Five Deaths Demand Justice Petition

[Widow]

Seeing as someone bumped it, just thought I'd give a wee update ...

Still no further word from the office of the Minister of Labour. I have my own speculation on what that hold up is.

Coroner's Judgement of Inquiry is STILL not ready for release to the public.

A summary report on the findings of RJ Waldron's is being prepared.

The RCMP criminal investigation remains open.

There WILL be news before the year is out.

[Widow]

Kirsten;

Your husband should have been related to someone important in Quebec if you wanted the Transportation Safety Board of Canada to do a full investigation;

CTV.ca

One person falls off a boat in either international or USA waters and you get this major investigation while your accident which is much more relevant is ignored. How will the Chair defend this apparent disparity?

http://www.tsb.gc.ca/en/reports//marine ... 6f0024.pdf

[Widow]

For those whose interest continues, RJ Waldron's has now released their Summary Report and a letter to the Coroner with suggested recommendations.

From the letter to the Coroner:

We recommend that the BC Coroner Service make the following recommendations to the Transportation Safety Board of Canada;

6. The Transportation Safety Board of Canada should review its occurrence classification policy to achieve the legislated mandate of investigating aircraft accidents to determine the cause, and to make recommendations to prevent recurrence. The Transportation Safety Board of Canada did not fulfill its obligation in this occurrence.

I will be publishing the report and letter in full in the near future. If anyone would like copies in the meantime, please feel free to contact me

Stay tuned.

[Widow]

AQW Summary Report

Coroner Recommendation Letter

Due to the corrosion of parts after recovery in July of 2005, and because no adequate inspection or investigation of the original wreckage took place before that of RJ Waldron & Co., the cause of the presumed forced or precautionary landing was not determined. It was, however, concluded that the condition of the floats prior to impact directly contributed to this survivable accident becoming fatal.

Conclusions

The R.J. Waldron & Co. investigation determined that the aircraft crashed while the engine was at a low power condition, possibly indicating an intention to land – either forced or precautionary. There was no evidence of mechanical failure of the engine but it was not possible to determine if the carburetor, fuel, or ignition systems were functioning properly.

The rapid and unexpected sinking of the floats was the likely cause that turned this survivable accident into five fatalities. Recommendations to prevent a recurrence of this accident and to remedy identified safety deficiencies are contained in a separate document addressed to the BC Coroner Service.

[Widow]

November 18, 2008

Kirsten Stevens
492 S. McPhedran Road
Campbell River, BC
V9W 5K5

Dear Kirsten:

Let me first say that I find it personally appalling that the families of the men killed in the floatplane crash on February 28th, 2005 have had to take the lead on determining what caused the death of the five men.

The regulatory agencies have not only let you and the families of the men killed in the crash down, they are letting down the hundreds of workers who depend on transportation by floatplane to travel to their respective workplaces. Whether by floatplane, truck, car or boat we continue to see forest industry workers killed on their way to or from work. Unless we find out what happened we are
destined to repeat these horrific events.

I fully support your request to have the regulatory agencies that have jurisdiction in this tragedy to complete a full investigation of all the events that lead to the crash and to identify the causal factors so this type of accident never happens again.

The full extent of the law should be applied to those that have been negligent in preventing this accident up to prosecution under the criminal code.

I will raise this issue with my colleagues at the next WorkSafe Board of Directors meeting to ensure we uncover all the factors associated with this tragedy.

Thank you for all the work that you and the families have done.

Yours truly,

Stephen Hunt,
Director
SH/sml

cope 343

cc: Roslyn Kunin, Chair, WorkSafeBC
Tom Pawlowski, BC Forestry Coroner
Ron Corbeil, Health, Safety and Environment Coordinator, District 3

[Mitch Cronin]

The full extent of the law should be applied to those that have been negligent in preventing this accident up to prosecution under the criminal code.

That statement wouldn't seem to me to be supportive of this sentiment:

I fully support your request to have the regulatory agencies that have jurisdiction in this tragedy to complete a full investigation of all the events that lead to the crash and to identify the causal factors so this type of accident never happens again.

