The Walrus (magazine): Fly at your own risk
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The Walrus (magazine): Fly at your own risk
"Fly at your own risk", written by Carol Shaben, is a hard-hitting piece on the aviation industry, focused on the air taxi sector.
Ms. Shaben has a personal interest in air safety. In the article, she discloses herself to be the daughter of Larry Shaben - the Alberta Housing Minister who survived the Wapiti Aviation crash that claimed the life of the provincial NDP leader, Grant Notley, and five others in 1984. The accident was followed by a precedent setting lawsuit, Swanson & Peever vs. Canada, which found Transport Canada to be one third responsible for the deaths.
http://safeskies.ca/files/safeskies/docs/Walrus.pdf
Ms. Shaben has a personal interest in air safety. In the article, she discloses herself to be the daughter of Larry Shaben - the Alberta Housing Minister who survived the Wapiti Aviation crash that claimed the life of the provincial NDP leader, Grant Notley, and five others in 1984. The accident was followed by a precedent setting lawsuit, Swanson & Peever vs. Canada, which found Transport Canada to be one third responsible for the deaths.
http://safeskies.ca/files/safeskies/docs/Walrus.pdf
Last edited by Widow on Sat Oct 17, 2009 10:33 am, edited 1 time in total.
Reason: Edited title, so as not to be confused with the Walrus aircraft!
Reason: Edited title, so as not to be confused with the Walrus aircraft!
Former Advocate for Floatplane Safety
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Re: The Walrus: Fly at your own risk
I thought that article was very well written, covering many aspects of a highly technical topic, and explaining the problems clearly.
The Old Fogducker
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Re: The Walrus: Fly at your own risk
Agreed, great article.
Thank you Kirsten for helping us fix our broken system. We are stubborn and sometimes we feel that change is bad, I know that even I was not very open to hearing your perspective at first.
We need you though, your voice is a powerful one, and I hope that your story and your ambition can turn this degenerative tide of aviation regulation and culture around. I hope someday I can help (beyond the scope of my own flights), and I really hope that someday the culture of aviation will allow pilots to be praised for making safe decisions instead of let go.
Just the other day I saw a member of our management strongly encouraging pilots to go flying in weather that was known to be below our company limits, I should have gotten the person on tape or video or something. Surely I would be fired though. Maybe my boss will decipher who I am and I will be "laid off" anyways. Oh well, perhaps it's worth it.
Sincerely,
Anonymous for now
Thank you Kirsten for helping us fix our broken system. We are stubborn and sometimes we feel that change is bad, I know that even I was not very open to hearing your perspective at first.
We need you though, your voice is a powerful one, and I hope that your story and your ambition can turn this degenerative tide of aviation regulation and culture around. I hope someday I can help (beyond the scope of my own flights), and I really hope that someday the culture of aviation will allow pilots to be praised for making safe decisions instead of let go.
Just the other day I saw a member of our management strongly encouraging pilots to go flying in weather that was known to be below our company limits, I should have gotten the person on tape or video or something. Surely I would be fired though. Maybe my boss will decipher who I am and I will be "laid off" anyways. Oh well, perhaps it's worth it.
Sincerely,
Anonymous for now
Re: The Walrus: Fly at your own risk
For those too lazy to click the link

THE WALRUS· NOVEMBER 2009
TRANSPORT
Fly At Your Own Risk
Why is Transport Canada moving toward self-regulation for the countrys airlines?
BY CAROL SHABEN
THE WIDOW
IN A SMALL BALLROOM at the Best Western Hotel near Vancouver's airport, Kirsten Stevens, a tattooed single mother of three, rises to take the podium, her hands trembling. Dressed casually in black cords and an emerald green shirt, the forty-two-year-old resident of Campbell River, BC, known as the Widow to many in attendance, stands out from the suit-clad presenters who preceded her. Petite-just five feet three and 115 pounds-with a barely tamed bob of cinnamon-coloured hair and brown eyes, she surveys the audience from behind stylish cat's-eye glasses.
"This is going to be my first time telling this story," she says, clearing her throat and glancing at the sheets clutched in her hands. "Four years ago, I could not have conceived of speaking at an aviation leadership forum. Four years ago, I was a housewife with two children and a newborn baby. In just under two weeks, it will be the fourth anniversary of the day I became a widow-the day the picket fence blew down."
On February 28, 2005, Stevens' husband, Dave, a professional logger, and four others were en route from Campbell River to a camp near Knight Inlet on BC's rugged west coast when their De Havilland DHC-2 Beaver float plane plunged into the water just six minutes after takeoff. Two days later, Dave's body, buoyed by the survival jacket Kirsten had bought him years before, washed up on Quadra Island, five kilometres from where the plane had taken off. His was the only body ever recovered. The autopsy showed that he had escaped the aircraft largely unharmed, only to succumb to severe hypothermia and drown while awaiting a rescue that never came. A resident of Quadra Island heard cries for help but couldn't see their source. It had taken four hours for the office of the air carrier (which has since shut down) to alert search and rescue teams, even though staff knew the plane was missing within twenty minutes of takeoff.
Dave's death opened a chasm of what-ifs for Stevens. "What if the aircraft was perfectly maintained?" she asks her audience. "What if aircraft were always tracked? What if there had been no delay in notifying authorities of the missing aircraft? Could the accident have been prevented? Could all five men have been rescued? Could they have rescued the only man wearing a life jacket-my husband? Could we have celebrated a successful emergency water landing like the one on the Hudson River, instead of mourning the losses of five families? Ten children left without their fathers?"
