"Danger overhead: Why Transport Canada cuts are a red flag"

[golden hawk]

http://www.theprovince.com/news/canada/ ... story.html

Danger overhead: Why Transport Canada cuts are a red flag for small commercial aviation safety


BY SARAH SCHMIDT, POSTMEDIA NEWS MARCH 31, 2013


OTTAWA — Thirty-nine seconds after takeoff, the co-pilot of a Beechcraft King Air reported a problem with the right engine to the control tower at the Quebec City airport and said the aircraft was returning to land.

“We’re unable to climb,” he reported on the early morning flight to Sept-Iles on the north shore of the St. Lawrence before the last communication on June 23, 2010.

Nine seconds later, the small plane, less than 50 metres above the ground and travelling at 100 knots, disappeared from radar. It crashed into a field, hurtled 35 metres along the ground, hit a berm, then broke up and caught fire.

The two crew and five passengers survived the initial impact, but died quickly, likely from the fire’s intense heat.

The accident was a brutal, tragic example of a peril facing Canadians who travel and work in places served by small air operators. Because of their small size, crashes involving these companies don’t usually garner national attention. Yet they are shockingly common.

Just as shocking is the regulatory vacuum into which these small commuter operations have fallen — an issue that alarms Canada’s Transportation Safety Board.

Some recent accidents:

-In November 2012 a crash near Snow Lake, Man., killed a Gogal Air Service pilot who was on the first leg of a trip to bring seven miners back to their homes in Eastern Canada.

-In December 2012 a flight chartered for Keewatin Air crashed during a second landing attempt in blowing snow at the Sanikiluaq airport in Nunavut, killing a six-month-old. The aircraft belonged to Winnipeg-based Perimeter Aviation.

-In January 2013, in a disaster that got publicity because of its location, a three-man crew from Calgary-based Kenn Borek Air died after their Twin Otter crashed into a steep mountain slope in the Antarctic.

Air taxis and small commuter operations are essential parts of Canada’s transportation network. They bring residents from the North back home. They transport tourists to fishing lodges. They do aerial survey work.

They carry people such as public servant Gerald Joncas, aboard that fatal 2010 flight leaving from Quebec City for Sept-Iles and operated by air taxi service Aeropro.

Joncas, a financial administrator for Canada’s Department of Aboriginal and Northern Affairs who travelled regularly to remote spots, was working on a new school project for an Innu community. At 58, he was a grandfather of two little girls, and his blended family included the two grandchildren of his partner, Rita Roy.

More than two years after Joncas perished in the Aeropro crash, Roy says, “I’m sure there were times when things happened, there were some doubts or fear, but he didn’t express them.”

“I think it’s something we avoided talking about,” she says.

Aeropro’s crash was one of 44 accidents involving air taxi operations in Canada that year. Air taxi accidents accounted for more than half of the 86 commercial flight accidents in 2010 — among aircraft of any size.

In 2012, there were about three accidents a month involving air taxis: nearly half of all commercial accidents, or 34 of 72.

Together with other small operators — doing aerial surveys or patrolling pipelines, providing commuter access to remote towns, or offering chartered helicopter services — they accounted for 91 per cent of commercial aircraft accidents and 93 per cent of commercial fatalities from 2002 to 2011.

That’s 859 accidents in smaller commercial aircraft throughout the decade, and the deaths of 253 people — including 169 in air taxi crashes alone.

These statistics “hit you in the face,” Transportation Safety Board chairwoman Wendy Tadros told Postmedia News. “That’s where we have to go in our investigations to see what we can learn and what needs to be done.”

Small air operators are being pushed to take on more direct responsibility for their own safety practices as Transport Canada — and other regulators worldwide — pull back from the detailed, routine, hands-on safety inspections they once did for all commercial aircraft.

The regulators are wrestling with how to oversee an ever-expanding civil aviation system without any corresponding growth in their own resources to monitor safety. The government’s choice of tool for this over the last decade is known as a “Safety Management System,” or SMS.

The idea is simple: require all air operators to develop their own means of identifying potential safety hazards in their operations, then make them develop plans to address them. The air operator then sets up an internal reporting system to address complaints or concerns from its own staff.

Under SMS, Transport Canada inspectors no longer routinely do what they once did: perform regularly scheduled audits and direct inspections of aircraft and personnel. Now they mostly assess, primarily by reviewing company records, whether aviation firms have their own effective safety protocols. Hands-on inspections do still happen, but much less frequently than in the past.

