Canwest News: Feds not meeting air-safety rec's

[Widow]

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

Ottawa Citizen

[Chuck Ellsworth]

kirsten is it possible for the public to get the minutes of these safety discussions and the names of those who are making these decisions?

It would be nice to know the qualifications of the people who make these decisions.

[freakonature]

Can someone explain to me how a TAWS would have made a difference in the Sonicblue accident?

[Widow]

Sure it's possible . ... what are you looking for, specifically? If it's the so-called "floatplane safety review", I can fill you in on who was involved. The ATIP request was made by my MP on my behalf, and they neglected to ask for minutes ... but there are still names attached.

[flyinthebug]

Kirsten: Congrats on this getting the media attention it should be. A step in the right direction. Its just sad to see TC letting us ALL down the way they have. The deeper they dive into this, the more crap they find! Ignoring recommendations.. some for 76 months is unacceptable from OUR regulator. If "Joes air service" was 76 months ignoring audit findings.. they would be 75 of those months with no AOC.. yet the people setting the bar can only meet 50% of their "findings".. This must be a joke? right?

Freakonnature.. I must agree that a TWAS wouldnt have made any difference in the SB crash IMHO only.

Fly safe all
Cheers

[Widow]

Thanks flyinthebug ...

Re the TAWS:

2.4 Equipment
SEIFR operations are at increased risk of collision with terrain in mountainous regions where there are generally fewer airfields, unique terrain features, and fewer available sites for off-field emergency landings.

The GPS in the aircraft had an expired aviation database. The provision and use of out-of-date information, particularly during an emergency, can lead to an increased risk to flight safety.

Many aviation-approved GPS databases do not normally include roads or water bodies or other terrain features that could be useful in identifying potential emergency landing areas in the event that an emergency airfield is not within gliding range. Although equipment is available to display terrain warning information, Canada has no requirement for such equipment to be installed on aircraft engaged in SEIFR operations.

When the CAR restriction disallowing SEIFR operations in designated mountainous regions was removed without including a requirement for TAWS equipment, the level of safety to SEIFR operations was significantly reduced. Inclusion of a requirement for TAWS equipment in SEIFR operations would not only increase the margin of safety, but also move to harmonize Canadian regulations with the United States regulatory environment.

http://www.tsb.gc.ca/en/reports/air/200 ... 6p0010.asp

The TSB thought it might have made a difference ...

[flyinthebug]

When they do away with SPIFR altogether, thats when they will have accomplished something!

Widow, as I said it was just my opinion and based only on personal experience and local knowledge of the area where the crash occured.

What truly concerns me from this report is that TC itself does not adhere to its own regulations? As I pointed out above, how long do you think ANY airline or air service in Canada would be in operation if they were to ignore 50% of their audit findings for over 6 years from TC? We all know if you ignore their findings, your shut down. This is exactly what concerns me in this report is who at TC is accountable for this failure to comply? Who has the stroke to FORCE TC to find short and long term solutions to their own shortcomings?

I was hoping there would be a bit more input on this thread as I truly am seeking an answer as to who "polices the police?" Whos gonna pull TCs AOC for failing to comply with audit findings from THEIR OWN department (TSB) .. Am I the only one thats annoyed as s*it over this?

Remember, THEY (TC) set the standard and we are to follow their leads. If this is the case, those of us in management that used to dred TC audits can all now relax as we only are required to meet 50% of the standards that TC sets for us? outrageous statement isnt it?.. but it is after all what they are doing? Pls correct me if im wrong here? See what this does to safety as a whole? And we wonder why there are the problems that there are within our wonderful industry.

Keep on em Widow!
Fly safe all, Cheers.

[Chuck Ellsworth]

This is exactly what concerns me in this report is who at TC is accountable for this failure to comply?

Their structure is such that regardless of how incompetent or untrustworthy any one of them are they are protected totally.

