I'm going to read initially from what I've written. It's a little longer than seven minutes, but I'll cut it short.
I would like to personally thank the steering committee for taking the time to let me appear before you today to express my ideas. It should be made clear that I am here on my own accord, speaking as Citizen Carson, not Inspector Carson, or Captain Carson, or Dr. Carson--all of these euphemisms we attach to ourselves to make it easier for others to deal with us.
It should also be made clear that I personally am a believer in safety first and pretty much everything else second, including profit. I can unequivocally state that I am a supporter of concepts like SMS.
First, what is my background? It includes about 40 years of work experience, 30 of them in aviation; four university degrees, one in aeronautical engineering, including a PhD in applied math; approximately 10,000 hours of flying, all civilian, including for two prime ministers and several CEOs of a couple of Canada's largest corporations. I have been any number of things in my aviation career, including flight safety officer and occupational health and safety officer at a couple of companies. Many years ago I took a course on system safety at the University of Southern California in San Diego, and just recently I took TCCA's course on SMS.
SMS is not a new concept. It has been around in various forms for many years. There are many things about an SMS program that would be highly beneficial. It is certainly a better idea to have everyone in any organization safety conscious instead of vesting that job solely in an individual like me, for example, with minimal staff, as many air operators have done in the past.
Having the onus put on an organization to have them operate within a safety-minded culture is certainly better than operating any other way. However, although the concept of safety in itself can mean very specific things, it is sort of like a religion: you either believe in it or you don't. By that I mean you either believe you can operate safely within the rules and do the job cost effectively or you believe the rules you have been asked to follow are merely suggestions and the only thing that matters is the bottom line. Safety is expensive. Far too many aviation companies believe the regulations are just that, guidelines, and it is okay to bend them to the limit, if not outright break them, as long as nothing goes wrong or you don't get caught.
Hence the subject of my visit. In front of you today is something that I think is missing, in part, in order to make SMS work. And I would like to see it work.
Pilots need a nationwide self-governing, self-regulating professional association to which all professional pilots--and I mean those flying for hire or reward--must belong. In view of the changes presently occurring in the aviation industry with the introduction of SMS--a form of what I like to call “supervised” self-government and self-regulation for the air operator industry--they need it to provide a pilot input to balance company management, government regulators, and clients in the dynamic bargaining process that determines the industry environment. They need it to provide them with real whistle-blowing protection, since they will be the ones under SMS who really know what will be going on in the future, in my opinion. They need it to set standards for technical education required for the various types of aviation jobs, from entry-level commercial pilot to captain of high-performance passenger-carrying jet. They need it to ensure they receive the proper ongoing education to enable them to do each job with confidence and competence as they progress through their careers. Ethics will be taught and examined.
When I first wrote this paper, I talked only about pilots, since I am a pilot, but I would now extend the same concept to licensed maintenance engineers and certificated dispatchers. Also, for the record, I sent my ideas twice through TCCA's issues reporting system, and then in the form of a discussion paper to my current director and to the association to which I belong. So I have tried to communicate with a number of people.
What is missing from SMS is a check and balance system, in my opinion. It is one thing to give supervised self-government and self-regulation to an air operator, to the management, and the owners of a company, but it is an oversight not to give the same thing to the licensed pilots, maintenance engineers, and dispatchers who do the work. For example, without the licensed pilots employed by the company, the company cannot operate. These licensed individuals need their own self-governing, self-regulating association that will provide them the protection they very much need from any unscrupulous employer on those occasions when an employee feels the need to blow the whistle on the company for safety violations. We've had incidents of this in the past, recently in Toronto. This body needs to be the licensing authority for these individuals, not the governing authority, in my opinion.
Other professions have self-regulating associations that influence the environment their members work in, set professional qualification standards, and continue to judge their professional competency. Such professional associations also intervene on behalf of their members or the general public, if necessary, when there are security and safety concerns. Engineers, doctors, and lawyers all have self-regulating associations, as do other professions.
Anyone who wishes to practise one of these professions must satisfy the standards set by the association and must be a member in good standing. These associations also discipline members who have failed to meet the obligations and responsibilities of their profession. No one gets a free ride.