The transition to SMS, which began in 2005, was bumpy but is now complete at Canada’s large commercial carriers, which say the new system works.

But it’s in disarray at small carriers. Who’s to blame depends on whom you speak to.

The initial target date to make SMS mandatory at small carriers was 2009, and some began the process, but Transport Canada decided at the end of that year to push the deadline until at least January 2011.

The department has since indefinitely postponed the mandatory implementation of SMS for air taxi and small commuter operations, and there is confusion — and growing industry unrest — about next steps for these small commercial companies.

Despite the postponement, Transport Canada stopped its routine inspections even of the small carriers — treating each as if they actually had an SMS in place. Many feel the result has been a safety vacuum.

There are two issues: this delay in implementing SMS now that there is less direct government oversight; and whether, even if SMS were implemented, it would be the right call for small air operators.

SMS may work at a large carrier, such as Air Canada or WestJet, with internal expertise and resources to draw on, but air taxis are often run as family businesses, with slim profit margins. They are also more likely to be flown by inexperienced pilots eager to log flight hours, working under higher-risk conditions — for instance flying older aircraft or landing on remote airstrips not overseen by air traffic controllers.

The Transportation Safety Board’s most recent watch-list, which annually flags issues posing the greatest risk, focuses on what it sees as the rocky transition to SMS at companies such as Aeropro, which lost its licence to operate after the 2010 crash — its fourth accident in eight years.

The safety board wants SMS adopted at all small air operations. Until then, it “remains concerned regarding the risks to Canadians.”

To many, SMS is a safety step forward.

“You’re inspecting the operator at a higher level,” says Bill Voss, who recently left his post as president of the Flight Safety Foundation in Virginia to return to the U.S. Federal Aviation Administration as an executive in aviation safety.

“You’re got regulators forcing operators to step up and to really demonstrate an understanding of their operation and their risks, as opposed to looking at all the minutiae — the quality of your logbook entries; do you have proper training records? Those things are important on some level but are not nearly as significant as forcing the operator to show you that they’re competent and able to manage their risks.”

Transport Canada says it’s hard for small air taxis and tiny commuter operators to handle these tasks, however, so it hasn’t required them to have an SMS despite reducing its own traditional inspections and audits.

Safety oversight today — for all carriers — largely means periodic, on-site reviews of a company’s documentation by Transport Canada, focusing on a given operational system. In the jargon, that review is known as a Program Validation Inspection (PVI).

There had been signs of trouble long before the latest Transportation Safety Board watch-list — and even before the Aeropro crash in 2010. The problem encompassed not just small operations.

In 2008, Sheila Fraser, then Canada’s Auditor-General, probed how Transport Canada handled the transition to SMS at large air carriers. She concluded Transport Canada had failed to sort out how the day-to-day work of its inspectors should change as SMS-related activities took up more time at the expense of traditional inspections.

Fraser also said she had expected Transport Canada to continue traditional oversight during the transition.

The large operators made the change to SMS. Yet, with the small operators, Transport Canada decided to simply drop traditional oversight during the — now-postponed — transition.

“We felt that it doesn’t make sense to have one way of inspecting an SMS company and another way of inspecting a non-SMS company,” Transport Canada assistant deputy minister of safety and security Gerard McDonald said in an interview.

The industry association representing many smaller operators says they’re ready for SMS regulations — but companies are waiting for Transport Canada to set out the rules.

“I think safety consciousness is there,” said John McKenna, president of the Air Transport Association of Canada. “It’s just that some companies will always try to cut corners … That’s what Transport Canada’s job is: it’s to make sure these people are no longer in operation.”

Transport Canada seems wary of taking the plunge.

“They say, ‘Yes, we agree with SMS but we don’t think industry is ready for it yet.’ Basically, what that means is they are not ready for it,” McKenna said, pointing to staff shortages at Transport Canada.

Transport Canada disagrees. “What we’re trying to do is assess whether or not implementing SMS for (these smaller) carriers is going to achieve the desired result,” said McDonald.

Safety oversight today — for all carriers — largely means periodic, on-site reviews of a company’s documentation by Transport Canada, focusing on a given operational system. In the jargon, that review is known as a Program Validation Inspection (PVI). “We recognize smaller carriers don’t certainly have the capacity to implement the same type of SMS system that Air Canada does,” McDonald said. “You know, some of them are mom and pop organizations, so what do we ask them to do?”