After a three-day search failed to turn up any trace of the downed plane or the victims, government authorities handed the matter over to the RCMP, which classified it as a missing persons case. A month later, all official searches were completely shut down. Stevens expected that a government agency would investigate the deaths of her husband and the four others as workplace fatalities, but none did. Pooling their meagre resources, the families recovered the wreckage and, later, the plane's engine. Stevens also appealed in vain to a wide and varied list of authorities: the federal minister of transport, infrastructure, and communities; BC's minister of transportation and infrastructure; Canada's Transportation Safety Board; the federal minister of labour; the provincial ministry of labour and citizens' services; the provincial ombudsman of justice; her provincial MLA; her federal MP; several BC senators; the standing committee on transport and communications; and BC's Workers' Compensation Board. Eventually, the families hired a private investigative firm, which found that the plane's floats were "leakers" long overdue for reskinning, that there were non-conforming parts on the aircraft, and that the plane was due for a major overhaul. The firm also speculated that the airline had not carried out mandatory 100-hour inspections of the plane's engine.
The only official report Stevens received came from BC's chief coroner's office-more than four years after the crash. The account, she says, was riddled with inaccuracies and omissions and failed to provide her or the other victims' families with any sense of closure. The Transportation Safety Board of Canada - the independent agency mandated to investigate crashes for cause and contributing factors-did not follow up, claiming there was nothing new to be learned. (Nor, says Stevens, is there any reference to the accident on the TSB's website, which lists only two passenger deaths by air taxi in 2005, the year of her husband's crash.) In a discussion with the coroner, Stevens learned that Bill Yearwood, the board's Pacific Region manager for aviation, had submitted a preliminary report on the accident, which she obtained by submitting an access to information request. In Yearwood's account, the TSB'S inspection showed no evidence of problems with the aircraft's engine, performance, or maintenance. Instead, it indicated that poor weather and the pilot's qualifications and experience may have been factors-an outcome Stevens refers to as "blaming the dead guy."
When she realized her husband's death might have been prevented, Stevens began reading everything she could about the aviation industry: Canadian aeronautics regulations, the Aeronautics Act, crash investigation reports, civil aviation studies and recommendations, and books with titles like Managing the Risks of Organ izationalA ccidents; Black Box: Why Air Safety Is No Accident; and Flying Blind, Flying Safe. She also joined AvCanada, Canada's busiest aviation employment website and discussion forum, where she discovered that many aviation professionals shared her concerns about the lack of oversight of Canada's commercial air carriers.
Then she got vocal. Fuelled by coffee and menthol cigarettes, she worked six hours a day out of a dimly lit den at the back of her three-storey house, not far from where her husband died. She wrote letters to unions and government officials, and launched QuestForJustice.ca and a blog called DHC2 Widow's Space, both dedicated to aviation safety. She initiated a petition to Stephen Harper's office, asking for a.public inquiry into her husband's accident and the air taxi industry in Canada. Slowly, others in the air safety community started paying attention.
Her mission has since broadened to encompass the overall decline in Canada's aviation safety standards, and especially recent federal legislation involving a cost-cutting approach called safety management systems. SMS is a form of industry self-regulation in which airlines develop and maintain their own safety protocols. Under SMS, the responsibility for hands-on monitoring largely shifts from the government to the airlines themselves. The legislation has been making its way through Parliament in various forms since 2001. Its latest incarnation, Bill C-7, An Act to Amend the Aeronautics Act, died last September when Parliament was dissolved in advance of the federal election, but Transport Canada is moving ahead with SMS nonetheless. The department intends to have the protocol fully implemented across all regulated civil aviation organizations by November 2011. In concert with other critics, Stevens charges that the government is using self-regulation to justify extensive cutbacks to traditional oversight programs. She has mounted a spirited campaign to stop Transport Canada, garnering support from pilots, victims' families, whistleblowers, and organizations across the country.
When Stevens finishes speaking, the audience gives her the only standing ovation of the day. As she makes her way back to her table, the first person to offer a congratulatory hug is Yearwood. During the coffee break that follows, delegates surround her. Among them are two old-time pilots. “We learned something from you,” says Horst, a robust, greying man with a thick German accent. “We always have our life jackets in the back. We’re going to wear them.” Wilf, a former air force pilot with a wiry build, raises a finger in the air. “Accountability,” he says with conviction, “that’s what’s needed.”
THE PILOT
SMS has already been implemented in many corners of Canadian aviation, including at major airlines like Air Canada and WestJet. Next on the horizon are the country’s smaller operators, which have fewer resources and face greater risks than the big carriers. Transport Canada’s supervision of this sector has traditionally been lax, raising serious concerns about the 600 operators flying more than 2,000 small aircraft nationwide. This fleet encompasses air taxis (single- or multi-engine planes that can carry up to nine passengers) and commuter craft (multi-engine or turbo-powered planes, plus helicopters, carrying between ten and nine-teen passengers).
Collectively, such operators transport upwards of 100,000 passengers a year in Canada, serving as feeders for the major airlines, and providers of specialty services such as transporting tourists to fishing lodges and the injured to hospitals. They also conduct aerial work, carry workers to various service jobs in industry (logging, hydro, and district court services) and ferry food and freight to remote northern communities. The sector accounts for more than half the country’s commercial aviation — and a disproportionate number of its accidents and fatalities.
Bush flying, the forerunner of modern air taxi and commuter operations, originated in the Canadian North, where poor weather, harsh terrain, scant roads, and the isolation of communities made air transport essential. In his 2004 book, Bush Pilots: Canada’s Wilderness Daredevils, Peter Boer notes that early bush pilots “endured the aggravation of malfunctioning equipment, primitive living quarters and the constant threat of death for relatively low wages… They took satisfaction in surviving in the face of almost overwhelming odds. Landing a plane in the middle of a snowstorm, changing an engine in the middle of the dreaded Barren Lands of the Northwest Territories or hiking endless hours through the bush in search of aid were commonplace events.”