Regarding common interests, many professional pilots—again, those who use their licence to fly for hire or reward—have no opportunity to belong to any association. I'm aware of only three major trade associations for pilots in Canada: the Canadian Federal Pilots Association, for pilots employed by the federal Department of Transport, to which I belong; the Air Line Pilots Association, Canada, ALPA Canada, for pilots employed by various regional airlines; and the Air Canada Pilots Association, ACPA, for a grand total of approximately 4,000 pilots.
The last time I checked, over 19,000 aviation licences, belonging to commercial and airline transport pilots, are in force in Canada, enabling their holders to offer their services as professional pilots. The vast majority of professional Canadian pilots, who work as flight instructors, bush pilots, charter pilots, corporate pilots, agricultural spray pilots, air ambulance pilots, or any other of the many varieties of flying jobs in aviation, have no professional association.
I could go on at length; I'm limited in my time here.
For those who belong to a professional association, say, regarding the law.... If you read this section on education, you'll understand a lot more about where I'm coming from because this forms a lot of it. It's a couple of pages, and I have to skip over to a section entitled, “Other Functions”. If you read that, then you'll appreciate the next comment.
I dealt at length with knowledge and licensing as a responsibility of the proposed professional pilots association, because I feel it is the foundation upon which any claim to professionalism must be made. That's essential. However, besides knowledge and licensing, the professional pilots association would take responsibility for representing pilots and providing specialist assistance—say, in accident investigation—and for encouraging and even sponsoring research into airframe, engine, and system design, and into the civic aspects of aviation personnel management and interpersonal behaviour, something that today we call the human factors.
Another important function would be presenting the pilots' point of view as a group on proposed legislative changes, as part of the consultation process with industry owners and operators. Company management is judged by whether they show a profit at the end of the year. While pilots are by no means immune to the profit motive, they are also aware that the high salaries they may earn mean little when you arrive first at the scene of an accident.
Membership in a professional pilots association must be mandatory for all pilots who fly for hire or reward, just as professional engineers must belong to their provincial professional association if they are paid for their services as engineers. Such professional membership must be a legal, regulatory requirement with no waivers or exceptions possible. Voluntary membership in a professional association would not be sufficient.
In conclusion, to accomplish the changes I have suggested will take organization, experience dealing with government, and certainly familiarity with the aviation industry, at the very least. The existing pilots trade associations could act as the nucleus around which a professional association, such as I have outlined above, could grow.
A professional association also needs legal status. We must have a federal professional pilots act, or something similar, to give the association legal existence and the powers it will need.
As well, federal empowerment will address our obligations under the Convention on International Civil Aviation. The remaining requirements would be hard work and some dedication.
Thank you for listening.
I'm now prepared to take any questions.
:
I'd like to thank the committee for this opportunity to finally speak on a subject that is well known to me.
Let me first give you my background in aviation. My career spanned 30 years in aircraft operation. Most of my 9,000 hours were on Twin Otter aircraft on wheels, floats, and skis. I've flown for small airlines and corporations in the Arctic, Antarctic, North Africa, and the Middle East. My last posting was in the Maldives, before TC's enforcement division in Ottawa hired me in May 1998.
During my early days at TC, I was involved with the basic aviation enforcement course that all inspectors were required to take as a prerequisite to obtaining their delegated authority under the minister. I gave the course introduction and included, among other topics, the report of the Commission of Inquiry on Aviation Safety, the Dubin report; the Commission of Inquiry into the Air Ontario Crash at Dryden, Ontario, the Moshansky report; and Swanson v. Canada, arctic wings and rotors. Managers were not required to take this training, even though they held a delegated authority.
I soon realized that the information I was presenting the attendees did not reflect the actual situation or expectations of the inspectors in exercising their delegated authority. It appeared to me that management's main concern was to get out of the enforcement business and the liability issues inherent in that responsibility. We were not practising what we preached.
I transferred to the system safety branch, where one of my duties was to sell the SMS to the regions. They balked. I was also tasked to study and report on air crashes. I joined the work group called the TRINAT, which was an initiative by TC's international aviation branch. The group was made up of representatives from Canada, the U.S., and Mexico. We were tasked with analyzing 276 crashes to determine root causes.
The criterion was all aircraft with 10 to 200 seats. The breakdown was twenty for Canada, seven for Mexico, and the remaining files were from the U.S.
Of the 20 Canadian crashes, 25% had a root cause of “lack of regulatory supervision”. This was not our interpretation; this information was quoted from TSB reports. I do not know what happened to the TRINAT study after I left TC.