McDonald said he has no qualms about boarding any plane in Canada, no matter how small.

“But I want to stress, if we find that there’s any operation that we’re responsible for the oversight of that’s in any way unsafe, we take appropriate action, up to and including shutting them down.”

But Transport Canada doesn’t always seem to be looking.

In an audit of its civil aviation division released in April 2012, current Auditor-General Michael Ferguson found that the department completed only 67 per cent of “planned inspections” noted in Transport Canada’s 2010-11 annual surveillance plan. Annual surveillance is reserved for what are deemed higher-risk air operations, but the audit noted these high-priority inspections at about 500 companies were postponed or cancelled because resources were not available or inspectors didn’t have time.

Transport Canada won’t say if this surveillance activity backlog has been cleared, but that it’s now completing, on average, 94 per cent of scheduled inspections each month.

What we do know, is what Transport Canada did — or failed to do — with Aeropro.

The investigation report, recently made public, revealed that Transport Canada conducted a PVI at Aeropro in October 2009 — and it didn’t go well. For example, inspectors discovered the company hadn’t had a chief pilot for its commuter operations for a full year. Transport Canada’s PVI manager said the department would conduct what’s known as “enhanced monitoring” at Aeropro, 90 days of intense Transport Canada scrutiny of the operator.

That “enhanced monitoring” never happened. Transport Canada’s regional director, following a risk assessment, decided against it.

Doug Calder, a former air force pilot, joined Transport Canada in 1990 and eventually became the superintendent of certification before retiring in 2008. He looked after big jets and says they are the priority when it comes to risk.

“At a certain point, risk management becomes ignoring risk,” said Calder. “747s make big holes, Cessna 172s make small holes. You’ve got one inspector, he inspects the 747. It’s an exaggerated case, but it’s exactly what it is.”

Calder added: “Little regional operators around the country don’t make very big holes and they don’t hit the front page of very many big newspapers, so the risk that they’re managing is always the political risk.”

In the Aeropro crash, the absence of on-the-ground inspection meant Transport Canada didn’t know, for instance, that the company had directed its pilots to take off with reduced engine power, even though the FAA-approved aircraft flight manual for the Beechcraft A100 King Air included no such provision.

TSB investigators flagged this practice, which was designed to stretch the life of the engine, as a cause and contributing factor in the crash. The poor safety culture at Aeropro was also cited.

Daniel Slunder, head of the union representing pilot inspectors at Transport Canada, says in the old days Transport Canada inspectors conducted “check rides” — they would have observed pilots taking off without full power and would have put a stop to the company’s practice.

Looking for shortcuts is not uncommon, said one pilot at a small operation who asked not to be named. “We call it playing ball, it’s kind of twisting the rules, bending the rules. It’s these subtle little nudges in a bad direction.”

Gord Marshall thinks Transport Canada will have to abandon altogether its hopes for eventually having SMS at air taxis and smaller commuter operators and restore — even boost — traditional front-line inspections.

“I’m hearing from inspectors inside, they’ve been at this for almost 10 years to try and figure how to make (SMS) work and if you can’t do it in 10 years, the likelihood of coming up with a reasonable approach, I just don’t think it’s going to happen,” said Marshall, who worked as an inspector of maintenance operations for 17 years at Transport Canada in B.C. until 2006.

Whatever Transport Canada decides, it’s too late for those who died during Aeropro’s last flight.

“There were things that weren’t okay. There were infractions and Transport Canada didn’t act before. That I don’t understand at all,” says Rita Roy, the partner of federal civil servant Gerald Joncas.

“It took seven deaths for them to act.”

© Copyright (c) Postmedia News

[CID]

I'm curious. What do you think TC would have done differently if they had 3 times the inspectors and used the old audit processes? Many of the accidents cited in the story above haven't even been investigated yet for cause. It hasn't been determined if any sort of lack of oversight occurred.

What I do sense is a new movement from the operators who are scrambling to find ways to blame their woes on the regulator. I've been around awhile I personally haven't seen an increase of accidents in this sector. Yes you get a few bunched together once in awhile but that's the way chance works.

Read this:

http://www.tsb.gc.ca/eng/stats/aviation/2010/ss10.pdf

You will find that Air Taxi accident rates have been steadily decreasing but they have always had high comparative accident rates.