This industry will not ever be safe if the hunt em down and shoot em attitude grows roots.

[Cat Driver]

This industry will not ever be safe if the hunt em down and shoot em attitude grows roots.

Better to just sweep it under the carpet is it Mitch?

[Mitch Cronin]

Now why on earth would you say that .?

[Widow]

Maybe if an owner/operator was actually, finally held responsible when they really really should be, those shitty ones that are still out there would learn a lesson.

You can only slap someone on the wrist so many times before they cease to notice.

[Mitch Cronin]

I'm glad to see someone with some authority shares your point of view Kirsten. I just don't think threats of prosecution are any way to get to a safer aviation industry. On the contrary, I think those very threats will make discovery of causal factors very difficult. I think people will enter protection mode and avoid saying too much, and generally avoid co-operation (just as the ferry crew did)...and further, less potential for trouble will come to light in the first place because, fearing prosecution, people will keep quiet.
I think it's obvious there's a delicate balance required and a heavy hammer will have a negative effect on safety.
...but I sure can understand you wanting your pound of flesh for what happened.

[Chuck Ellsworth]

I think it's obvious there's a delicate balance required and a heavy hammer will have a negative effect on safety.

So the conviction and sentencing of the pilot in the Keystone fatal accident has only had a negative effect on safety because it drove the practices of ignoring the rules underground Mitch?

[Mitch Cronin]

I don't know ., I suppose only time will tell...

[Widow]

...but I sure can understand you wanting your pound of flesh for what happened.

I don't believe that justice will ever be served in this case. I look at the big picture and I see it can all be laid at the feet of one man. One man who didn't want to pay to train the dispatcher (his girlfriend as he cheated on his wife), who didn't want to pay for a radio in the office or to hire out the "flight-following", who didn't want to pay to have the floats overhauled almost two years before the crash, who didn't want to pay for new parts or for full 100hr inspections .... who was found (by Worksafe and the Coroner) responsible (lack of training, illegal maintenance, etc.) for the death of someone before our accident, and another death after our accident.

The other families feel differently. They have not been able to forgive anyone and they want a piece of every person/entity that was involved in allowing this to happen. But, they don't understand this industry quite the way (at least I think) I do. It's possible that had we had any closure, any at all by now, that some of that anger would have been released by them ... the authorities don't seem to understand how their treatment of this case has prolonged and exacerbated our grief.

The owner of (now defunct) MJM Air though, he SHOULD have been charged criminally. It has nothing to do with whether it's aviation or any other industry.

Everybody "gave up" information slamming him - to us. None of the authorities wanted to listen.

[Chuck Ellsworth]

widow, do you think Nowzek reads these posts?

[Widow]

Why would he? Do you think he suddenly started caring?

[Chuck Ellsworth]

No.

[Widow]

----- Original Message -----
From: <min.labour-travail@hrsdc-rhdsc.gc.ca>
To: <Kis.ca@telus.net>
Sent: Tuesday, December 23, 2008 11:52 AM
Subject: Demand for Canada labour code Investigation





Ms. Kirsten Stevens

Dear Ms. Stevens:

This is in response to your electronic message of September 2, 2008, addressed to my predecessor, concerning the tragic loss of your husband's life. I also acknowledge receipt of your electronic messages of November 7 and 26, 2008. Please accept my apologies for the delayed reply.

Labour Program officials have reviewed and discussed this matter with officials at Transport Canada. In this case, only the pilot was an employee under federal labour jurisdiction and an investigation was conducted by Transport Canada as required under the Canada Labour Code and the Aviation Occupational Safety and Health Regulations into the circumstances of his death.

Since the other passengers, including your husband, were employed by two companies that are provincially regulated, and to the extent that they were at work when the accident occurred, WorkSafe BC is best placed to respond to your concerns. We have contacted WorkSafe BC to apprise them of the results of our investigation and you may reach them at:

6951 Westminster Highway
Richmond, British Columbia
604-231-8888
1-888-967-5377
http://www.worksafebc.com/claims/review ... efault.asp

I would like to offer you my sincerest sympathies and thank you for taking the time to write.