One of the crashes we reviewed in the group was the Davis Inlet crash on March 19, 1999, TSB report number A99A0036. The crash, lack of investigation, and the eventual cover-up were indicative of the malaise that permeated Transport Canada.
Upon further investigation into the file, I discovered that the pilot had four previous crashes and a multitude of fines, suspensions, and letters of counselling. Some of the comments in the pilot's enforcement file were as follows:
March 1991:
Pilot had enough hard violations pending. No further action. Not in public interest to spend more time on this possible violation
May 1991:
Mr. XX has a habit of ignoring IFR procedures and I am anticipating that with fines imposed he will get the message.
That was a $250 fine, by the way.
June 1991:
Mr. XX will probably be a repeat offender.
August 1991:
Flagrant disregard for established rules and procedures caused an accident that could have produced fatalities.
April 1993:
Previous sanctions have not changed this individual's method of operating, and I do not think this will either. We will hear from this gentleman again.
After the pilot's last crash, which killed his copilot, on March 19, 1999, there was no enforcement investigation, as required by Transport Canada and ICAO. The Transportation Safety Board confidential preliminary report contained reference to the pilot's flying record; the final report did not. His licence was not suspended by TC until three years later.
As a result of the crash, the TSB issued recommendation A01-01, which stated:
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.
This was the most important recommendation since the Moshansky commission.
On July 13, 2001, Transport Minister David Collenette stated in a press release:
In advance of the TSB recommendation, Transport Canada initiated a phased study to review safety oversight methodology, resources and practices, with the goal of ensuring that air operators and crew consistently operate within the safety regulations
It goes on to say:
Transport Canada will respond to the findings of that study as the next step in continually improving the safety of the air taxi sector.
This study is known as the DMR report. The DMR report was impossible for anyone to understand, so it was reworked and reissued as DMR 2. The total cost was $750,000. The final draft copy was dated September 10, 2001, and was to be delivered the next day in Victoria—that was 9/11. For obvious reasons, the issue was shelved.
I was blocked at every angle from trying to get a copy of the DMR that had already been offered up to the Privy Council as satisfying the recommendation. I was told in writing by a manager at head office that the DMR was a failed document, and management didn't want us referring to it.
After finally getting my hands on part of the DMR report, I could not find any reference to remote areas. The more I searched for the rest of the report, the more isolated I became, until my health was brought into question. I was sent to Health Canada for a psychiatric assessment. After nine months on leave without pay, I resigned from TC.
Davis Inlet is an important study of what ails the regulatory program. The crash, investigation, and the eventual cover-up were indicative of the malaise that permeates TC. Inspectors are not allowed to do their job. TC knew the pilot was going to reoffend. They did nothing and somebody died.
It is my opinion, and I quote from Swanson, that:
Transport Canada officials negligently performed the job they were hired to do; they did not achieve the reasonable standard of safety inspection and enforcement which the law requires of professional persons similarly situated
See Swanson v. Canada.
I think the SMS concept is workable, but it can only work if there is a strong enforcement component. I get nervous when reports are mandatory and confidential.
Everything I have stated here can be backed up with documents.
Mr. Danford and Mr. Carson, thank you for coming, even if it is late in the hearing process.
I found that your presentation—which I read before I came here, so it wasn't that I wasn't paying attention when you were speaking—was instructive for a couple of reasons. I hope you will correct me if I have misunderstood or misinterpreted what you said.
I think both of you dealt with the issue of the highest level of safety established by the minister, or the acceptable level of safety by the minister. I wonder whether you would spend a moment distinguishing between two.
As I understood both of your presentations, you were really talking about liability: that the minister or Transport Canada through this SMS system, as proposed, unamended, would put off to the industry the responsibility to set levels of safety and be liable for them. In one, it says the minister continues to be liable for all levels of safety, with an obligation--it's an imputed obligation--that there will always be improvements in the levels of safety.
So what is acceptable today would be the highest standard today, but it may not be the highest standard tomorrow. An acceptable standard tomorrow must, of necessity, be higher.
Could you spend a moment distinguishing the two for me?
As I said, when I had finally done enough of flying around the world and seeing sights that I didn't want to go back and see, I transferred off one airplane to get on a domestic airplane so I could stay flying in Canada.
I totally agree with the ICAO statement. We have to make improvements. We can't let our guard down. And if this is what we were going to do, no, I wouldn't go there. We have to maintain a certain level of inspection, I believe.
