:
Thank you, Mr. Chairman.
Mr. Chairman and committee members, it is a distinct privilege to address you on this occasion. My name is Virgil Moshansky. Some of you may know me as the commissioner of the inquiry into the Air Ontario jetliner crash at Dryden, Ontario, in 1989 that killed 24 people. My commission became a full-blown inquiry into aviation safety in Canada that took three years to complete.
I spent a further three years advising Transport Canada on the implementation of my commission's 191 recommendations for regulatory reform. My work has been recognized by many, including Transport Canada itself, which presented me with its Canadian aviation safety award in 1995. I continue to consult internationally on aviation matters.
I will deal primarily with clause 12 of Bill . In order to put things into context, I will begin with a little pre-Dryden crash history.
Transport Canada's regulatory efforts went off the rails in the 1980s because of two inconsistent and mutually incompatible policies introduced in 1985 by the federal government of the day, namely deregulation of the airline industry and the policy of fiscal restraint.
Despite government assurances such as are being heard today that aviation safety would not be allowed to be compromised, Transport Canada upper management ignored urgent requests by managers in the aviation regulatory directorate for funding of the badly undermanned inspectorate force. Airline audits and in-flight monitoring, the twin backbones of aviation safety, ceased almost entirely in the months leading up to the Dryden crash, because of a lack of resources.
A cursory Transport Canada audit of Air Ontario five months before the March 10, 1989, Dryden crash, did not even examine the Air Ontario F28 aircraft implementation program. Lack of regulatory oversight virtually left Air Ontario to its own devices, allowing it to set its own inadequate safety standards and enabling it to get away with unconscionable safety deficiencies in its operations, all of which contributed to the crash.
A January 20, 1989, prophetic warning by the acting chief of air carrier operations that air carrier inspection was “no longer able to assure the Minister of the safety of large air carrier commercial services in Canada” and “that a major accident is inevitable in this country” was rebuffed by Transport Canada senior management as inflammatory. Seven weeks later, at Dryden, Ontario, 24 people paid for this cavalier attitude with their lives.
Today, 18 years after Dryden, history is repeating itself, only worse. Cost-cutting is again in vogue at Transport Canada and has been for some time. Transport Canada management have publicly admitted this. Regulatory oversight is not being merely reduced. Except for limited focused audits, it is being systematically dismantled under Bill . All of this is occurring in the face of a predicted doubling of the size of the aviation industry by 2015, as per Transport Canada's own estimates.
In the years following the release of my final report, Transport Canada did a commendable job of addressing most of the major safety issues and regulatory lapses that were identified by the Dryden Inquiry.
After a period of relative calm, numerous serious aviation safety concerns have now returned to haunt the Canadian aviation system, as documented in a remarkable series of newspaper articles in June of 2006 entitled “Dangerous Skies”, written by three investigative reporters of the Hamilton Spectator, Toronto Star, and Waterloo Record newspapers. I recommend that the committee members read these articles, if they have not already done so.
In my view, any objective observer would have to call their findings disturbing. They simply should not be dismissed out of hand, as some have attempted to do. What stands out is that the current deterioration in the state of aviation safety in Canada, as chronicled by these investigative reporters, is coincidental with Transport Canada's progressive reduction in the number of its aviation inspectors since Dryden and its ongoing withdrawal from regulatory enforcement.
This is an ominous sign for the future of air safety in Canada, particularly if Bill is allowed to proceed in its present form. Many front-line aviation industry workers, expressing fears for their jobs, spoke out on condition of anonymity, but a number of brave souls allowed their names to be published. A few of the latter drew the wrath of their airline employers. Some were suspended for speaking out, thereby highlighting the urgent need in Canada for meaningful whistle-blower legislation.
I am very surprised and disappointed that unlike the case in the United States, the new Canadian whistle-blower legislation provides no protection whatsoever for airline employees, who are the front-line workers closest to the problems and the violations and therefore most in need of such protection.
Clearly it is in the public interest that they be encouraged to report infractions and therefore that they have such protection. I strongly urge this committee to press for whistle-blower protection similar to that in the United States.
Having examined the recent Pollara survey of aviation inspectors, it seems to me that this committee would benefit greatly by hearing from some of these inspectors. The committee must certainly view with concern the alleged attempt on the part of the regulator to dissuade them from appearing before it.
