil on the windscreen and smoke scarring indicated that an engine problem may have precipitated a crash landing.

The TSB investigators disagreed. Finally, in September, 2007, the families' search team pulled up the engine. After another review of the available evidence, investigators concluded no mechanical malfunction had occurred.

Frustrated with the TSB response, the families turned to an outside investigator. He found problems with the plane - illegal replacement parts, inadequate patches on the floats - as well as systemic issues that may have contributed to the accident. Ms. Stevens said she has learned a lot about the workings of the aviation industry since her husband's death.

Numerous recommendations have been made over the years dealing with the safety of the small planes flying into bad weather, but implementation of the changes has been spotty, she said.

Mr. Danford worked for five years at Transport Canada, from 1998 when he started in the enforcement area until he left on sick leave.

A self-proclaimed whistle-blower, he said he was pushed out of the department for allegations that the regulators were not doing their job.

He is now helping out a small but highly vocal group that is making plans to go to Parliament Hill in January to lobby for significant changes in the role of Transport Canada and TSB. "I expect by the time we get there," Mr. Danford said, "some of the families from the latest crash will be with us as well, knocking on some doors."

DANGER IN THE AIR

A job flying in the small planes commonly used as air taxis and for charter flights in British Columbia is almost as dangerous as logging, the deadliest job in the province.

In the past 20 years, the death rate for those flying in a small fixed-wing plane with a pilot and nine or fewer passengers was marginally less than the death rate for logging, according to statistics compiled this week by WorkSafeBC for The Globe and Mail.

The death rate was 28.7 per 10,000 person years of employment in logging, compared to 27.6 per 10,000 person years of employment aboard small planes.

The statistics have varied significantly over the years. The fatality rate for flying in small planes was significantly higher than logging from 1988 to 1997, with the rate for logging at 25.7 per 10,000 person years of employment and the rate for flying at 41.6 per 10,000 person years of employment. It reversed in the following decade as the rate for logging increased significantly. From 1998 to 2007, the death rate in logging was 36.1 per 10,000 person years of employment, compared to 11.1 per 10,000 person years of employment for flying.

The hazards of flying in B.C. are well known: mountainous terrain, difficult weather and remote geography are compounded by pilots with little experience and self-dispatch practices. The variety of activity is also unusual. The smaller planes are used for heli-skiing, heli-logging, fire suppression activities, game hunting and sightseeing as well as air-taxi services.

Increased risks have given B.C. a disproportionate number of the accidents in the country. B.C. accounts for 105 of 507 accidents over the past decade in Canada involving small planes with a pilot and nine or fewer passengers, according to statistics from the Transportation Safety Board of Canada.

The statistics also show that the Grumman Goose, a sturdy Second World War-era plane that has been in two fatal accidents within the past four months, is relatively safe. It flies without computer instrumentation, but has been involved in only four of the 105 accidents reported in B.C. over the past 10 years.

THE FACTS

When the Grumman Goose took off from Vancouver on Sunday, the visibility was less than five kilometres, meaning the pilot had to get special permission from the tower. He got the permission.

TSB SMALL*, COMMERCIAL

PLANE ACCIDENTS BY PROVINCE

Que. 78
Nfld./Lab. 16
N.S. 2
Man. 64
Sask. 29
Alta. 58
B.C. 105
N.B. 3
NWT. 42
Yukon 25
Ont. 64
N.Y. 2
Idaho 1
Nunavut 18
TOTAL 507

*703-air taxis seat nine or fewer

DEATH RATES COMPARED

Over the 20 years, the death rate for flying is just below that of logging - 28.7 per 10,000 person years of employment for logging, compared to 27.6 per 10,000 person years of flying for a living.