Anyway, the story is all over the place. Lots of open ended statements about crashes in a sector that doesn't mandate SMS yet. Yet the writer stealthily implies that SMS is the cause while not acknowledging that accident rates are steadily decreasing. Can you say "hidden agenda"?

[SRV]

The problem isn't oversight, it's the "eyes" that do the overseeing. The attrition rate of industry experienced Civil Aviation Inspectors has exceeded the replacement rate of the Inspectors. And not only that, the new hires lack industry experience.

The fight to break the CFPA is the problem, there is no attraction for a qualified pilot to join TC, the flying program has been slashed to a pittance of its former self, internal training has ground to a halt all in the name of a balanced budget.

Public Safety is too expensive.

[armchair]

The fight to break the CFPA is the problem

I agree with everything you said, but can you expand on the quote above?

[sprayrail]

So SRV, let me get this straight, the root of the problem is that there just aren't enough pilot inspectors with experience to do the job and so aviation safety suffers. I think you need to have a good look around you and realize that doing route checks and reviewing training records and operational flight plans does not make anyone any safer. The current cuts within government have an effect on the whole organization including those within it that do most of the heavy lifting throughout the year and are rarely away doing sim training on aircraft you'll likely never see.

[All Sides]

So SRV, let me get this straight, the root of the problem is that there just aren't enough pilot inspectors with experience to do the job and so aviation safety suffers. I think you need to have a good look around you and realize that doing route checks and reviewing training records and operational flight plans does not make anyone any safer. The current cuts within government have an effect on the whole organization including those within it that do most of the heavy lifting throughout the year and are rarely away doing sim training on aircraft you'll likely never see.

I believe that what SRV is trying to say in a nutshell is: that if you gut the ability for inspectors to maintain some form of currency for their chosen profession, they will have fewer experienced applicants; that if you cut the budget to the bone there will not be any oversight (already isn't); that weakening the CFPA will reduce remuneration, resulting in fewer applicants; and that the whole aviation industry will be less safe. Correct me if I am wrong SRV.

The old system of hiring ex-military pilots and techs with no civilian aviation experience didn't work, TC was just starting to hire a higher percentage of civilian aircrew. Unfortunately, SMS was introduced to limit liability and reduce TC costs. I think that a shortage of inspectors will only make a terrible situation worse from a safety standpoint, not that the old system didn't have serious deficiencies. If there is no oversight, all you have is anarchy. Tell me how that makes our job safer?

[armchair]

We all know Sarah Schmidt is right, that Moshansky is right, and that Slunder is right - and so is the TSB which is incapable of driving this message through to the public without those aforementioned people. In fact, Schmidt, Moshansky, Slunder and many others such a Widow, Bevington, several whistleblowers and then some , have screamed this out and loud for years. The problem? The government doesn't give a shit, and when I say the government, I don't mean the rank and file at TC, I mean the Conservatives, and particularly the Treasury Board and its evil-doer Tony Clements.

In part II of her current 3-part series on aviation safety, Schmidt merely repeats what she has said in previous identical efforts since 2008, but still will probably get some random investigative award from seem attention-seeking media group. She said something like "they [government] can't dismiss Moshansky..." Well, dear and dedicated Sarah, I hate to break it to you, but they not only totally dismiss the old guy, they absolutely don't care about you, him, the inspectorate, and the cavalry of horses we pretend to ride on. Indeed the only hope is a major crash with 100+ "blacks", one that will bite the bullet for the rest of us, but a remote First Air crash in Rez ain't enough. We need AC or WJ to play land dart at Pearson, no less. Or a major runway collision. Or another Wapiti or Cranbrook but smart politicians know better than fly 703.

On the pilot inspector file, there will always be ATPLs ready to join up, but the new establishment truly hates pilots and is doing is best to replace them with non-licensed generalists, or simply eliminate as many pilot inspector positions as they can. Indeed TC is no longer an "employer of choice" for pilots, at least, not as much as it used to be.

On the "best safety record ever", we are currently riding on the safe system established by Dubin and Moshansky in the 80's and early 90's. NAVCAN is strong but also vulnerable with recent very close calls on significant runway incursions... Very low probability...but disastrous severity. Industry needs and wants a strong and involved inspectorate, one that matters and works with industry. Moshansky is right, and he knows the government dismisses him. The TSB Watch List is also right, but TC can only pay lip service to it because it has no resources to do anything about it.