There are many good features in Bill I most certainly agree with the requirement that each air carrier have in place a safety management system, or SMS, with safety accountability vested in a top executive. This in fact is exactly what I recommended in MCRs 100 to 103 of my final report, which recommendations probably, unknown to most, represent the genesis of present-day SMS.
However, I must voice major concern with the second objective of the SMS initiative, which is the downloading from Transport Canada onto the air carriers of the responsibility of establishing and carrying out their own safety protocols and oversight of regulatory compliance, including enforcement.
I respectfully submit that if SMS is to succeed, it must be accompanied by an effective, properly financed, and adequately staffed system of oversight and enforcement on the part of the regulator. That is the key factor that is missing from the Transport Canada SMS initiative, and it has the overwhelming potential to be the Achilles heel of SMS, especially in the case of secondary carriers, the charter and air taxi operators.
Historically, this is the area where the bottom line has the greatest impact and where the greatest risk to aviation safety resides. Some are barely economically viable operations and simply do not have the financial ability of the major carriers to maintain a proper SMS. It is extremely naive to think that under SMS a financially strapped operator is, on its own initiative, going to place necessary safety expenditures ahead of economic survival. The historical record hardly inspires faith in the voluntary implementation of safety measures by some such carriers, especially in the absence of strong regulatory oversight.
It is of very great significance that in those few countries that have introduced a form of SMS into their civil aviation systems, not a single one has abandoned regulatory oversight. Think about that.
The SMS concept relies on self-reporting of violations and safety concerns by airline personnel. This is a potential weakness of SMS. Historically, self-reporting and even confidential reporting is a hard sell. Fear of peer recrimination is a serious inhibiting factor that militates against such reporting, as is also the fear for job security. The absence of whistle-blower protection compounds the problem.
Transport Canada refers to the Australian experience with SMS in support of its own SMS initiative. The problem is that Transport Canada is only telling half the story. It leaves out the part about regulatory oversight.
Most significantly, under the Australian SMS regime, a strict regulatory oversight responsibility for monitoring surveillance and enforcement rests with the Australian Civil Aviation Safety Authority, or CASA, Australia's equivalent to Transport Canada. The CASA SMS manual places the obligation on CASA itself to enforce civil aviation laws pursuant to the Civil Aviation Act of 1988.
Excerpts from pertinent sections of the CASA manual state the following. Section 2.2:
The Civil Aviation Act 1988 places responsibility on CASA to conduct the safety regulation of civil air operations...by means that include 'developing effective enforcement strategies to secure compliance with aviation safety standards'.
That appears in CAA 9(1)(d).
The following statement of policy is of particular significance. “The key focus of CASA's enforcement will be to address safety by consistent and appropriate enforcement action.”
The former manager of flight safety at Qantas Airlines and deputy chairman of Airservices Australia, has stated the following:
It seems that what is proposed in the Canadian Bill goes beyond anything I have heard of with an NAA (National Airworthiness Authority) and would seem to abrogate one of its core functions (perhaps even under the Convention itself and possibly Annexe 13 re safety systems.
The translation is that Transport Canada's approach to SMS may well be in violation of international aviation law.
My Australian source goes on to say, and I quote:
...no attempts have been made...
--that is, in Australia--
...to lessen the amount of surveillance - recently CASA changed from conducting two annual audits to one, but would have many more operational surveillance activities and more unannounced surveillance.
It occurs to me that Transport might already have done some benchmarking with Australia, in which case the committee should insist on seeing the results and conclusions.The committee may wish to seriously consider this suggestion.
There is an important difference between the present situation and that at the time of Dryden: Transport Canada policy is now being dissected in public and in advance of legislative enactment. There is still room for positive change.
In the interests of the safety of the Canadian air-travelling public, I urge this committee to reject the proposed dismantling of the aviation regulatory oversight system as implicit under clause 12 of Bill C-6, which is already under way, and to prevail upon the federal government to provide adequate funding to Transport Canada to enable it to carry out its traditional regulatory oversight and enforcement functions parallel to the SMS initiative, and to meet its obligations under the ICAO convention and avoid the slippery slope to another Dryden.
