----- Original Message -----
From: McDonald, Gerard
To: Kirsten Stevens
Cc: Clitsome, Mark ; Yearwood, Bill
Sent: Monday, June 02, 2008 1:59 PM
Subject: RE: Follow-up: NCAP
Dear Mrs. Stevens
I am responding to your request for information regarding a "National Compassionate Assistance Program (NCAP)".
You are correct that as a result of the involvement of a family member in the investigation of the TSB file #A98Q0114, the idea of a “Compassionate Assistance Program" was discussed. After many discussions and meetings, it was decided that the TSB was not the best organization to develop this program since there are other programs available for grieving families.
Instead the TSB developed a policy on the dissemination of occurrence information to Families, Loved ones, and Survivors (FLS). The purpose of this policy is to provide timely, factual, contextual information about the investigation process, activities, and progress of on-going investigations, to families and loved ones of fatally injured persons, and survivors (FLS), as appropriate to their needs and the circumstances of the occurrence investigation. It is my understanding that the Investigator in Charge and the TSB Pacific Regional Manager have been keeping you informed with the factual information regarding occurrence # A05P0039.
Please find attached a copy of the TSB Policy on Occurrence Information Dissemination to Families, Loved ones, and Survivors (FLS).
Gerard McDonald
Executive Director
From: Kirsten Stevens
To: McDonald, Gerard
Sent: Monday, June 02, 2008 5:55 PM
Subject: Re: Follow-up: NCAP
Dear Mr. McDonald
Once again, thank you for your response to my inquiries with respect to the NCAP. As you have advised me that the TSB has instead developed the FLS program, I would like to take the time to state emphatically that this program did not work for the families of those lost with C-GAQW. As a representative of the families of all five men on board, I can speak with authority.
I note that the document you have sent with respect to the FLS indicates that a Post-Investigation Evaluation is normally done following the release of the TSB’s final report. Although this accident will not have a final report (unless you advise differently in your response to my email dated June 2nd, 2008), I would like to formally request that an evaluation and lessons-learned report of the FLS in respect of A05P0039 be completed in consideration of the following information.
To begin with I shall clarify for you whom the primary contact should have been for each person on board the aircraft.
Arnie Feast (pilot): Sally Feast (sister, only living relative)
David Stevens (pax): Kirsten Stevens (spouse)
Doug Decock (pax): Allison Decock (spouse) - secondary contact Kevin Decock (brother)
Trevor Decock (pax): Doug Decock Sr. (father) - secondary contact Kevin Decock (brother)
Fabian Bedard (pax): Darla MacDonald (common-law spouse)
When the aircraft was declared missing, contrary to the Principles of the Policy which states “that the carrier/operator has the fundamental responsibility to the victims and their families for dealing with their individual needs”, not one next of kin was contacted by MJM Air to inform us that the aircraft had been declared missing at approximately 2:15pm on the 28th of February 2005. Passenger next-of-kin were contacted by their respective employers after 6pm, while the next-of kin to the pilot was left a message on her answer machine by a stranger after 8pm. At no time in the weeks immediately following the accident, did MJM Air representatives contact any family member to express their condolences or offer support, or to explain what would happen “next”. I have learned that this is common practice from operators who may be, at least in part, culpable. So much for the operator’s fundamental responsibility.
No family member was contacted by anyone at the Transportation Safety Board following the accident. No explanation was ever received about how an investigation would (or would not) proceed, or what that investigation would (or would not) entail. The first contact any of us had with the TSB was in June 2005 when an advisor to the families contacted the TSB to request assistance long after the official search was called down. Even at this time, the investigator met only with Kevin Decock and there was no discussion with respect to the accident investigation itself. When the TSB sent it’s first “letter to the coroner” in June 2005, the families were not notified. Although the aircraft wreckage (sans engine) was recovered (by the families) on July 28, 2005 the TSB examination was cursory, and nothing was taken at that time for examination. We were advised by our legal representatives to await the TSB report. When the second letter, post recovery, was sent to the coroner in September 2005, again the families were not notified. It was only through our contact with the coroner in October 2005 that we learned a letter had been released and requested a copy, which was received in November.
Greatly dissappointed with the contents of the letter, we requested a meeting with the TSB, the Coroner and TCCA, which took place in December, 2005. Although TCCA refused the request, this was the first time other family members had any contact with anyone from the Transportation Safety Board, and the first time for any of us with respect to the accident investigation. Unfortunately, the comments and conduct of one of your investigators was so insulting to grieving family members, and both he and the second investigator seemed so uninformed with respect to aircraft type, that we preferred to limit further contact to the Regional Manager. Mr. Yearwood has been, since this meeting, compassionate and communicative and most helpful within his mandate, including calling in a knowledgeable investigator from another region in December 2006. Of course, this led to our being informed that the TSB did not have the expertise to comment on how float condition (landing gear) may have contributed to the fatal nature of the accident! Most surprising as this was hardly the first floatplane accident in Canada.
Unfortunately, the communication from the TSB with other involved agencies has also been poor. To exemplify this, we were recently informed by the Coroner Service that the reason for the delay in their Judgement of Inquiry (and decision with respect to an Inquest) was that they had never been informed by the TSB that a full report would not follow the initial “letter to the coroner” - that the accident had been given a Class 5 Occurrence designation. Had they known this, it is likely the families would have received some measure of closure through the Coroner’s Report in early 2006.
None of this addresses the fact that at no time preceding your email of June 2, 2008 did anyone explain to us who would be responsible for a Canada Labour Code investigation, fines and enforcement action if deemed necessary. We had considerable information within days of the accident that was relevant to this part of the investigation (as well as the TSB investigation), but grieving as we were, we expected the official agencies to uncover and investigate the same issues we had identified. With four working loggers on board, we were horrified to learn (in 2007) that the WCB had no jurisdiction to investigate, fine or enforce, despite being an insuring party. We were informed by the WCB that a CLC investigation was the responsibility of Transport Canada. As you know (but we did not) Transport is only responsible for an investigation into the safety of the pilot, whose remains have never been recovered – which they use as an excuse not to investigate. The RCMP file remains open, and they have informed me that they did not receive a copy of the last engineering reports from the TSB.
We are of the opinion that, in the case of this accident, the TSB investigators assigned decided in advance of recovery (and without respect to the many witnesses who heard the aircraft in trouble that morning, information about poor operational practices and dispatcher training by MJM Air, or on-going maintenance issues with the aircraft C-GAQW - all of which the families were aware), that the accident was due to weather and/or pilot error. Instead of actually looking for a cause, they used only the information which suited their pre-determination after the fuselage, and then the engine, were recovered - again by the families.
All of this has lead to continued hardship, both emotional and financial, for all the families (and their friends). I do not believe this to be a part of the FLS policy.
As you may be aware, my continued research and advocacy has resulted in my contact with the grieving loved ones from several other aviation accidents in recent years. They have expressed to me a similar dissatisfaction with communication and compassion received from the TSB. I would be happy to provide you with further information should you so request.
Please confirm that an evaluation and lessons-learned report will be initiated with respect to the FLS and the accident A05P0039, and that we will receive a copy once complete.
Respectfully,
Kirsten Stevens