Logging Small planes
88-97 25.7 41.6
98-07 36.1 11.1

THE GRUMMAN G-21A

Reportable accidents, in B.C., since 1988

'88 1
'90 1
'91 2
'92 1
'93 1
'94 3
'01 1
'06 1
'08* 2

*as of Nov. 18

TONIA COWAN/THE GLOBE AND MAIL

SOURCE: VANCOUVER AIRPORT; ENVIRONMENT CANADA; WORKSAFEBC-THE WORKER'S COMPENSATION BOARD

November 14

Report on fatal air crash exposes gaps at Transport Canada

 
 
 
Report on fatal air crash exposes gaps at Transport Canada
Sarah Schmidt, Canwest News Service
Published: Wednesday, November 12, 2008
OTTAWA - Transport Canada broke its own rules when it cancelled an audit program just months before a fatal plane crash during its transition to a self-policing civil aviation system.
 
The information was contained in a confidential draft report obtained by Canwest News Service.
 
The Transportation Safety Board's draft investigation report, dated Aug. 1, 2008, documents the events leading up to a Transwest Air (TWA) crash in Sandy Bay, Sask., on Jan. 7, 2007.
 
In addition to finding "repeated" and "routine" regulatory infractions on the part of King Air pilots at the regional airline - to the point where crew were "likely unaware that many were actual policy and procedural deviations" - the board found big gaps in Transport Canada's role as regulator.
 
"Although Transport Canada safety oversight processes identified the existence of supervisory deficiencies within TWA, the extent of the deficiencies was not fully appreciated because of the limitations of the current inspection/audit oversight system."
 
Two flight crew and two emergency medical technicians were aboard a King Air aircraft en route to pick up a patient from the Sandy Bay Health Centre when it crashed into trees near the runway after an aborted landing attempt. The 52-year-old pilot died of his injuries; the other three suffered non-life threatening injuries.
 
The board's findings, related to causes and contributing factors, focus on TWA's deficient supervision of the King Air operation and failures of the crew. But the board also identifies several "findings as to risk" concerning Transport Canada's deficiencies. It's one of three crash reports expected in the coming months to single out the department's failure to provide proper oversight during the implementation of the safety management system (SMS).
 
The system is similar to changes currently being made to Canada's food inspection, where the onus shifts to companies to identify hazards and manage their own risks.
 
The pilot's widow, Debbie Wolsey, is challenging the findings. In her brief to the safety board, she places blame on Transport Canada's failure to properly regulate the company, to which her husband Rick Wolsey voiced concerns about his 24-year-old crew member.
 
"It all ties in to Transport Canada not fulfilling their responsibility in ensuring safety in the aviation industry," Wolsey said in an interview.
 
"I do not want Rick's death to have been worthless. If it has to prove a point in regards to the safety of the aviation industry, so be it," she said.
 
At the time of the crash, TWA was at phase two of SMS implementation, championed for civil aviation under the previous Liberal government after the Grits introduced SMS to the railway industry in 2001. The draft report said TWA was not yet in a position to identify hazards in any proactive way, and Transport Canada was not scheduled to conduct an on-site SMS assessment until April 2007.
 
Noting a challenge at Transport Canada to maintain its regular audit schedule and oversight role during the transition to the new system, the draft report highlights a decision made in June 2006 at a budget meeting of officials in Transport Canada Civil Aviation's Prairie and Northern Region. The decision to cancel a regional audit program "in order to manage workload" without assessing risk was contrary to its own risk-management policies.
 
"Reallocation of resources without assessment of associated risks could result in undetected regulatory non-compliance," the draft report concludes.
 
While "this issue did not contribute to the accident," the board identified it as a risk factor.
 
Meanwhile, because the company's reporting system and SMS were immature, the report found that TWA did not effectively capture and respond to a reported problem of pairing the two pilots together. Both had reported problems about each other.
 
The draft report also found problems with Transport Canada's auditing system.
 
It failed to include a key finding in its January 2006 compliance audit - a concern the company had less control of its La Ronge base, where the crew involved in the crash was based, than its Prince Albert and Saskatoon bases. Transport Canada also failed to conduct an on-site visit to follow up on two aspects of the company's corrective action plan.
 
Instead, TWA's file was closed in August without any visit, and the draft report says a "usability problem" with the corrective-action-plan form means this gap in oversight is likely widespread.
 
