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.