As usual, it's all about money. Safety ain't cheap, and soon enough we'll be reminded of it.

[Prairie Chicken]

That's a good article. I think Ms. Schmidt hits the nail squarely on the head.

Unfortunately I also have to agree with armchair. The bottom line is money.

[SRV]

Armchair/All Sides et al:

Absolutely. Those are indeed the facts.

sprayrail: your points are fair but not my point.

[human garbage]

...The government doesn't give a shit, and when I say the government, I don't mean the rank and file at TC, I mean the Conservatives, and particularly the Treasury Board and its evil-doer Tony Clements...

I stopped reading at that point. Blaming Darth Harper and his minions as the root of all evil at TC is facile beyond belief. The rot started long before the CPC. Ask Cat if they were in office when he was bent over...

[Cat Driver]

The rot started long before the CPC. Ask Cat if they were in office when he was bent over...

The rot has been growing for decades.

My legal fight with TCCA was wrongdoing by TCCA not me.

It has been quite a few years since my case was decided and it was proved they denied me due process, the $250,000.00 I was supposed to get has yet to show up....and I doubt if it ever will.

Who is accountable for these failings at TCCA?

Obviously no one.

Who do I personally hold accountable?

Two former DGCA's and the present RDGA in my region.

At least I had the satisfaction of proving they do not obey the very laws they are sworn to uphold and I can without fear once again state.

" If I see a TCCA official approaching me I am in far greater danger than if I were being approached by a common street criminal "

[2.5milefinal]

SMS
PVI

Pretty acronyms that only work on paper and don't do very much for the little guy that works at a small outfit.

[SRV]

Merlin the magician started the downhill trots although for a period from 2000-2005 the moral was very high amongst the Rank and File. Presently Treasury Board meddling should be a red flag but is completely denied by the royalty in YOW.

[CID]

During the decades-long down-slide that Cat Driver has described, aviation safety has done nothing but improve statistically. Was he part of the solution or part of the problem?

The old public "common sense" mantra that more police makes for a safer society just doesn't work. Police don't prevent crime, they enforce compliance by arresting and making charges AFTER the crime is committed.

If there is little indication of crime in a specific area, flooding the area with police makes no sense.

Yes, there are crooks and morons out there and there always will be but it's becoming much harder for those crooks to start up commercial aerospace operations.

It's a bizarre situation in some ways as mirrored by many AvCanada posts. I read complaints about how difficult it is to become certified as an operator and disgust at SMS which places the onus on the operator to prove themselves to TC to secure and continue to hold certification....only to complain that more "police" would be a better solution. I read between the lines and realize that people generally want to just make a few bucks flogging a death trap with strangers for a few years like the old days!

One thing we need to remember about people like Moshansky is that the they are not technical experts. He was (is) a legal expert who relies on the technical expertise of others to form the legal basis of decisions. Moshansky's icing work was a masterpiece as it was backed up by some of the best technical experts in the world.

His latest rants on SMS and the state of aviation safety don't enjoy the same credentials. He's just using his "gut" for the most part. It's like having Bill Lear giving legal advice on constitutional law.

I'm not sure if SMS will be a Godsend or if it will even work but I've had similar feelings about every single other TCCA policy in history. I've watched as people declared the CARS as the death knell of aviation. Still waiting.....

[SRV]

CID:

I agree, however SMS is only a tool. Those at TC who use the tool are not being given a fair working environment from which to work as you are painfully aware. ie, CFPA CBA in turmoil, despite the what the union haters say.

[Cat Driver]

During the decades-long down-slide that Cat Driver has described, aviation safety has done nothing but improve statistically. Was he part of the solution or part of the problem?

Good question.

Lets look at facts.

I took TC to task for abuse of power and won my complaint.

During my career of over thirty thousand hours of accident free flying and never having been charged with non compliance to the law as well as having been in management in several 703 through to 705 companies, and having owned several of my own aviation companies I would suggest I was part of the solution.

[CID]

That's a feat anyone would be proud of Cat Driver. Well done.

[Cat Driver]

That's a feat anyone would be proud of Cat Driver. Well done.

Thanks:

I became a member of the new college of pilots even though I no longer fly for a living.

My reason for joining was to hopefully be a benchmark to those who are starting a flying career.

By examining my career they can understand that you can say no when it is necessary and live to be old and have had a successful career to look back on.

. E.