Close your eyes and picture a herd of Musk Oxen in a circle protecting the weak in the herd from an enemy....that is TC and the mentality of the two groups are similar.

Who has the stroke to FORCE TC to find short and long term solutions to their own shortcomings?

That is easy, your politicians specifically the Minister of Transport, but don't get your hopes to high because to get him to act is damn near impossible.

I tried but got zero co-operation from him for my efforts.

The fix is in so deep you would need to have something really criminal to even get them to take notice.

Now if you could mobilize hundreds or even better thousands of Canadian citizens screaming through the news media demanding the Minister step in and clean up that cess pool in tower C in Ottawa he would maybe do something.

[safetywatch]

The most alarming thing is that neither the Conservative government, nor the three opposition parties have said a damn thing about all this. As we all suspected, politicians of all political stripes are a waste of space and fresh air. This is why we elected them - to hold people accountable.

[planett]

This will be forgotten by the powers that be within weeks. Another Dryden type accident might attract some longer lasting attention.

[CD]

In some cases, you're going to have a cast a wider net than just a single government department. By reviewing the CARAC NPA System, you will discover regulatory change proposals going back to the late 1990's that are not yet published. Most often, the status is listed as "legal editing" or "pending Canada Gazette, Part I", which I take to mean the Department of Justice. Some of the notable ones that have been discussed here before caught up in that void are for flight and duty times, which cleared the CARAC consultation process back in 1999/2000 but are still waiting for the Justice review or Gazette consultation process.

It would be interesting to know how many of the safety recommendations might be in the same boat - a proposal was made for change but it's either sitting waiting for a legal review or was opposed by industry/employee associations and withdrawn (lots of those listed on the NPA System as well).

[Hot Fuel]

Just for clarity the TSB is not a department of Transport Canada as stated by flyinthe bug, nor did or do they present audit findings. They are a separate investigative body that is tasked with investigating transportation related accidents, they don't audit they investigate. I addition they don't present audit finding, they make recommendations. There is a significant difference between the two. I'm not saying that the recommendations that have been put on the table are bad I'm just pointing out that there is no legal obligation to act on a recommendation. Perhaps that is the biggest problem with the system, there is no mechanism that allows the TSB to trump T/C on issues involving safety and prudent recommendations drafted by authorities in their respective fields.

Hey J...I saw in another post that you said you wouldn't fly again, how bad did you bust yourself up in that mishap?

[flyinthebug]

Hot Fuel.. TY for the clarity. So the TSB is just another toothless government agency with a shiny title and absolutely of no use to anyone:/
FYI.. I do realize that they wernt actual "audit" findings but they were recommendations from our safety branch (TSB) so I still ask how these recommendations are so easily ignored and for so long.

I am busted up pretty badly.. Broken L arm in 7 places 3 below elbow 4 above..smashed elbow thats been rebuilt with a 4 hour surgery and barely works. 5 breaks to right cheek, broken orbital r eye in two places (requires another surgery to replace the bone and insert a metal plate under the eye to try to bring it back into place) over 130 stitches and im STILL smilin (with fake teeth too now cause the good ones were all knocked out)
It was a hell of a ride HF.. One i will never forget.

Anyways, thanks for the clarity and I dont want this thread going off in the wrong direction as there have been some good opinions offered.

Fly safe all
Cheers

[55+]

The TSB reports directly to Parliament, not to any other Federal Government Department or Agency. It managerial levels are not structured like a typical Government with a Minister, DM or a series of ADMs. It, along with the RCMP and DND have investigative powers only, no regulatory power aka Transport Canada (Aviation, Rail, Marine). That’s why they make “recommendations” but they do take issue with the regulatory authority in their investigations as well all know.
In the minor dealings I personally had with TSB providing interpretation on TP-308 Instrument Design Criteria on investigations where Instrument Procedures questions were raised, I found the men/women at TSB quite professional and no air of authority like can be found with the ‘Regulatory” people.