Hugh Danford, a former civil aviation inspector at Transport Canada, says the draft report rightly identifies gaps in the regulatory system, but it's wrong to highlight human error and company shortcomings in its findings about causes of the crash.
 
"If you're going to regulate, you should regulate. Putting anybody in charge of the bottom line, of signing people's paycheques, and at the same time ensure safety, is an untenable situation for any human being."
 
And a specialist in civil aviation who has reviewed many crash reports by the Transportation Safety Board said he was surprised to see so many pages in the draft devoted to problems with the implementation of SMS, yet the board only devoted two concluding paragraphs on the matter.
 
Overall, the trend identified in the report reflects a problem with the implementation of the new system, the expert said. SMS was supposed to act as another layer of safety, but "it's been used or abused," allowing Transport Canada to "do less" and "discharge or pass more responsibility to the operators, which reduces the effectiveness" of the government regulator.
 
Transport Canada is aware of problems with the implementation of SMS. In May, the department accepted all key findings of the Auditor General's critique of its oversight of air transportation safety.
 
In planning for the transition and shifting resources from traditional oversight activities, the Auditor General found the department did not document risks, such as the impact of the transition on oversight of safety. Transport Canada also failed to identify how many inspectors and engineers it needs during and after the transition, the auditor general found.
 
In the case of the TWA crash, a separate investigation conducted by Transport Canada, obtained under Access to Information, found the airline contravened two sections of Canada's labour code by failing to provide employees with the instruction, training and supervision to ensure their health and safety at work - as well to ensure its supervisors were adequately trained in health and safety.
 
TWA also planned to produce documents about concerns raised by the pilot and the first officer about each other, but their manager "destroyed all pertinent documentation" before leaving the company after the accident, according to Transport Canada; the draft TSB report also noted that "some of the pilots were aware of a concern that the captain had about the first officer's landings."
 
Canada became the first country in the world to expand safety management systems (SMS) to civil aviation.
 
Under SMS, traditional oversight and auditing activities are reduced while companies put in place a system for managing safety risks linked to their operations. In short, Transport Canada no longer focuses solely on conducting inspections and audits and instead assesses the processes companies have in place for ensuring safety.
 
Implementation in civil aviation is expected to be completed in 2010. Here are the key benchmarks:
 
Effective date of regulations and industry sectors
 
May 2005 - Airline operators and companies that perform maintenance on their aircraft
January 2008 - Principal airports and air-traffic service providers
January 2009 - Other airports
March 2009 - Small operators (including air taxi and community operators) and companies that perform maintenance on their aircraft
September 2009 - Airplane and helicopter flight training units
January 2010 -Companies with delegation from Transport Canada to certify aircraft
December 2010 - Aircraft manufacturers, heliports and water airports
Source: Transport Canada; Report of the Auditor General of Canada, May 2008
The journalist and one of the survivors were interviewed on CBC Radio this morning ... http://www.cbc.ca/morningedition/media/20081114sandybay_47564.ram
November 04

SMS: The Listeriosis of Aviation

In a recent conversation, ex-Transport Canada Civil Aviation inspector Hugh Danford called Safety Management Systems (SMS) "The Listeriosis of Aviation"
 
Interestingly enough, an article in yesterday's Ottawa Citizen seems to be making a similar comparison:
 
The Professional Institute of the Public Service of Canada says swift action is needed following the listeriosis tragedy and a continuing crisis with tainted food and unsafe consumer products.

Réjean Simard, president of the institute's applied science group and scientist at Transport Canada, said the Canadian Food Inspection Agency should learn from the same mistake made 10 years ago in railway and civil aviation, when industry was charged with policing itself.
 
September 02

Critics Slam Transport for switch to SMS

 

Critics slam changes to aircraft safety inspection system

Critics slam Transport Canada's plan to hand more responsibility for safety checks to airlines

Last Updated: Tuesday, September 2, 2008 | 5:10 AM ET

By David McKie CBC News

(Dolores Ochoa/AP) Transport Canada's man in charge of aviation safety doesn't like the term SMS, referring to it as a "buzzword." But Merlin Preuss has nevertheless spent a fair bit of time recently defending the concept, which he says will lead to a more accountable aviation industry — and safer skies. Critics such as retired justice Virgil Moshansky, on the other hand, argue that Transport Canada's Safety Management Systems allows the industry to police itself, which is akin to "putting the fox in charge of the hen house."