Today the bulk of Canadian aviation still happens in the North. The pilots who fly in the bush tend to be young and inexperienced, and they work in a highly competitive market subject to a kind of “go fever” that encourages them to take risks and push limits. And the conditions in which they fly remain as perilous as ever: bad weather and difficult terrain, not to mention poorly maintained planes. They also typically fly alone. Most rookie pilots cut their teeth with small operations — and since those who can’t make it here often don’t make it at all, the pressure to conform is high.
Owners of air taxi services, meanwhile, were typically bush pilots themselves, and they tend to run their businesses with the same hard-driving attitude, expecting their pilots to fly on a shoestring and to get the job done regardless of weather, fatigue, or cargo load. That they often operate in remote locations further erodes the government’s ability to oversee them.
Erik Vogel understands the perils as well as anyone. Standing six feet three, with broad shoulders, a full head of dark hair, and a neatly groomed moustache, he’s the picture of confidence in uniform. Today his uniform is a firefighter’s, but twenty-five years ago, in 1984, it was that of a rookie pilot with Wapiti Aviation, a small air taxi operation in northern Alberta. That year, his ten-seater Piper Navajo Chieftain slammed into a shrouded ridge, killing provincial NDP leader Grant Notley and five other passengers. (Disclosure: one of the four survivors of the crash was my father, Alberta housing minister Larry Shaben.)
Vogel hadn’t wanted to fly that night. The weather was bad, and his co-pilot had been bumped to accommodate another paying customer: Notley himself. Vogel had lost twenty-five pounds in the five weeks he’d been with Wapiti, and had flown seventeen flights the previous week. He’d also been on call for medevac flights. And he didn’t trust his plane. Its autopilot system had been acting erratically, one of its wing de-icers had broken during a flight earlier that day, and one of its automatic direction finders was also malfunctioning. Getting into the small, uncontrolled airstrips along his flight path would be treacherous. He was in way over his head, and he knew it. He also felt he had no choice but to fly. If he refused, he risked losing his job. Thirty-three pilots had quit or been fired from Wapiti in the previous year.
The crash ended his career. “There’s hardly a day that goes by that I don’t think about it,” he says, seated at a small table at a Vancouver Starbucks. Among the firefighters at Station 4 in Burnaby, he is known as Mr. Safety — a reputation that doesn’t bother him. “I don’t ever again want to be the one to have something bad happen on my watch,” he says.
Vogel still experiences déjà vu when news of other airplane crashes hits the media — for example, the Sonicblue Airways accident in January 2006 near Port Alberni, BC, in which the pilot of a small plane died along with two of his seven passengers. After the crash, the pilot’s father, Jonathan Huggett, com-plained publicly about conditions at Sonicblue, alleging that his son had been abused, grossly underpaid (junior co-pilots with the company normally earned a meagre $28 for a fourteen-hour shift, amounting to about $7,300 a year), and forced to fly in dangerous conditions. “It was Wapiti all over again,” says Vogel, shaking his head. Like Wapiti, Sonicblue had a history of safety violations, though Transport Canada did not suspend the carrier’s licence until after the fatalities occurred.
Whereas the Sonicblue crash was caused by a faulty engine part, Vogel acknowledges he made a mistake the night of his crash, descending below the minimum en route altitude through a bank of thick cloud in an attempt to spot the dim lights of a snow-covered airstrip. Talking about it, he curls his hands into fists then opens them wide, splaying his fingers. “Arthritis,” he says matter-of-factly. When he felt the trees hitting the plane, he instinctively raised his hands in front of his face. They were mangled in the crash, and he’s been losing feeling and mobility in them ever since.
"I run into burning buildings now, and I think my new career is much safer,” Vogel says. To support his three children, he also drives an eighteen-wheeler on his days off. When he’s trucking, he notes, he’s subject to constant checks to ensure he doesn’t exceed his duty time of fourteen hours a day, and his rig can be spot checked at any scale.
During the public inquiry into the crash, he asserted that Transport Canada was partially to blame for allowing airlines like Wapiti to cut corners, push their pilots, and put lives at risk. Then, in a precedent-setting case in 1990, the widows of two men killed in the crash sued the federal government and won. The judge in Swanson v. Canada (Minister of Transport) ruled that Transport Canada was one-third responsible for the deaths, having failed to sanction Wapiti for its repeated violations in the years preceding the crash.
Vogel hoped things would change for the better after Swanson, but he doesn’t think they have — a belief confirmed by “Jason,” a young pilot who declined to give his real name for fear of being blacklisted. Jason affirms that many of today’s bush pilots are cowboys, and says that those who promote a culture of safety are often dismissed. Last year, for example, he shared the cockpit with the owner and chief pilot of his company, during which he was expected to fly perhaps ten metres off the water with a planeload of passengers. “I told my boss I wasn’t comfortable flying below the minimums,” he says. His boss told him to lower them. This season, the company didn’t hire Jason back, saying he “hadn’t been helpful.” Another rookie pilot, who Jason says flew “like an idiot,” remained on the company’s roster.
THE WHISTLE-BLOWER
“Swanson meant a lot to me,” reflects Hugh Danford, a former aviation system safety inspector and course instructor with Transport Canada. Danford, who lives on a peaceful tract of farmland forty minutes from Ottawa, along the Rideau Canal, once taught new inspectors about Wapiti and the Swanson case as part of Transport Canada’s basic aviation enforcement course. “I used it as an example of why inspectors need to do their jobs,” he says, surveying his recently planted plot of garlic. Looking back, he now believes that Swanson, rather than ushering in an era of government responsibility, actually created a chill, marking the beginning of his department’s efforts to get out of the enforcement business.