Yours sincerely,

Rona Ambrose
Minister of Labour

Still, no one wants to tell me if the CLC investigation for Arnie (the pilot) was, or will be, re-opened in light of the findings of RJ Waldron and ongoing TCCA Enforcement investigation.

[Widow]

----- Original Message -----
From: Kirsten Stevens
To: min.labour-travail@hrsdc-rhdsc.gc.ca
Cc: mintc@tc.gc.ca ; Merlin Preuss
Sent: Wednesday, January 07, 2009 10:49 AM
Subject: Re: Demand for Canada labour code Investigation


Dear Ms. Ambrose,

Thank you for your reply. As I have yet to receive a reply from Mr. Baird, the Federal Minister of Transport, our concerns about the Transport Canada investigation remain. In a letter dated April 24th, 2008, Dave Nowzek (Regional Director, Civil Aviation) stated:

"Based on the total absence of causal information, no witnesses to the event, no confirmed cause of death of the pilot or recovery of his body, the investigation was then placed on hold pending outcome of the Transportation Safety Board's investigation. The results of the TSB investigation provided no further information that would have assisted the CLC investigation. The investigation was subsequently closed."

This would seem to contradict the assertion that Transport Canada conducted an adequate investigation. As the findings of RJ Waldron & Co., performed after the Transportation Safety Board of Canada refused to do a full investigation and report, revealed information with respect to the condition of the aircraft prior to departure, and said findings have resulted in a new Aviation Enforcement investigation, it is incumbent upon the Ministry of Transport and the Federal Ministry of Labour to ensure that this new information is examined as required under the Canada Labour Code and the Aviation Occupational Safety and Health Regulations.

We, therefore, continue to await assurance that Transport Canada will re-open its investigation with respect to the working safety of the pilot, Arnold Feast.

At this time, we further wish to highlight RJ Waldron's recommendation that "The Transportation Safety Board of Canada should review its Occurrence Classification Policy to achieve the legislated mandate of investigating aircraft accidents to determine the cause, and to make recommendations to prevent recurrence." Especially in the case of working fatalities, a thorough TSB investigation and report is essential to the other agencies with investigative obligations – including Transport Canada, provincial Worker’s Compensation Boards, RCMP, Coroner Services, etc. Although we forwarded the RJ Waldron Report and Recommendations to the TSB Board of Directors, and the President of the Queen’s Privy Council, on the 7th of November, we have yet to receive any response. I am attaching a copy of my letter for your convenience. Please confirm that you, as the Federal Minister of Labour, will ensure that the TSB policy is reviewed to make certain that no other workers in Canada will be failed in the way our families have been.



Respectfully,

Kirsten Stevens

On behalf of the Stevens, Feast, Bedard/MacDonald and Decock families


C.C. Honourable John Baird, Federal Minister of Transport
Merlin Preuss, Director General, Civil Aviation

As a matter of note, the Coroner Service (in its infinite wisdom) has sent the Waldron report to the TSB to be "vetted" before deciding how to procede with their report. What a farce. They didn't want to investigate, but now get a chance to decry an investigation which criticizes them for that choice? We are going to hit the four year mark and STILL have no Coroner's Report.

[Cat Driver]

For those of you who do not understand what widow is up against I have copied a paragraph from the thread about working for TC, I must first warn you that I have no idea if the author of this is a TC employee or just some teenager posting from the family computer.

First, and most importantly, get what used to be called the Statement of Qualification (S of Q), and now is referred to as the "Statement of Merit Criteria". Read very carefully, as the entire interview and hiring process is based on this, and during the interview they may only ask questions pertaining to the merit criteria. Now, having said that, the criteria tends to be really broad. Search Gov't of Can websites and determine exactly what is meant by the terms in the Merit Criteria. Or, contact an HR officer and ask specific questions. What do THEY mean when they refer to "values" and "ethics"? YOU know what that means to you, but you need to know the definition of what it means to THEM. Think back to your own history and be prepared to give examples of how you have applied "values" and "ethics" in your past life.

Regardless of who wrote that the part in red is what widow is having trouble with.