So as we move into an era of deregulation for many major industries, who are Canadians to believe?

SMS (Safety Management Systems), the shorthand Transport Canada uses to describe its new approach, makes the aviation industry responsible for implementing systems designed to ensure safe air travel in Canada. Under the concept, the federal department will do fewer direct safety audits of air carriers, instead keeping watch over safety checks done by the airlines themselves.

In a spring report, federal Auditor General Sheila Fraser examined Transport Canada's march toward fully implementing its air safety management system. The report uses the following example to define the safety management system:

"For example, instead of conducting an inspection to assess whether the tires in the aircraft landing gear are sufficiently inflated, Transport Canada will assess whether a company has the systems in place to ensure that the tires are inflated, following up if necessary. The goal is to make companies more accountable for the management of risks. Transport Canada will still be accountable for safety oversight. The department maintains that safety management systems will allow more thorough identification and resolution of potential safety problems, making the transportation system safer."

'I would strongly recommend that the federal government assume a proactive approach to taking the pulse of the aviation safety in this country, before another major air disaster occurs, as is being predicted by many responsible and informed individuals in the aviation industry.'—2007 report by retired judge Virgil Moshansky

SMS is akin to trends in other industrial sectors, such as the food industry. In the wake of a massive meat recall caused by a deadly outbreak of listeriosis in August this year, the Canadian Food Inspection Agency is facing questions about allowing the industry to, in the words of the Agriculture Union of the Public Service Alliance of Canada, "police itself."

Though SMS was introduced in the late 1990s, it was only in 2005 that Transport Canada began asking larger carriers to start developing their own systems. According to the auditor general, the entire airline industry is expected to have safety management systems in place between 2011 and 2013. "Until then, Transport Canada has the task of managing the transition, while continuing its oversight responsibilities," the auditor general's report says.

Assessing SMS

One of the findings after the inquiry into the 1989 crash of an Air Ontario Fokker F-28 jet in Dryden, Ont., in which 24 people died, urged Transport Canada to hire more inspectors. In a 2007 report entitled The Role of the Judiciary in Aviation Safety: The Inside Story and Legacy of Dryden, retired judge Virgil Moshansky, who headed up the Dryden inquiry, repeated a warning that he had issued to parliamentarians months earlier:

"Having regard to the documented systemic problems in the aviation industry which have been surfacing for some time now, I am of the view that, 18 years after the Dryden crash, another wakeup call to Transport Canada is overdue. I would strongly recommend that the federal government assume a proactive approach to taking the pulse of the aviation safety in this country, before another major air disaster occurs, as is being predicted by many responsible and informed individuals in the aviation industry."

Critics like Moshansky argue that Transport Canada is eliminating many of the checks and balances it needs in order to ensure safety, at a time when the department is relying on the industry police itself.

Lack of resources

John Scott, who has been a pilot for 42 years, used to work for the federal aviation safety board as an accident investigator and now speaks for the Retired Airline Pilots Association of Canada. He remembers a time when Transport Canada had more inspectors than it currently employs.

'According to the International Civil Aviation Organization (ICAO), the rapidly expanding aviation industry and the limited resources of oversight authorities make it increasingly difficult to sustain the existing approach to managing safety.'—Auditor General Sheila Fraser

"They would go to airlines, or flight schools, and they would be the ones conducting the tests. They would do the evaluations and they would give you your ticket," Scott said. "Over time, the number of inspectors has continually decreased. I'm not going to say that Transport Canada has abrogated their responsibility, but the responsibility for checking has essentially devolved to the companies."