Before he went to work for the government, Danford was a pilot. His career spanned thirty years and took him to places as far flung as the Arctic and Antarctic, North Africa, the Middle East, and the Maldives. Sixty-two, with a ruddy complexion, blue eyes that sparkle behind wire-rimmed glasses, and a full head of white hair, he’d be a shoo-in for a shopping mall Santa — if, that is, he weren’t so angry.
Danford started at Transport Canada in 1998. Shortly after being hired, he was appointed to a tri-national safety working group of Canadian, American, and Mexican aviation experts seeking to determine the root causes of North American airplane crashes. In 25 percent of the Canadian accidents he reviewed, lack of regulatory supervision appeared to be the problem. One of those accidents involved the “controlled flight into terrain” (literally, flying a plane into the ground) of a De Havilland dhc-6 Twin Otter off Davis Inlet, Labrador, in 1999. Marcel Jaspar, the pilot in command on the flight, which killed its twenty-two-year-old first officer, Damien Hancock, had been in four previous crashes and had a lengthy enforcement record with Transport Canada.
In spite of this, the department took no action against the pilot or the airline immediately following the Davis Inlet crash. Nor did it investigate the incident (it wasn’t until 2002, after Danford submitted a report, that Jaspar’s licence was suspended). The accident report released by the Transportation Safety Board in 2001 stated, “In certain areas of commercial operations, the safety oversight efforts of Transport Canada have been somewhat ineffective.” As a result of these findings, in June of that year the tsb issued Recommendation A01-01, which Danford calls one of the most important safety regulations in years. It urged that “the Department of Transport undertake a review of its safety oversight methodology, resources and practices particularly as they relate to smaller operators and those operators who fly in or into remote areas to ensure that air operators and crews consistently operate within the safety regulations.”
When he checked the government database that tracks Transport Canada’s responses to tsb recommendations (which the department is required to submit within ninety days), Danford found that the department was on record as having satisfied Recommendation A01-01. One of the initiatives cited as proof was a plan to implement a new safety protocol known as SMS. Another involved the hiring of a consulting firm to conduct a comprehensive review of the department’s safety oversight program for commercial operations.
Danford went looking for a copy of the review. And that, he says, is when the trouble began. His superiors told him to leave it alone; one, he says, referred to it as “worthless.” Eventually, he located the report — conducted by Montreal’s dmr Consulting Group at a cost to taxpayers of $690,000 — and discovered that it had nothing to do with Recommendation A01-01. “Transport Canada lied to Parliament,” he says.
His attempts to bring the situation to light made for some heated discussions. He had his mental health questioned, was arrested for uttering threats, and was ultimately forced to resign in 2004. The days that followed were dark ones, and he didn’t emerge until three years after his resignation, when a friend encouraged him to testify before Parliament’s Standing Committee on Transport, Infrastructure, and Community. Danford managed to get himself on the agenda for a review of Bill C-6, An Act to Amend the Aeronautics Act — the legislation sanctioning the controversial aviation safety management systems protocol.
The minute he entered the political fray, Stevens found him, and the two have been collaborating ever since. “She’s like a sister to me,” he says. His involvement in the campaign and the relationships it has forged have helped him overcome his anger. “Who knows?” he adds, scuffing the dirt under which 900 cloves lay buried. “If this garlic comes up, maybe I can make a living.”
THE PROTOCOL
Canada’s civil aviation fleet is the world’s second-largest, with close to 3,000 operators. It currently carries upward of 99 million passengers annually — a number that is expected to grow by 40 percent as of 2015. Like airlines in other countries, Canadian carriers are under intense pressure to cut costs and keep planes flying without interruption. According to the International Civil Aviation Organization — the UN agency responsible for supervising the safe and orderly growth of international aviation — the rapid expansion of the industry is making it increasingly difficult to manage safety with traditional methods. The icao has concluded that the solution is safety management systems, and has asked its member states to require airlines to establish them by 2012.
Safety management systems originated in the chemical industry in the early 1980s, with the aim of shifting to a focus on overall processes — that is, the interaction of human, organizational, technical, and environmental factors — rather than individual events. Presumably, this would allow organizations to identify potential hazards early on and take appropriate preventive measures. The approach has since gained favour in other industries. In 2001, for example, the Chrétien government introduced safety management systems into the Canadian rail sector.
Transport Canada has been promoting SMS for the civil aviation industry since at least 1999. One of the leading voices supporting the push is Merlin Preuss, who recently retired after a lengthy tenure as Canada’s director general of civil aviation. Preuss, who declined to be interviewed for this piece, has long maintained that SMS will allow for more thorough identification and resolution of potential problems. He describes the traditional regulatory approach as reactive, and suggests that SMS will make companies more responsive and proactive.
However, NDP MP and former transportation critic Peter Julian believes the experience of Canada’s rail system shows otherwise. “We saw derailments increase,” he says. Indeed, a 2008 report on the rail industry’s safety management policy, quietly tabled in Parliament last year, found that implementation had been inconsistent, and that Transport Canada hadn’t dedicated enough resources to the initiative. More recent data from the Canada Safety Council shows that fifteen major incidents had taken place on Canadian railways between January 7, 2007, and March 5, 2008 — more than in the previous six years combined. “The problem of SMS all along,” says Julian, has been that “theoretically, it’s a more intelligent way of approaching safety because companies are involved as well,” but in reality governments have tended to use the protocol to justify cutbacks.