I have a friend I flew with in one company in Bell. He went on to become a director of flight ops for another company in Toronto, and he jokingly said to me one time that...well, when we were flying, we operated a certain way. He said, “Well, those certain things that we did when we were operating together, Paul, we won't have to do anymore.” And I said, “Well, I hope not. I hope you can't get away with what you're suggesting.” And this was to somebody I had a lot of respect for.
I don't think we can let down our guard just because we're a very safe area in which to fly. We are. I think we need to work hard to maintain that, and that's what I think SMS will help do, but I think we have to be careful how we go about implementing it.
I hope I've answered your question without sounding--
:
To answer your question, yes. I just think that after all these years--and we've been flying airplanes since Kitty Hawk, for a hundred-plus years--that being a professional pilot.... We use the words “professional pilot”. We call ourselves that, but are we really professional in the sense of other professions? The answer is no.
You're an engineer, sir, so you know that when you got your degree as a graduate, as I did, that was a degree. It didn't allow you to practise engineering until you became a PEng. Professional engineering is self-regulating and self-governing, and it's empowered by provincial acts. Audits are done by the Canadian Council of Professional Engineers. Pretty much every three years they'll hit every engineering school in Canada.
It is done that way because it means that the people who do the work control those who are doing the work. So if you've been an engineer for 20 to 30 years, you will then get involved in controlling the people who are actually going to follow behind you.
To my mind, it's time that aviation come of age in some ways, grow up.
I stood in front of a dispatch one day with a director of flight operations. It was 80-some years into aviation, and I just turned to him and said, “Sir, don't you think after all this time we'd be a little bit further ahead than we really are?” We were having a bit of a discussion over some winter operations question.
I think with a self-governing, self-regulating association for the people who are licensed to do the work, in the long run, if we started now, then 10 years from now we would see a different environment out there, and you wouldn't have to talk to people like me. You just wouldn't. That's my wish.
I don't think self-governing, self-regulating professions are the be-all and end-all, but when we look at the way we do business in a democratic country like Canada, I think it's the way to proceed. And then the words “professional pilot” will actually mean “professional”.
:
Mr. Chairman, it's not my custom to move more slowly than necessarily, but I was rather struck by the forcefulness of the two presenters, and I must say—and I don't know whether anybody else felt the same—that it has put some things in a different frame of mind for me. There's a different perspective from which I'm addressing all this.
Just bear with me for another 30 seconds, if you will.
I thought the last question and answer section dealt more with the professionalism of pilots and the establishment of a professional self-regulating body. I have some level of experience and expertise in that area, and I'm not sure that's where we had been going, through all of this, because in my mind, the SMS system involved a lot more than just simply whether the pilots were competent or not. But on the issue that was raised by two people, the reason I say it's forceful is because for two individuals to come forward and actually use the word “lie”, relative to what the department has been saying regarding this piece of legislation, that has to be a cause of concern for people, not because someone would willy-nilly say that, but because someone would actually have the courage to come before a committee and use that kind of language, without hiding behind any “they say” or an anonymous source.
I say that because today we've received two other submissions that we have not yet had the chance to examine—that is, one from the Air Canada pilots, I believe, and the other one from the professional pilots association.
I'm just wondering whether we are rushing ourselves into a clause-by-clause study without having an opportunity to reflect on what the last two witnesses have said and what these other two submissions will ask us to commit.
So I'm going to suggest for your consideration—I'm not going to present it as a motion, and I'm going to go along with the committee's schedule, if need be—that we take advantage of the fact that the technical experts from the department are here and that they've already submitted clauses for amendment, that we simply hear what they have to say to their clauses and then take it from there, rather than see if they'll provide input as we go along.
I would prefer to hear their rationale today, rather than as per need.
:
Well, with this legislation, Mr. Volpe, what we're proposing is improvement in aviation safety in general. What you heard today was information regarding specific situations that sometimes was taken out of context. I'm happy that we've been given the opportunity to answer to this.
Mr. Danford was talking about an accident that happened about 10 years ago. There was an accident, yes. Afterwards, the pilot had a couple of violations. If you look, he flew for five or six years without any mention on his file. Things were going well. Unfortunately, there was another accident.