In her report, the auditor general pointed out that "in 2006, air transport in Canada carried 99 million passengers, up 6 per cent from 2005, and the number is expected to grow 40 per cent from 2006 to 2015. According to the International Civil Aviation Organization (ICAO), the rapidly expanding aviation industry and the limited resources of oversight authorities make it increasingly difficult to sustain the existing approach to managing safety."

During his appearance before Parliament's public accounts committee this summer, Preuss, Transport Canada's director general of civil aviation, was asked about the number of inspectors. He conceded there were 134 vacancies, but offered little elaboration. In an e-mailed response, Transport Canada explained that 15 of those vacancies are engineers — as opposed to inspectors. The department's inspectorate workforce now stands at 737. Taking the vacancies into consideration, Transport Canada is unable to fill 15 per cent of its inspectorate workforce.

Mike Wing, national president of the Union of Canadian Transportation Employees, which represents the civil aviation safety inspectors who work for Transport Canada, said Preuss's testimony shows the number of people conducting inspections is diminishing. That means there will be increased reliance on the industry to monitor itself with little oversight from Transport Canada, Wing said.

Air transport in Canada carried 99 million passengers in 2006, up 6 per cent from 2005, and the number is expected to grow 40 per cent from 2006 to 2015. (Michael Probst/AP)"This is about changing the type of inspection that we do," he said. "We're going to be primarily just taking a look at safety management. There will be much fewer specialists in the system. There will be people trained on SMS and things to look for in safety management systems, but it doesn't mean that those people have got the technical background that the inspectorate has traditionally had to ensure safety."

While Preuss conceded that the number of inspectors Transport Canada will need under SMS is an open question, he categorically denied that his department is abrogating responsibility for safety. Transport Canada will still conduct its own inspections under SMS, but in addition, it will now monitor the industry's safety systems, which are much better than they used to be, he said.

"No, we're not even asking [the industry] to police themselves. We are asking them to identify hazards before they become big problems … and you break a rule, you've created a hazard virtually by definition," Preuss said. "So one of the things we've asked them to do is put a system in place that shows us that yesterday and today and tomorrow, you're in compliance with the current regulations. And that gets inspected, and we have all the enforcement tools we had yesterday and we will apply them — and we have."

However, an internal memo from November 2006 casts some doubt on the vigilance with which the department will monitor the industry. In his paper, The Role of the Judiciary in Aviation Safety, Moshansky sums up that memo: "Transport Canada instructed its aviation inspectors not to initiate any further enforcement investigations into regulatory contraventions and to close all open cases against SMS certificate holders."

Whistleblower protection

Another important check on the system is protection for employees — whether with the airline industry or Transport Canada - who speak out about safety concerns. The Accountability Act offers some protection, and so, too, does bill C-7, the piece of legislation that gives Transport Canada the legal authority it needs to fully implement the security management system. The bill is currently in its third reading before Parliament and has not yet passed into law.

Charlambe "Bobby" Boutris, FAA aviation safety inspector and Boeing 737-700 Partial Program Manager for aircraft maintenance at the Southwest Airlines (SWA) Certificate Management Office (left), testifies on Capitol Hill in Washington on April 3, 2008, before the House Transportation and Infrastructure Committee hearing on FAA safety oversight of airlines. (Lawrence Jackson/AP)In order to get a sense of how important whistleblowers can be, one need only look at the United States and the experiences of Bobby Boutris and Doug Peters. The two inspectors with the U.S. Federal Aviation Administration spoke out publicly about safety concerns at Southwest Airline after unsuccessfully attempting to deal with the problems internally.

In Canada, bill C-7 does offer some protection, although it has no specific whistleblower protection.

"Although whistleblower protection was not introduced, the House [transport] committee agreed to add a number of new provisions to the bill that provide additional protection for employees who provide information under management systems and voluntary reporting process," states a Library of Parliament summary of the progress of bill C-7.

The summary has this to say about the additional protection: "The House committee further clarified under the new section 5.392(3) that a Canadian aviation document holder shall not use information disclosed under the management system in disciplinary proceedings against the employee who disclosed the information unless sanctioned under the management system. It also added section 5.392(4) to protect an employee who disclosed information in good faith under the management system against reprisals, including measures that adversely affect them, the employee's employment, or working conditions, from the Canadian aviation document holder."