Transport Canada has already introduced SMS to the business aviation sector, granting rule-setting responsibility to the Canadian Business Aviation Association in 2003. The decision in effect gave an industry trade association and lobby group oversight of the safety of its own members’ aircraft. In 2007, Transport Canada reviewed the changes the association had introduced and found a system plagued with problems. No structured system had been put in place, nor any procedures for cancelling or suspending an airline’s certificate. And some member companies had been operating without safety management protocols for five years.
“It’s the listeriosis of the aviation industry,” Danford says, referring to SMS implementation. Last year’s tainted meat scandal, which resulted in twenty-two deaths, occurred after the Canadian Food Inspection Agency shifted responsibility for food testing to the meat-packing industry. Following the outbreak, Richard Arsenault, a manager at the cfia, said, “It’s like in aviation: we can’t look under each jet engine of an airline, but we can make sure the maintenance service works.” As it turned out, not only had inspectors failed to swab for listeria on the plant floor, they had failed to check company records properly, to ensure that packers had performed the necessary tests and that their results were above board.
Ultimate responsibility for the transition to SMS lies with John Baird, Canada’s minister of transportation and infrastructure. According to a department insider, Baird has been especially wary of allowing civil servants to speak to the media about SMS, a subject the insider acknowledges is a “hot potato” for the ministry. Baird declined repeated requests for an interview, but in a letter to Ottawa’s Hill Times newspaper in March, he wrote, “Safety Management Systems are about adding more accountability to the inspection system, while maintaining the responsibilities of the federal government. In fact, the government continues to conduct independent audits and has access to more information than ever before. What SMS does is add another layer of accountability.” In a written response to an interview question for Baird, Transport Canada’s manager of media relations and monitoring, Patrick Charette, referred to SMS as “another layer of safety.”
“That is an absolute fabrication,” responds retired Alberta judge Virgil Moshansky, an internationally respected aviation authority. Lean and distinguished, the straight-talking former justice of the Court of Queen’s Bench is also a long-time pilot. Nearly two decades ago, that combination of credentials landed him the signature appointment of his career: head of the commission of inquiry into the 1989 Air Ontario crash at Dryden, a commuter airline accident in which twenty-four people died. Though tasked primarily with investigating the causes of the crash, Moshansky saw the commission as an exceptional opportunity for an in-depth review of the entire Canadian aviation system. His groundbreaking 2,000-page report, released in 1992, was arguably the most exhaustive judicial review in Canada’s aviation history. Its findings resulted in a number of significant aviation safety improvements, including stringent new de-icing procedures. It also helped earn him the Order of Canada in 2004, for singular dedication to enhancing aviation safety.
Moshansky now fears the gains he helped win are being eroded. Canada is the only country in the world introducing SMS without maintaining regulatory oversight,” he says from his Calgary home. He alleges that implementation of the new system is motivated primarily by budget concerns. “Transport Canada management is well rewarded for cost cutting,” he says. “And they save money by cutting the number of inspectors.”
He also notes that the government’s civil aviation inspectorate is significantly smaller than it was at the time of the Dryden inquiry, and has grave doubts that Transport Canada can ensure a safe aviation environment for the travelling public as a result. The department’s solution to this shortfall, he says, has been to axe its oversight programs, notably its national audit program. Under that system, cancelled a few years ago, federal inspectors conducted detailed checks and on-site monitoring of airline operations, meaning they boarded planes, rode along on flights, and studied maintenance logbooks. Moshansky’s paper also mentions a November 2006 directive from Transport Canada to its inspectors, which instructed that no enforcement action be taken against an SMS-covered enterprise except in rare circumstances. The judge tells of receiving confidential notes from the department’s inspectors expressing serious concerns about these trends. “The time is past due for a commission of inquiry to investigate the state of aviation in this country,” he says.
Last year, the Auditor General of Canada, Sheila Fraser, examined Transport Canada’s handling of air transportation safety. In her annual report to Parliament in May 2008, she commended the department for its leadership in introducing safety management systems, noting that Canada is one of the first countries in the world to do so in the aviation sector. However, she also raised a number of concerns. In reallocating resources from traditional oversight activities to SMS activities, she wrote, “the Department did not document risks, such as the impact of the transition on oversight of air transportation safety, or identify actions to mitigate the risks. Nor did it forecast the overall costs of managing the change. In addition, it has not measured the impact of shifting resources from traditional oversight to the new approach.”
Fraser later told a parliamentary committee that “Transport Canada could not demonstrate to us that it is carrying out a sufficient number of inspections during the transition.” She also noted that the number of inspectors and engineers in the department has decreased by 8 percent in the past five years, that “Transport Canada has not yet identified how many inspectors and engineers it needs, with what competencies, during and after the transition,” and that there is a “risk that the Department will not be able to recruit the people it needs in a timely manner.”
Greg Holbrook, former national chair of the Canadian Federal Pilots Association — the bargaining organization representing approximately 470 professional pilots who work as Transport Canada inspectors, tsb investigators, and civil air navigation professionals — asserted in an interview earlier this year (prior to taking a job as a Transport Canada inspector himself) that the International Civil Aviation Organization never intended for safety management systems to replace regulatory monitoring. “It’s like jumping into the water without a life preserver,” he said. He further contended, in concert with Moshansky, that SMS implementation wasn’t about safety. “If we go back to the documentation Transport Canada put together in 2001 [the same time Recommendation A01-01 was issued],” he said, “the proposal to implement SMS was justified to senior staff based on saving dollars, reducing the number of employees, and ultimately reducing the liability to the minister of transport.”
As pilots working in safety and enforcement at Transport Canada retire, he continued, the government is replacing them with “accountants” focused on inspecting paperwork rather than planes. His members were concerned. A survey commissioned by the cfpa in 2007 showed that while almost all respondents thought SMS could improve aviation safety in theory, two-thirds said that SMS as it was being implemented by Transport Canada would increase the likelihood of an aviation accident. One surveyed federal employee complained, “If the general public knew the amount of decisions made by Transport Canada supervisors regarding the safety of the air travel system in this country who are not professional members of the aviation community there would be a mass revolt.”