At that time, because of international requirements with respect to accident investigations, we had an agreement with the Transportation Safety Board that we would not get involved in a parallel regulatory investigation until the TSB, which actually is the investigative authority in Canada, had finished their investigation. When they finished their investigation, we would start a parallel investigation. And that's what we did in that case. That's the reason we were not involved earlier.
Later on, there was a change in policy, and we decided to immediately launch a parallel investigation whenever there was an accident, and we've been doing that since. Those things were about 10 years ago, and there has been improvement made since that time.
Now, Mr. Danford was talking about Air Transat, and he said that SMS didn't work. Well, you know, what's interesting is that Air Transat was the trigger for us to start establishing SMS. When the Air Transat accident, or incident, happened, there was no such thing as SMS. We did investigate and we did charge Air Transat with a $250,000 fine. I remember, because I was there. There was an investigation and there was a big fine levied. After that, we more or less told Air Transat that as a condition of continuing operations, even before we drafted regulations, we would establish a pilot SMS project with them. This was a condition for us to allow them to continue their operations. And they did, and it went very well. After that, we mandated SMS through our regulations.
There was no SMS at the time of the Air Transat incident, so that information was a little bit inaccurate.
:
We fully agree with you that SMS is good--and everybody else agrees--but we also need to have safety oversight. We have safety oversight now, and many of the people who have testified may not have seen what we've done since we established SMS. We now have new policies, and there are other ways of inspecting, auditing, assessing, and validating all those carriers and their systems. So we recognize that legitimate concern.
When Minister Cannon testified two weeks ago, he told you we were coming forward with at least three specific amendments. The first one is to reassure the Canadian public that there will be continuous safety oversight by using inspectors to carry out inspections in the field. That's something that is coming.
From my understanding of this committee when I listened to all the testimony and questions from members, the designated third party to certify is a concern. We realize that. We already gave our commitment verbally that it was never our intention to ask the Air Transport Association of Canada to certify Air Canada or WestJet. Now we have to put our money where our mouth is. We're going to put it in writing, and Minister Cannon has announced that we will make an amendment saying that there will be a safety study. He believes it will have to be a very low-risk activity---and also non-fare-paying air transportation of passengers. So I think this will go a long way.
The next concern was on the protection provisions for the internal SMS reporting, as well as the universal voluntary, non-punitive reporting process. The pilots' union asked us to give them more protection than we were giving. I've heard some other unions, more labour-related unions, asking for no protection at all for whistle-blowers. We believe we have struck the right balance. We even brought forward a couple of new amendments there.
In an SMS environment we want employees to work with employers. My colleagues and I feel that a whistle-blower program, where people could tattle-tale willy-nilly, without really having substantiated information against their employer, would be negative. That's the danger. We want people to work together, and unless the whistle-blower program made very important punitive provisions against people making false reports, or things of that nature, I believe it would be difficult. So we're not favouring that approach.
With the protections we're giving, we believe that people will bring forward as much safety information as possible. We don't think having a whistle-blower program would add to that information. On the contrary, I think it would turn off the tap and less information would come in between the employer and employee. It's not because we're against it; we just want to get the best system possible.
:
We could have done that. We wanted to have the officials here first and then we had all the other witnesses. I think the problem with the other witnesses is they didn't give you the facts in their proper context, because there's much more to this.
On the question of the cancellation of the national audit program, yes, the national audit program was cancelled, but it was replaced by something else. So it's fearmongering. People are thinking there's no inspection and this is simply not true. There is process validation, there is program validation, there is assessment, and it's much more thorough than it used to be under the audit carried out through the national audit program, which was, by the way, only an administrative constraint to take some people from the regions and some people from HQ.
You could have asked the question of Mr. Carson, I believe, who took his SMS course two weeks ago...that yes, there are things that have replaced the NAP. But if you ask the question, was the national audit program cancelled, they will say yes, it was cancelled. You have to put things in context.
Now you're talking about an agenda. We have no choice. You want Canada to respect the international agreements. ICAO has just mandated SMS in all the activity fields in aviation on the international level, and we're following them. But we are, as mentioned by the ICAO witnesses, at the leading edge. We're considered as probably the first country...to have as good an approach with respect to SMS as Canada has. So we are at the leading edge, and we are required by ICAO, so we have no choice.
I don't think it should be pushed. If we had the opportunity to explain to you...and we could, if you wanted. We could take one day and give you all those presentations that we give at the SMS course and explain to you really what it's all about, and you would be impressed and surprised. It's not all those negative things you hear.