Video
  • Doug Peters testifies at an FAA hearing about reaction to his whistleblowing activity (1:52).
  • Bobby Boutris on discrepancies he discovered with safety compliance reporting by the airline industry (8:32).

As far as Transport Canada's director of policy and regulatory services, Franz Reinhardt, is concerned, bill C-7 protects employees.

"Transport Canada needs as much safety information as possible, so that's why we encourage employees to report internally through non-punitive, voluntary reporting within the company to make sure the company will have identification of safety hazards and can take corrective measure[s] as soon as possible, even before small incidents evolve into bigger accidents," Reinhardt said. "And in bill C-7, we have drafted the provisions for a whistleblower protection for individuals reporting internally who would be afraid of reprisals … regarding their employment. So if they do avail themselves of that internal reporting system, they may rest assured that, if no followup is made and they report publicly, that they will be protected and there will be no danger for their employment."

Union president Wing disagreed with Reinhardt's assessment.

"I don't see anything in the legislation that says that is the case … the [transport] committee did have an amendment to ensure whistleblower protection within this act. They [parliament] turned down that amendment," Wing said. "So in my mind, this act does not have that protection."

Scott of the Retired Airline Pilots Association of Canada also said there isn't enough protection.

"Until the Canadian government through the legal body produces a very clear whistleblower protection for aviation, then we're not there yet," he said.

"If the Canadian government were to have a look at the whistleblower protection that's been established in the United States, that is as good a founding to use as a premise … because they have done an awful lot of research," Scott added.

In addition to the need for increased traditional inspections and better whistleblower protection, critics such as Scott and Moshansky also feel there should be regular inquiries into air safety, preferably of a judicial nature, where witnesses can be compelled to testify.

They also feel that a third party, much like the office of the federal auditor general, should be set up to monitor whether Transport Canada is doing its job.

Without these checks and balances, the critics charge, Canada is setting itself up for potential disaster.

August 30

The Tragic Legacy of Swissair Flight 111

An incredible article by the founder of the International Aviation Safety Association, just another widow ... (feel free to read TCCA in place of FAA).
 

The Tragic Legacy of Swissair Flight 111

 

 

Tuesday, 26 August 2008

By Lyn Romano

(Wife of Ray Romano, killed in the crash, and founder of the International Aviation Safety Association) 

Image

Lyn and Ray Romano, obviously taken before Ray’s fatal flight.

Nearly one decade ago, on 2 September 1998, Swissair Flight 111 crashed into the waters near Peggy’s Cove, Nova Scotia, Canada.  Some of the milestones that have transpired over the intervening ten years are: my two sons graduated from high school and are attending college; my daughter and her family moved to upstate New York, and I continue to struggle, on a daily basis, to make any meaningful progress without my husband, Ray, who was killed in the crash, by my side.

When I established the International Aviation Safety Association (IASA), on 4 March 1999, it was my passionate desire to right many of the erroneous and long overdue aviation safety issues which the Federal Aviation Administration (FAA) had willfully overlooked. The deceitful cloak of Cost Benefit Analysis (CBA), the FAA’s guiding force for inaction, should have been repudiated and trashed the night of the crash, when 229 innocent human beings were killed. The “translation” of CBA (in my humble opinion) is:

 

Enough human beings must be killed in a plane crash before correcting a dangerous situation, in order for the “fix” to be considered economically feasible.

It is a pragmatic and bureaucratic perspective that disavows human worth and familial affiliations. The same CBA model is applied to the economics of any proposed routine (and non-lethal) technical fix to airplane hardware. There’s no discrimination for human worth.

Someone had to speak out for all the senseless deaths and the many families destroyed by the FAA’s lack of attention to:

The hazards associated with specific aircraft wiring insulation types, snaked throughout the airliner and long known for their propensity to arc when chafed or cracked.