THE HUSH-UP
Transport Canada’s below-the-radar implementation of SMS has underscored long-standing concerns about the secretive nature of the department. In a 2007 paper presented to the Royal Aeronautical Society, Justice Moshansky revealed for the first time the challenges his commission faced during its three-year investigation into the Air Ontario crash in Dryden. Among other revelations, he wrote that the commission had contended with the sheltering of evidence, a lack of access to witnesses, widespread opposition, and threats of a Federal Court injunction by Transport Canada counsel for allegedly going beyond the terms of his mandate.
Twenty years on from the inquiry, he noted, “the public still continues to be without direct representation in aviation concerns. When the system breaks, the executive branch of government determines causality and identifies violations of legislative branch requirements. No one accountable to the public acts to establish the basis and appropriateness of these requirements and whether executive branch actions are sufficient and competently performed.” The result, according to Moshansky’s paper, is that “reporters and investigators are often unaware of significant aspects known only to airline safety managers.”
None of this surprises Robb Cribb, a reporter with the Toronto Star and former head of the Canadian Association of Journalists. Speaking from Toronto, he described Transport Canada as “one of the most resistant ministries when it comes to public accountability.” Cribb worked alongside colleagues from the Hamilton Spectator and the Kitchener-Waterloo Record on a major investigation into Canada’s aviation industry, published over 2006 and 2007. He and his fellow journalists were forced to wait four years for aviation accident data they requested from Transport Canada in 2001. It wasn’t until 2005, after they took their case to Canada’s information commissioner, and just days before the two sides were scheduled to go to court over the matter, that Transport Canada finally released the information. “I was astounded at how far they would go to protect data that is readily available in the US,” says Fred Vallance-Jones, a twenty-four-year veteran journalist who worked with Cribb on the investigation.
Last year, the CAJ nominated Transport Canada for its Code of Silence Award, for “proposed draconian secrecy provisions in amendments to the Aeronautics Act” — the same legislation that includes SMS. According to the CAJ, “If implemented, these will see a veil of secrecy fall over all information reported by airlines about performance, safety violations, aviation safety problems and their resolution.” Under the proposed legislation, voluntary reporting about safety-related incidents — including material from flight data recorders and self-reported violations — will remain confidential. Transport Canada argues that these measures are a necessary cornerstone of trust in a successful SMS. However, such legislation allows the department to shield information from public scrutiny by designating safety reports as “mandatory exclusions” under the Access to Information Act. Safety reports would therefore not be subject to access to information requests; they could never be released, nor reviewed by the Access to Information commissioner.
Most troubling of all to Transport Canada’s detractors, however, is that it is moving ahead with SMS even though the Conservatives have twice failed to pass supporting legislation in the House of Commons. “This is just contrary to democracy,” says the NDP’s Peter Julian. “One of the oldest rules of Parliament is that the government may not act without the legislative authority granted by the House of Commons and the Senate.” With opposition mounting, it has become unlikely that Bill C-7 will be reintroduced.
Transport Canada’s Patrick Charette responds to such complaints by saying, “Legislative powers are already in place for SMS expansion.” And indeed, the Aeronautics Act allows Transport Canada to introduce amendments to Canadian aeronautics regulations without parliamentary approval. Critics of SMS have therefore turned to the only recourse they feel they have left: capturing the public’s attention.
THE SUMMIT
This past April, Kirsten Stevens orchestrated an unprecedented gathering of parliamentarians, professional pilots, aviation experts, accident survivors, victims’ families, and whistle-blowers on Parliament Hill. The purpose was a round-table discussion on the decline of air safety in Canada. Fourteen people spoke for more than three hours on the crisis facing Canadian aviation, among them Stevens, Hugh Danford, Peter Julian, Greg Holbrook, and Jonathan Huggett, as well as representatives from the Canada Safety Council, Teamsters Canada, the Canadian Union of Public Employees, the Federal Accountability Initiative for Reform, and Canadians for Accountability. At a press conference afterward, NDP transportation critic Dennis Bevington remarked, “From what I heard, this is a disaster waiting to happen. Transport Canada and the Transportation Safety Board have developed a culture of secrecy, where whistle-blowers are persecuted and fatal accidents are seen as just a cost of doing business.
Also present in Ottawa this year, if a bit earlier in the spring, was a woman named Freda Hancock, the mother of the twenty-two-year-old pilot killed in the Davis Inlet crash that first attracted Hugh Danford’s attention. The 1,500-kilometre flight west from her tiny Labrador community was the first time in the decade since her son’s death that the soft-spoken, elegant woman had found the strength to speak personally with the former Transport Canada inspector. Hancock said that when he first contacted her, five years after the crash, she wasn’t able to hear what he was telling her — that the system had killed her son. “They’re the people who were supposed to protect you and keep you safe, and you realize they failed you,” she said from Danford’s home, where she was staying. “I took all of this for granted. I didn’t stop to think that somebody wasn’t doing their job.”
In the wake of the round table, Danford was left feeling optimistic that the hardship he’d inflicted on his family and himself might not have been in vain. “All 900 heads of garlic came up,” he said in a recent phone conversation. He’d just mailed a box of bulbs from his harvest to Stevens, who was still putting in full days on her campaign. She’d just launched SafeSkies.ca,designed as a virtual rallying point for aviation safety advocates, and a watchdog for transparency and public accountability at Transport Canada. “We need people who are willing to stand up and be vocal and tell the truth,” she told me, “or we’ll see more victims — like those at Davis Inlet, like those at Dryden, like those at Wapiti, like those in my accident. It’s people like me who can remind everyone why it’s so important to do it right the first time.”
