The Canadian Federal Pilots Association is not opposed to SMS. We have great concerns about Transport Canada's SMS, which has become the sole layer of safety in Canada.
By way of introduction, I've been a pilot for 40 years. The bulk of my experience was with the Canadian military, where I served for 23 years, instructing on jets and patrolling Canada's ocean coastline. I worked at Transport Canada for the remainder of my career training pilot inspectors, managing the approved check pilot program, and in other areas.
Just as I served the Canadian public in the military, I consider the work I now do to be in the public interest.
Our members are 382 licensed pilots who work as inspectors at Transport Canada and the Transportation Safety Board. We also represent 32 licensed pilots who work at Nav Canada.
I can tell you that the number of licensed pilot inspectors is at its lowest. Today we have 50 fewer inspectors than when I last appeared before this committee in November 2009 when Transport Canada promised to hire more inspectors.
One of the first witnesses who appeared before your committee was Auditor General Michael Ferguson. His testimony cast long shadows of doubt over the evidence placed before you by Transport Canada officials concerning rail safety. Among other things, Mr. Ferguson told your committee that Transport Canada had completed only 26% of the SMS audits of rail companies the department said were needed to ensure compliance with safety regulations. This and other comments were in sharp contrast to remarks of Transport Canada officials who testified to you only days before Mr. Ferguson.
I think Mr. Watson's comment, following the Auditor General's testimony, was most appropriate and I quote:
...I sense that if we were to read between the lines, not only did Canadians expect better from Transport Canada, I suspect you did as well, and I know the government expected better too.
Some of you will be familiar with the Auditor General's review of Transport Canada's aviation safety program. His office conducted an audit in May 2008 and a second one in April 2012. When you line up the audit findings for rail and aviation, the parallels are striking. According to the Auditor General, both Transport Canada's rail and aviation safety programs fail in these areas: the number of inspectors and engineers needed to ensure safety is unknown; significantly fewer inspections are done than planned; the minimum acceptable level of surveillance to ensure safety is not established; and there's no documented rationale for changing the acceptable minimum level of surveillance.
Officials may try to assure you that all of these issues have been addressed, but Transport Canada's rosy forecast is based on a simple sleight of hand. Inspections, once required annually, can now be as infrequent as once every five years. That's one way to stretch your inspection resources, but does it have anything to do with safeguarding the public?
It is important to emphasize that aviation SMS is not intended to be a stand-alone buffer against safety failure, and it never was. This makes perfect sense. Redundancy is an important principle in safety; when one fails, another is in place to ensure that nothing bad happens. Yet today aviation SMS is pretty much the sole safety program, as Transport Canada has all but abandoned direct operational oversight of airlines.
Canada was among the first countries to embrace aviation SMS. In 2005 it was first introduced among the major carriers. There was no beaten path to follow, it was an experiment. As a brand new approach, Transport Canada did not anticipate the implementation of SMS would consume all its inspection resources, and then some. Something had to give and that something was direct operational oversight, which all but disappeared. We seldom, if ever, conduct no-notice inspections, ramp checks, pilot check rides, and other activities that once gave us a window into the state of safety of an airline.
Other safety concerns are being cut to this day under the weight of cumbersome SMS. For example, TC is cancelling all comprehensive SMS assessments for airports and aerodromes in favour of doing only more narrowly focused process validation inspections.
When Transport Canada tells you about the thousands of audits and inspections it's done annually, you should keep in mind three important points. First, the numbers are inflated. The Auditor General blew the whistle on Transport Canada's inspection claims with respect to rail. Transport Canada simply cannot conduct up to 30,000 inspections with only 250 front-line pilot inspectors.
Second, the audits and inspections they talk about involve nothing more than reviewing documents and telephone interviews. It's a superficial exercise that allows serious problems to go unaddressed.
Finally, TC expects to see the accident rate increase and adjusted its forecast performance targets to account for it. The increase, if it materializes, will equate to between 40 and 50 more accidents in 2014 than occurred in 2011. You'll find that at tab 3.
Just a few months ago we asked civil aviation safety inspectors about SMS, and nine in 10 aviation inspectors report that Transport Canada's SMS actually prevents them from correcting safety problems in a timely fashion. This is up from 80%, who worried that this would be the case in the early days of SMS.
Give this your serious consideration. These individuals are professionals, as noted by one of the National Airlines Council of Canada witnesses earlier this week, they care deeply about their work and the safety of the travelling public. Virtually the entire aviation inspectorate thinks SMS is better at hiding safety problems than solving them. You have the full survey report.
I want to bring your attention to two specific examples of the consequences of this reality.
Just months before a First Air jet crashed in Nunavut, a Transport Canada assessment found no problems with the airline safety management system; in fact, it was stellar. Yet, the investigation into the August 20, 2011, crash by the Transportation Safety Board discovered many safety shortcomings of the airline, which contributed to the accident, including the fact that the First Air safety management system was not working properly. Twelve people died in this controlled flight into terrain, and it could have been much worse had the accident occurred with a plane full of passengers landing at a major airport.
Today commercial operators in Canada could go for as long as five years without a single SMS assessment or program validation inspection. That's far too long, and well beyond the international requirement for annual inspections.
Transport Canada's own flight operations department is experiencing difficulties, in spite of SMS, according to documents we have acquired through an access to information request. Even with SMS implemented and the best of intentions, Transport Canada continues to fail to meet minimum safety requirements. TC has had two accidents—the last one was fatal—since implementing SMS.
Witnesses from Air Canada, WestJet, Air Transat, and the NACC testified earlier this week that the SMS partnership between industry and regulators safeguards the public. Members of the travelling public should be concerned when at least half of the partnership can't make SMS work and is crashing aircraft at a rate of every three years.
When we rely almost exclusively on superficial SMS audits and program validation inspections, safety problems get missed, with tragic consequences. Transport Canada's aviation safety program desperately needs to change.
For your consideration, we recommend the following.
Give total ownership and responsibility for SMS to the operators.
Have a concentration of SMS experts within a redesigned branch in Transport Canada available to conduct assistance visits to companies. Its mandate would be to help companies with SMS and to promote the benefits of SMS. These visits would be non-threatening, white-hat validations of assessments to assist the industry in the implementation of SMS.
For the majority of inspectors, simplify the auditing method by removing all of the SMS verification actions in favour of conducting more company visits and random no-notice inspections, including monitors, line checks, and office records checks. To improve intelligence gathering, document the results of all visits. Based on intelligence gathered over the year, return to the company to conduct an annual inspection. Using modern sampling techniques, look strictly for regulatory non-compliance in as many facets of the enterprise as time and finances will permit.
Apply enforcement action for non-compliance where the findings show that SMS wasn't followed or for a non-SMS company that did not make every effort to remedy the situation. This will entice the company to improve its SMS or to move to SMS to capture future errors. The approach uses positive reinforcement where the system worked, or negative reinforcement where the system—