You will note that she is dealing with Dave Nowzek as mentioned in her correspondence, Nowzek is the perfect example of the class of person that meets Transport Canada's " values and ethics " criteria.

From personal experience with Dave Nowzek I can state clearly and truthfully that you can not trust him in any way be it in writing or one on one verbally his word is not to be trusted.

I admire widow for her persistence in this matter, and hope that she eventually prevails in her quest for justice....it is very difficult when you are dealing with people who make their own rules concerning the meaning of values and ethics.

[Cat Driver]

Widow, I found a copy of the original report that was written by Bonita Smith on the M&M department in the Pacific Region under Nowzeks management.

[Widow]

Answer your phone

[Widow]

Wendy Tadros' reply to the letter in this thread, Concern for the Efficacy of the TSB, has been received ...

200 Promenade du Portage
Place du Centre - 4th Floor
Gatineau, Quebec
K1A 1K8

09 JAN. 2008
Transportation Safety Board of Canada
Chair

825-A05P0039
•
Mrs. Kirsten Stevens
On behalf of the Stevens, Bedard/MacDonald, Feast and Decock Families


Dear Mrs. Stevens:

I welcome the opportunity to address the concerns raised in your e-mail of November 07, 2008 by explaining the mandate of the Transportation Safety Board (TSB). In doing so, I will also clearly elucidate the basis on which the decisions were made with respect to level of investigation conducted on the tragic accident which took the life of your husband and four others. In addition, I am attaching the input of TSB investigators to the technical questions you posed.

With respect to your comments on the National Compassionate Assistance Program, I would ask you to refer to the e-mail that Mr. McDonald sent to you on June 13, 2008 8:30 AM on this specific issue. This e-mail explains to you the TSB Families, Loved Ones and Survivors (FLS) policy which has been in place since 2005. I am confident that the FLS policy provides appropriate guidance to our investigators. (See this thread: National Compassionate Assistance Program)

With respect to the decision on what level of investigation would be conducted, let me provide you with some background on the TSB and our legislated mandate. The TSB has been given the responsibility to advance transportation safety in accordance with the Canadian Transportation Accident Investigation and Safety Board Act.

In turn, the Act provides that the Director of Investigations (DOI) - Air has the exclusive authority to direct the conduct of investigations and this includes the authority to determine whether an investigation will be conducted and the appropriate level of investigation. With a wealth of experience in aviation and many years spent in the field of accident investigation, the DOI is well qualified to make these decisions.

I am sure you can appreciate that these decisions cannot and will not be based on the prospect for current or future legal claims. Rather, sound management practice requires that TSB's resources be balanced against the expected safety payoff so we can make Canada's aviation system safer. With over 380 aviation accidents reported to the TSB annually, it is the DOI's job to look carefully at this broad spectrum and to determine where best to assign our limited resources. The DOI takes great care in assessing whether the available evidence is sufficient to allow the Board to determine the causes and contributing factors. The other consideration he must bear in mind is whether a formal investigation would likely uncover new safety deficiencies in the transportation system.

The accident investigation system relies on the DOls being able to exercise their judgment day in and day out in accordance with established policies. This ensures that the same standards are applied across the Board.

The policy in this case is the Occurrence Classification Policy (OCP) which provides the DOI with a solid working tool with which to assess all aviation accidents. The OCP provides that the primary criterion for determining if an occurrence will be investigated is "whether or not such analysis is likely to lead to a reduction of risk to persons, property, or the environment." In other words, the TSB conducts a formal investigation of those accidents where we have the very most to learn and where we have the greatest opportunity to effect change. From time to time we do review and sometimes modify the OCP to ensure it meets our mandate and operational needs.

Mrs. Stevens, with respect to the deHavilland Beaver C-GAQW which crashed into the waters near Quadra Island, a decision was made to fund the recovery of the wreckage to a maximum of $10,000.00 and this commitment was honoured. In addition, dedicated and experienced TSB investigators spent countless hours analyzing the available evidence including a thorough tear down and examination of the engine. The TSB then made public the laboratory report on the engine which concluded the engine was developing power at impact. Let me assure you, the public resources expended on this occurrence are far in excess of most other class 5 occurrences assessed by the Board. (The private resources - of the families - well in excess of $250K now - means nothing, of course. It was OUR job to find, recover and analyze the wreckage.)