Link to original article from The Walrus.
Former Advocate for Floatplane Safety
Re: The Walrus: Fly at your own risk
Best damned garlic I've ever had the pleasure of consuming.“All 900 heads of garlic came up,” he said in a recent phone conversation. He’d just mailed a box of bulbs from his harvest to Stevens ...
Special thanks to "Jason".

Former Advocate for Floatplane Safety
Re: The Walrus: Fly at your own risk
Well at least the garlic made it to BC...
Re: The Walrus: Fly at your own risk
Beyond 90 Seconds
The official blog of markhorner.com
“Fly At Your Own Risk” is excellent journalism
Earlier this week, I came across a very compelling story out of Canada. The headline: “Fly At Your Own Risk: Why is Transport Canada moving toward self-regulation for the country’s airlines?”
I find that my mind keeps going back to reporter Carol Shaben’s story, featured in The Walrus magazine. So, I’ve decided to write a bit about it here, not just because the topic itself is worthwhile. But also because the reporting really shines.
This is journalism that matters. And it’s done the good ol’ fashioned way; with lots of digging and relevant interviews. To top it all off, Shaben is an excellent writer.
Perhaps you think you don’t care about some aviation story out of Canada. And maybe you really don’t. Still, here’s my little challenge for you: Read the first few paragraphs of Shaben’s story. And see if you really want to stop reading.
Former Advocate for Floatplane Safety
Walrus article
Just read the article in the latest Walrus magazine (walrusmagazine.com). Seems like the campaign is starting to gather some serious momentum and hopefully it will soon be an unstoppable force.
Good work Widow et al.
Good work Widow et al.
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Re: Walrus article
There's another really interesting article in there this month about how we use our brains to navigate, and how GPS might be impairing that. In that article, there's a link to a neuroscience lab that is doing research on the topic - they have a fairly long (~90 min) quiz that they are getting as many people as possible to take to discover more about how we do find our way around.
Say, what's that mountain goat doing up here in the mist?
Happiness is V1 at Thompson!
Ass, Licence, Job. In that order.
Happiness is V1 at Thompson!
Ass, Licence, Job. In that order.
Re: Walrus article
An important article. All new pilots should read it. Twice.
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Re: The Walrus (magazine): Fly at your own risk
I wear a tin foil hat which protects me from the GPS signals.There's another really interesting article in there this month about how we use our brains to navigate, and how GPS might be impairing that.
I am in the process of setting up a small business to make and sell them.
They come with either four or three gold bars embossed on the front.
Anyone wishing to buy one of these just PM me.

P.S. :::
For helicopter pilots it will come with a free turning rotor on the top...no gold bars though.
The most difficult thing about flying is knowing when to say no.
After over a half a century of flying I can not remember even one trip that I refused to do that resulted in someone getting killed because of my decision not to fly.
After over a half a century of flying I can not remember even one trip that I refused to do that resulted in someone getting killed because of my decision not to fly.
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Re: The Walrus (magazine): Fly at your own risk
Sign and mail the petition on Safeskies.ca if you wanna make a difference!
Re: The Walrus (magazine): Fly at your own risk
I read the article and was thoroughly impressed, but I have a question that has nagged me for weeks: where's the tattoo??
"What's it doing now?"
"Fly low and slow and throttle back in the turns."
"Fly low and slow and throttle back in the turns."
Re: The Walrus (magazine): Fly at your own risk
Former Advocate for Floatplane Safety
Re: The Walrus (magazine): Fly at your own risk
Being new to the aviation industry I find all of this fascinating.
I am 25, otherwise educated at post secondary institutions and have (stupidly?) decided I would prefer to be a pilot.
First and foremost, getting this kind of information is vital in knowing how to move forward with a career and make the correct choices.
Secondly, it baffles me that a government agency is doing its darndest to save money in an area that the public would very very easily accept expenditures. It just doesnt make sense to me.
Lastly, Widow, keep at it, I am sorry for your loss as obviously it has been tough on you. However I do believe what you are now doing is for the best.
Regards,
I am 25, otherwise educated at post secondary institutions and have (stupidly?) decided I would prefer to be a pilot.
First and foremost, getting this kind of information is vital in knowing how to move forward with a career and make the correct choices.
Secondly, it baffles me that a government agency is doing its darndest to save money in an area that the public would very very easily accept expenditures. It just doesnt make sense to me.
Lastly, Widow, keep at it, I am sorry for your loss as obviously it has been tough on you. However I do believe what you are now doing is for the best.
Regards,
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Re: The Walrus (magazine): Fly at your own risk
Unfortunately, it's not about saving money; they are as you pointed out, a government agency and therefore don't care how much money they spend. Sadly, it's all about reducing liability when something inevitably goes wrong. "We gave them the tools to police themselves and ensured they had all the procedures in place; they cheated, it's not our fault."ogc wrote:Being new to the aviation industry I find all of this fascinating.
I am 25, otherwise educated at post secondary institutions and have (stupidly?) decided I would prefer to be a pilot.
First and foremost, getting this kind of information is vital in knowing how to move forward with a career and make the correct choices.
Secondly, it baffles me that a government agency is doing its darndest to save money in an area that the public would very very easily accept expenditures. It just doesnt make sense to me.
Lastly, Widow, keep at it, I am sorry for your loss as obviously it has been tough on you. However I do believe what you are now doing is for the best.
Regards,
- Stan Darsh
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Re: Walrus article
Da magazin for dems smart people.luckyboy wrote:An important article that should be in an important magazine. What is the Walrus anyway?FOX69 wrote:An important article. All new pilots should read it. Twice.