Finally, I pose a question. Has the time perhaps now come for a system-wide inquiry to be held again in Canada to test the aviation system's vital signs? The widespread aviation safety alarms emanating from within the front lines of the aviation industry, as well as serious questions about the Bill C-6 clause 12 initiative, strongly suggest that indeed the time for such an inquiry has arrived. Eighteen years after the disaster at Dryden, now is the time for the federal government to assume a proactive approach to taking the pulse of aviation safety in this country, by establishing an aviation safety inquiry under the Inquiries Act to conduct an in-depth, system-wide check on the current state of commercial aviation's vital signs in Canada before another major air disaster occurs.
I submit, with respect, that this committee should consider recommending such an inquiry, and I thank you.
:
Yes, I certainly do. They reflect the situation that happened pre-Dryden. There was a shortage of inspectors. They couldn't carry out their oversight obligations. In the case of Air Ontario, as I mention in my presentation, they were let loose on their own, basically, to set up their own insufficient standards. I could give you a number of examples of deficiencies in what Ontario did, if you are interested.
For example, when they were first applying for certification, they hired an extremely experienced and competent F28 pilot from another airline. He had close to 30,000 hours, most of them on an F28. They brought him in so as to be able to say to Transport Canada, “We have this experienced pilot on our staff who is going to be overseeing our operation.” Of course, they obtained their certification.
Within one month, he was so disgusted with the lack of attention that was being paid to his indication of safety problems that he quit. He quit in disgust. Then, for the next year and a half, Air Ontario had no safety officer in its organization. There was really no safety organization.
Pilots were instructed, for example, to not note aircraft defects in their log books or aircraft manuals, because the entry of some of those defects would have resulted in grounding of the aircraft. What they told them to do was to write these defects down on scraps of paper, which were passed from pilot to pilot, and they were accumulated. And theoretically, I suppose, at some point they intended to look after them.
At one point, two of the pilots, a captain and a first officer, became so concerned with the large number of scraps of paper and defects in these aircraft that they entered them all at once in the operating manual, and the result was the aircraft was grounded. So what happened to them? They were suspended and disciplined for doing so, when they should really have been given a medal.
That's the sort of thing you have to be concerned about.
:
That's a very good question, but I think I've covered that in previous answers to some of the questions.
That particular area of the industry is especially in need of oversight. It seems to me that the situation, as it was exposed at Dryden, indicated that the basic problem was lack of funding of Transport by the government. For example, David Wightman, who was the ADM of aviation at that time, testified that he went before the program control board with a request for funding that they thought was extremely limited for the aviation directorate. That request was cut by 70%. They cut 70% of a request that, for all practical purposes, was a basic minimum of what was required.
What happened was that the aviation oversight program took a nosedive. They lost 400 inspectors. They weren't replaced. They weren't able to do the job at the time of the Dryden crash. As I mentioned earlier in my presentation, only a cursory audit of the F28 implementation program by Air Ontario was conducted, and they never looked into the actual F28 program itself. There were major flaws.
I'll give you an example of cost-cutting by an airline coming into the picture. At the time they acquired the F28, Air Ontario decided to fly it on a route that included Dryden. They thought ground-start equipment was mandatory at the airport. That meant that if the aircraft engines were stopped to de-ice, for example, and if the auxiliary power unit on the aircraft could not restart the engines, they would have ground-start equipment to do it. They budgeted $25,000 to purchase ground-start equipment for the Dryden Regional Airport. What happened was that they found out it was not a regulatory requirement, so they cancelled the order.
If there had been ground-start equipment at Dryden airport, that crash would not have occurred, because the pilot realized he had wings that were contaminated. His auxiliary power unit was not operating at the time, and had not been operating for about a week. This was one of the maintenance problems with their aircraft. There were many defects in the aircraft, but that was the major one.
If he had shut his engines down, he would not have been able to restart them. That would have had the effect of grounding the aircraft at Dryden and he would have had to answer to Air Ontario management for having done so and run up the expense of putting 70 passengers up in a hotel. So he decided to go without de-icing, because he could not shut the engines down.
What I'm saying is that if they had gone ahead with the purchase of the ground-start equipment—only a mere $25,000—that crash would not have happened. That's only one example, but I could cite dozens.