The dangers of the metallized Mylar thermal acoustic insulation blankets, present throughout the airframe and highly flammable when ignited by an arcing wire. The FAA was alerted to this deadly hazard by the Civil Aviation Administration of China (CAAC) in 1996, two years prior to the crash of Flight SR-111. The CAAC warned of blanket flammability after experiencing a severe fire on a Chinese-registered B737, but the letter fell on deaf ears at the FAA.

To add insult to injury, an FAA Designated Alteration Station, or DAS (Santa Barbara Aerospace), approved the installation of the in-flight entertainment system (IFEN) on the Swissair jet, and it proved incompatible with the doomed Boeing MD-11’s electrical configuration. It would later be confirmed that the technical expertise necessary to approve or deny such an installation was manifestly absent - yet the system was more or less “rubber stamped” in a bogus “approval” process. The urgency was predicated upon the profits expected to be made from this in-flight gambling system.

All of these subsequent revelations translate into a supreme lack of oversight by the FAA, and we learn via Congressional hearings that the FAA is too “cozy” with the airlines it is supposed to regulate (see Aviation Safety & Security Digest, ‘Congress Seeks Separation of Agency From Airlines,’ homepage).

Any reasonable human being would believe that each and every one of the Canadian Transportation Safety Board’s (TSB) recommendations, contained in their final report of the Swissair accident, would have been acted upon by the FAA with the utmost expediency. That being said, let us take a look at how important the FAA feels the deaths of the 229 individuals really are, by looking at where some of those recommendations stand ten years after the crash.

As recently as 29 June 2008, a fire broke out in the attic area of a B767, operated by Airborne Express, and it eerily resembles what the pilots aboard Swissair Flight 111 experienced. The aircraft was not airborne at the time, and it will be very interesting to learn from the investigation just how similar this incident is when compared to what transpired almost ten years ago aboard Flight SR-111 (see Aviation Safety & Security Digest, ‘Cargo Jet Fire Seems a Replay of Deadly Inferno,’ home page).

It would appear that not all flammable materials have been stripped from aircraft, as the TSB urged. The metallized Mylar thermal acoustic insulation blankets were ordered removed, but not without the FAA dragging its feet for a full year before giving the airlines an additional 5 years to accomplish the task. What about other flammable insulation materials? One of the TSB’s strong recommendations stated:

That regulatory authorities quantify and mitigate the risks associated with in-service thermal acoustic insulation materials that have failed the Radiant Panel Test.

Response Rating: Unsatisfactory

Is it possible that ten years after the crash of Flight SR 111 the TSB classifies this recommendation as “Unsatisfactory”? Apparently, that seems to be the case. This falls into the realm of complete and utter lack of respect for all those killed in the crash, not to mention a failure on the part of the FAA to accomplish its primary mandate as safety watchdog.

Another incident, which calls FAA oversight into question, is the recent grounding of hundreds of American Airline flights because of inattention to known wiring issues on their MD-80 fleet. American Airlines then assured the flying public that safety was never compromised. I find that claim rather absurd, considering the wide reaching effect of the grounding. At a time when airlines are struggling to remain solvent during a very difficult economic period for their industry, it is an insult for them to downplay the seriousness of the situation.

The stunning lack of FAA oversight is a phenomenon that recurs over and over again. It is this writer’s opinion that oversight should not stop at issuing Airworthiness Directives (ADs). It should include diligent follow-up, ensuring every AD issued is complied with within the parameters set forth. Trusting the airlines to comply, without any oversight by the issuing agency, is akin to leaving an unattended cookie jar on a table and directing children not to partake.

It would appear the FAA and Congress can live with the regulator being widely referred to as “the Tombstone agency.” While we are all expected to learn from our mistakes, in order to prevent history from repeating itself, the FAA appears not only to lack oversight, but insight and foresight as well

 

http://www.aviation-safety-security.com/current-newsletter/briefs/the-tragic-legacy-of-swissair-fligh.html

July 15

Lawmakers seek separation for FAA, airlines

By JOAN LOWY – 1 hour ago

WASHINGTON (AP) — A bipartisan group of lawmakers introduced a bill Tuesday aimed at ending the Federal Aviation Administration's sometimes cozy relationship with the airline industry and reversing purported complacency on safety oversight.