[flyinthebug]

Thank you for the insight and education 55+. Im starting to understand their role in our industry now.

[Hot Fuel]

The TSB has some really good investigators and some really good science behind them but its only effective when a) it gets used to determine a cause and b) when its experts recommendations get the consideration they deserve. It seems that the TSB can be willy nilly on what they investigate and what they don't, perhaps its a manpower problem I don't have a clue.

Probably equally frustrating for the people that put their heart and soul into determining a cause, making what they believe to be sound recommendations to minimize or eliminate risk only to see it get bogged down or outright buried in red tape.

[Widow]

About the TSB

The TSB is an independent agency, created by an Act of Parliament (the Canadian Transportation Accident Investigation and Safety Board Act, that came into force on 29 March 1990. The TSB consists of up to five Board members, including a chairperson, and has approximately 220 employees. Our Head Office is located in Gatineau, Quebec; however, most investigation staff are located in various regional and field offices across Canada where they are better able to respond quickly to transportation occurrences anywhere in the country.

... 220 employees, for ALL modes of transport! I'd call that a manpower issue ... and maybe why they had to come up with the "Occurrence Classification Policy". It makes no sense to me though. How can that classification occur before determining the cause and causal factors???!!

And I'll bet it's frustrating for those who have worked tirelessly to figure out what went wrong and how to prevent a similar occurrence/outcome ... only to have the rec delayed, forgotten or kiboshed altogether. What use the TSB if they aren't taken seriously by TC?

[Chuck Ellsworth]

I wonder how many actual in the field inspectors they have?

In other words how many people who actually leave their offices to examine accidents?

[flyinthebug]

There cant be many Cat because I recently learned that they didnt even inspect the plane in my accident at the crash site.. but rather waited until it was lifted out before they even sent a single inspector to have a look. ?? So in N. Ont region at least.. It would seem they are grossly under staffed OR over "managed". If they manage air, rail & marine.. That could keep 220 ppl quite busy. Sadly for those 220 professionals, their hard work is not respected by TC it would seem.. or they would follow all recommendations.. not just 50% that TC figured had enough public pressure that they had to act.

Fly safe all.

Edit for PS... I just want to be clear that I am not on any crusade against TC. I have a couple close friends that currently work for them and I know they give all they have to their jobs. I met many GOOD inspectors in the YWG office and formed lifelong friendships with another TC inspector some 14 yrs ago in YHD. Many of the ppl at Transport Canada are good people who really do try.. It appears the problems as usual flow downhill. I just didnt want it perceived that im against TC or its people. I simply have a problem with a regulator that polices itself and adheres only to "hand picked" recommendations by the TSB. I just want them to practice what they preach! After all, we do look to them for the standards right? Cheers

[55+]

South of the border it is the same issues between the NTSB and the FAA. The NTSB criticizes the FAA for lack/no action/oversight on issues as a result of their (NTSB) investigations.
Any major aviation investigation in Canada there is usually a “Ministers Rep” appointed by Transport Canada to observe in meetings and the like. They (Min Rep) do not take part in any field/site work as far as I know just to look after the interests of the Department When I was with TC this was delegated to System Safety I do believe.
There are a lot of observers on big investigations (airlines/manufactures/service providers (Nav Canada). Speaking of which I do know that Nav Canada was pissed at the TSB for publically releasing on their web site the HZTCU air /ground conversation on the SwissAir 1998 crash during the initial investigation stage. I do believe the TSB acknowledged they shouldn’t have done it and I think the media published the conversations as well.

[square]

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.

LOL, that just says everything.

[Chuck Ellsworth]

If a company outside of government were to have the same level of achievement in their production or service as TCCA how long would it last?

It is simply amazing how the owners of this organization ( the taxpayers. ) are so oblivious to the deplorable management of TCCA.

Sure there are many good people working for TCCA but they are getting to be fewer and fewer.

[Widow]

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

http://www.montrealgazette.com/safety+a ... story.html