Re: The Walrus (magazine): Fly at your own risk
Oddly, "dems smart people" tend to be the ones who act, rather than remain complacent.
Former Advocate for Floatplane Safety
- Stan Darsh
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Re: The Walrus (magazine): Fly at your own risk
True enough, although a quick survey of the types of posters here would suggest these stories would be better presented in comic form in MAD or MAXIM.
Re: The Walrus (magazine): Fly at your own risk
Kirsten, I had another look at your tattoo and yes, it is a real conversation starter, but I confess to being just a tad disappointed....
Now, back to your regularly-scheduled programming.
Now, back to your regularly-scheduled programming.
"What's it doing now?"
"Fly low and slow and throttle back in the turns."
"Fly low and slow and throttle back in the turns."
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Re: The Walrus (magazine): Fly at your own risk
For as much as a 'company' pushes their pilots to fly weather/ heavy/ crappy machinery... it's not 'the company' that cranks up the engine(s) and blasts off into the wild blue. Society can try to fix the ancillary effects of a fundamental flaw all it wants, but until the root cause is addressed, little progress can be made.
My condolences.
My condolences.
Re: The Walrus (magazine): Fly at your own risk
An interesting letter to the editor.
http://www.walrusmagazine.com/articles/ ... letters/3/Safer Trip
In “Fly At Your Own Risk” (November), Carol Shaben alerts us to Transport Canada’s dilatory response to questions surrounding the inadequacy of its safety oversight program: an apparently irrelevant $690,000 consultants’ study. Indeed, this is precisely the type of bureaucratic game I discussed some eighteen years ago in connection with the disintegration of the Transportation Safety Board’s sad predecessor, the Canadian Aviation Safety Board, in my book Improbable Cause.
But while Shaben looks to Justice Virgil Moshansky’s brilliant report on the 1989 Air Ontario crash at Dryden for a solution, his analysis was by no means the first. Roll back the clock another decade to the Commission of Inquiry into Aviation Safety, initiated in the wake of a deadly air crash at Cranbrook, BC. Based on exhaustive hearings and frightening case studies, Justice Charles Dubin urged the creation of a long-sought-after independent tribunal to investigate aviation accidents and conduct public inquiries in the interest of aviation safety. Had the resulting casb functioned as intended, Moshansky’s inquiry would have been unnecessary. (Judge C. H. Rolf had, presciently, made this very observation about his own inquiry into the 1984 Wapiti Aviation crash.)
After the CASB’s collapse, following the scandalous investigation of Canada’s worst-ever aviation disaster — the crash of the Arrow Air DC-8 in Gander, Newfoundland, in 1985 — the legislation drafted to replace it didn’t incorporate recommendations from a study (yes, another) by future Supreme Court justice John Sopinka that reiterated Dubin’s call for a truly independent tribunal. Instead, the new multi-modal tsb became “an agency of inefficiency, secrecy and chronic timidity,” according to yet another long-forgotten study — a year-long review of the TSB’s first three years of operation conducted by former Alberta cabinet minister Louis Hyndman.
Do we need yet another inquiry at this point to rediscover Justice Dubin’s remedy? Or should we focus on the record of thwarted reforms and the twice-failed implementation? Remember, every time history repeats itself the price goes up.
Les Filotas
Ottawa, ON
Former Advocate for Floatplane Safety
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Re: The Walrus (magazine): Fly at your own risk
Les Filotas' book Improbable Cause describes how the CASB board members were expected to be window dressing, like children seen and not heard, and leave all the decisions to the chair and his investigators.
The board members attempted to exercise their responsibilities as expected of any diligent board cognisant of their obligations to their constituency, in this case the public as opposed to stockholders. This was perceived as a rebellion by the great unwashed.
The government eventually abolished the CASB and the investigating staff transferred to the TSB.
Certain members of this forum are not particular fans of how TC is run. Mr. Filotas raised concerns that TC's bureaucratic failings are also endemic to the TSB, at least at its inception.
Having had the misfortune to witness a fatal accident, I have observed that in glaring contrast to the NTSB, the TSB holds the factual cards extremely close to its chest before and after any final report is issued.
NTSB dockets are accessible on the web in great detail. Try to find anything factual from the TSB on any open investigation.
The board members attempted to exercise their responsibilities as expected of any diligent board cognisant of their obligations to their constituency, in this case the public as opposed to stockholders. This was perceived as a rebellion by the great unwashed.
The government eventually abolished the CASB and the investigating staff transferred to the TSB.
Certain members of this forum are not particular fans of how TC is run. Mr. Filotas raised concerns that TC's bureaucratic failings are also endemic to the TSB, at least at its inception.
Having had the misfortune to witness a fatal accident, I have observed that in glaring contrast to the NTSB, the TSB holds the factual cards extremely close to its chest before and after any final report is issued.
NTSB dockets are accessible on the web in great detail. Try to find anything factual from the TSB on any open investigation.
- Dust Devil
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Re: The Walrus (magazine): Fly at your own risk
That won't be realized till every operator is crucified in the town square and people see that airplanes are still crashing.Blue Side Down wrote:For as much as a 'company' pushes their pilots to fly weather/ heavy/ crappy machinery... it's not 'the company' that cranks up the engine(s) and blasts off into the wild blue. Society can try to fix the ancillary effects of a fundamental flaw all it wants, but until the root cause is addressed, little progress can be made.
My condolences.
//=S=//
A parent's only as good as their dumbest kid. If one wins a Nobel Prize but the other gets robbed by a hooker, you failed
A parent's only as good as their dumbest kid. If one wins a Nobel Prize but the other gets robbed by a hooker, you failed