Several House Democrats and Republicans led by Public Works and Transportation Committee Chairman James Oberstar, D-Minn., said they were introducing the bill to force changes on the FAA that it has been reluctant to make on its own.

"We don't trust the FAA to do this on their own, and that's without regard to whatever administration is in place," Oberstar said. "There is a culture at the FAA that is evolving and changing and we need to change it more."

The House bill would:

_ Create an independent Aviation Safety Whistleblower Investigation Office within the FAA that would investigate safety complaints.

_ Direct the FAA to stop treating airlines as customers and halt the practice of allowing airlines to choose which FAA inspectors will inspect their operations.

_ Set a two-year "cooling off period" before FAA inspectors or FAA employees who supervise inspectors can go to work for an airline.

_ Require the FAA to rotate principle maintenance inspectors between airline oversight offices every five years.

_ Require the FAA to review its database of safety compliance reports monthly in order to spot trends and take timely action.

FAA officials weren't immediately available for comment.

Separately, the National Transportation Safety Board said Tuesday that it is investigating two runway incursions that occurred at Teterboro Airport in Teterboro, N.J. — one on June 25 and the other on July 9. A runway incursion is when any aircraft, vehicle or person intrudes in space reserved for takeoff or landing.

Late last month, the Department of Transportation launched an investigation into FAA practices, including how the agency reviews flight risk, its air carrier compliance measures and its oversight of maintenance practices.

In April, FAA inspectors testified at a congressional hearing that their jobs were threatened when they reported maintenance and inspection problems with some airlines.

The agency, under Acting FAA Administrator Robert Sturgell, took the rare step this spring of ordering the audit of maintenance records at all domestic airlines following reports of missed safety inspections at Southwest Airlines. The Dallas-based airline was hit with a record $10.2 million fine for continuing to fly dozens of Boeing 737s, which carried an estimated 145,000 passengers, that hadn't been inspected for cracks in their fuselages.

"Unfortunately the FAA seldom acts until they are pushed to act," said Rep. Jerry Costello, D-Ill. "That's one of the reasons why we've held so many hearings ... If I had my way, there would be major changes in personnel at the FAA."

With only a few months left on Congress' legislative calendar, the bill's sponsors acknowledged that it will be difficult to enact the measure this year. But they said they want to send FAA a strong message.

Rep. John Mica, the ranking Republican member of the committee, called the bill "a shot across FAA's bow."

June 27

Transport Canada Civil Aviation Whistleblower Website Launched

A new website has been launched about the Transport Canada Civil Aviation whistleblower, Hugh Danford, who testified before the Standing Committee in May 2007.  Subtitled as the "Swanson Management System", it details Mr. Danford's efforts to keep Transport Canada accountable for recommendations made by the Transportation Safety Board.  The site includes audio commentary from Mr. Danford as well as Transport Canada documents detailing their underhanded efforts to reduce the number of Civil Aviation Inspectors and hand off safety oversight to the operators themselves, thus reducing their civil liability.

 Please visit http://urcombot.googlepages.com/home to find out more about why Mr. Danford's is blowing the whistle.

June 12, 2008 System Safety Society (Ottawa) Presentation

On June 12th, 2008, a presentation was given by Capt. Donald L. Van Dyke (in lieu of Justice Virgil  Moshansky who co-wrote the presentation) at the System Safety Society in Ottawa.  Although the text of the presentation has not been made available, the handout “From Dryden to Bill C-7:  Legacy and Insight” is available here:  http://www.russona.com/ECC-SSS/Meetings/Presentations/From_Dryden_to_Bill%20C-7.pdf .

 

Note the conclusions on the second to last page ...

 

Judicial review

  • Process to be institutionalized
  • SARPs needed to internationalize concept

Commissions of Inquiry

  • Headed by superior court judge
  • Conducts periodic judicial review
  • Evaluates national aviation safety
  • Reports findings to State and ICAO
 
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