At this point, while the physical evidence suggests there was no issue with the performance of the aircraft, we are convinced that it may never be possible to conclude exactly what happened in the cockpit in last moments of this flight. Even though a number of theories could be advanced, in the absence of a Flight Data Recorder, a Cockpit Voice Recorder or survivors who could bear witness to the events, none of these theories could ever be proven with certainty and would forever remain speculation. In other words, there is no reasonable prospect that additional investigative time and resources will yield greater significant causal or safety information which will significantly advance transportation safety. (Floats, flight-following, life jackets, contacting SAR, communications, ELT's, etc., none of these things are relevant to the advancement of transportation safety??? The fact that recommendations have been made previously - and ignored, this too is irrelevant.)

For all of these reasons, I stand by the determination of the DOI not to expend any additional resources on further investigation. It is incumbent upon me to inform you that the TSB now considers this matter closed. It is my sincere hope that while you may wish the decision to be otherwise, the explanation I have provided has given you a fuller appreciation of the mandate of our organization, and in some measure, has helped to allay your concerns.

Concerning your document titled "Impasse" the best way to adequately answer each of the items you raise is to provide the responses directly below each one of your comments. For your ease of reference therefore, please find attached the answers to your technical questions, prepared by the Director, Air Investigations Branch.

I would also like to confirm that the TSB has reviewed the AQW Summary Report and the Coroner Recommendation Letter prepared by Mr. Heath, and inform you that no significant new information has been gleaned from these documents. Specifically, the report failed to prove that there was a mechanical problem or failure that prevented normal operation of the aircraft. (Again, floats anyone???)

We will certainly co-operate with the Coroner and will be providing this response to the Coroner's office in the hopes it will assist in their work. In fairness to my organization, I would ask that you also consider publishing this letter on the public website set up to bring attention to this accident.

In closing, I would like to extend our sympathy to you and others who are grieving as a result of this tragic accident.

Respectfully,
Wendy A. Tadros
Chair
Encl.
cc: Mr. Terry Smith, Chief Coroner

I must say, I am utterly astounded at the insensitivity and prevarication of this statement:

I am sure you can appreciate that these decisions cannot and will not be based on the prospect for current or future legal claims.

For the Chair of the TSB to have implied that our demand for a PUBLIC REPORT describing causes and CONTRIBUTING FACTORS, and MAKING RECOMMENDATIONS TO PREVENT FUTURE INCIDENTS AND ACCIDENTS is based on a desire to litigate is not only demeaning and disrespectful, but it is also obfuscates the FACT that the TSB failed to fulfill it's mandate in regard to this accident.

Grrr, I have so much more to say, but, have other obligations ... so I'll leave you with this thought ...

the physical evidence suggests there was no issue with the performance of the aircraft

Aren't floats considered landing gear, and as such, an essential part of the aircraft's "performance"????

[Cat Driver]

I must say, I am utterly astounded at the insensitivity and prevarication of this statement:

I'm not in the least astounded widow.

Arrogance is something these people come by naturally for the simple fact they have no personal accountability and can say anything they so desire being totally protected by their system..

I quit trying to deal with them because I was afraid I would end up as mentally fucked up as they are.

Remember I have had the misfortune of dealing with the top of these government outfits one on one and the urge to do something illegal becomes almost more than one can control.

[xsbank]

This is our country and these are the people who are operating the agencies that are supposed to help us and look out for us and ultimately protect us. Makes me feel pretty stupid that these dorks are treating us like opponents, how can you bear their platitudes about "your losses?"

They have the terminology wrong, though, its not the sort of triage thing they tout as being so useful that is the tool, its the personnel that are tools.

I'm truly sorry that you have to deal with such idiots, they have institutionalized the concept of 'entitlement.'

[Cat Driver]

Respectfully,
Wendy A. Tadros
Chair

Another faceless bureaucrat beavering away in some taxpayer funded office that from reading her letter has the same grasp of the meaning of compassion as a reptile.