![TC’s SMS: it means we’re not watching ,[object Object],[object Object],[object Object]](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
Recommended
Recommended
More Related Content
Similar to While Were Not Watching
Similar to While Were Not Watching (20)
Recently uploaded
Recently uploaded (20)
While Were Not Watching
- 1. While we’re Not Watching Transport Canada’s SMS is Failing Presentation to SCOTIC November 30, 2009
- 4. On paper, all looks well BUT
- 5. On paper, all looks well BUT
Editor's Notes
- Good afternoon and thank you for the invitation to address you. My name is Daniel Slunder and I am the National Chair of the Canadian Federal Pilots Association. The association represents licensed pilots who are Civil Aviation Inspectors at Transport Canada, Transportation Safety Board and Nav Canada.
- I regret to inform you that TC aviation inspectors now spend more time pushing paper than inspecting airplanes. With the introduction of aviation SMS Transport Canada has systematically dismantled the key components of traditional oversight, in contravention of ICAO requirements. Transport Canada cancelled enforcement action in October 2006. (Tab 2) There has not been a single enforcement action against a large commercial air carrier in two years, despite Transport Canada being aware of serious violations of the safety regulations. (Tab 3) The National Audit program was cancelled in March 2006. (Tab 4) Transport Canada quit conducting Pilot Proficiency Checks in December 2007. (Tab 5) As a result, there are now unqualified and unlicensed pilots operating aircraft in Canada. I refer you to correspondence in Tab 6 for one example of this: and there are more. In addition, TC has delegated licensing and oversight for entire segments of aviation to industry lobby groups like the Canadian Business Aviation Association, in direct defiance of our international aviation safety obligations. And, most recently, the requirement for operational inspections on a mandatory frequency was cancelled in January this year. (Tab 7) Instead of regular and comprehensive inspections, Transport Canada inspectors simply conduct paper reviews of company Safety Management Systems and follow-up with superficial on site “validations” of the paperwork. With SMS, we simply are not watching.
- Because of the shortness of time, I will relate only three examples of airlines which have broken safety rules while we’re not watching. These point to a systemic problem with SMS. Under normal circumstances, our reliance on assessing and evaluating management systems rather than actual aviation operations means that Transport Canada aviation inspectors do not see these incidents. Each of these examples documents incidents which would put lives at risk. The first example relates to an application for a flight permit. I refer you to Tab 8 in your book of documents. This is an application to modify a passenger carrying airplane...in this case to add fuel capacity in order to travel distances far exceeding its normal maximum range. This was to include the temporary installation of a High Frequency radio. The operator applied to TC, promising that the installation meets all requirements and regulations. Under SMS, an inspector’s job is to review this application and sign off that the paperwork is in order. Nothing else. As you can see on the next slide, the installation fell far short of paper promises.
- This electrical installation is held together with masking tape. Under SMS, this clearly dangerous installation slips under Transport Canada’s radar because we’re not watching.
- The power feed has been improperly hotwired through the instrument panel, creating a potential electrical short.
- This is an example of the use of illegal parts. Under SMS, TC inspectors no longer conduct Pilot Proficiency Checks; companies check their own pilots. For inspectors, this has closed an important window on flight operations, especially since TC policy is to replace audits and inspections with paper reviews. This image was taken by an inspector who stumbled upon this plane. Through a combination of extraordinary circumstances, this inspector was required to conduct a pilot check ride. When he saw the condition of this airplane he refused to fly in it. As you can see, the bolts used to attach the wing to the fuselage are clearly not intended for this purpose and could easily fail as a result of the stress they are not designed to withstand.
- The inspector also found parts anyone could buy at Canadian Tire improperly installed in this airplane’s electrical system. This airplane is not safe to fly, yet it has carried passengers in this condition, all because its state of disrepair was not visible through an assessment of this company’s SMS. Shouldn’t TC oversight be adequate enough to ensure a plane in this condition is not allowed to fly?
- The next example I will describe is chilling in its similarities to the crash of the Air Ontario jet that killed 24 people 20 years ago at Dryden Ontario, a seminal event in Canadian aviation that led to a full inquiry and the re-writing of the Canadian Aviation Regulations. On October 9, 2009, Air Canada 271 with passengers and crew diverted to Grand Forks, North Dakota due to closure of Winnipeg airport. This led to a series of life threatening decisions that could easily have resulted in tragedy. The first breech of the regulations occurred when the aircraft was refueled with the engines running while the passengers were still onboard. Why would the Captain allow such a dangerous procedure that contravenes the CARS? Turns out the AC plane was dispatched without the equipment in working order necessary to re-start the engines. This is the same circumstance that caused the captain of the ill-fated Air Ontario plane to take-off from the Dryden airport without de-icing. Second, even after being advised by a passenger – who is also an airline captain – that the jet’s wings were contaminated by ice the Air Canada pilot decided to take-off anyway. In effect, he was acting as a test pilot with crew and passengers on board.
- Some members of this committee regularly travel to Winnipeg, so this is personal. We travel the same skies. I want to assure you that I have personally brought the details of all of these examples to the attention of senior management at Transport Canada. The decision to freeze the roll out of Safety Management Systems for 703 and 704 operators is good news but highlights concerns about the safety of all air carriers where SMS is a requirement. The problems, this decision acknowledges, are undermining the safety of the big airlines which carry the vast majority of travelers. We no longer are confident the major carriers are compliant with safety regulations To address this urgent situation, we recommend a number of critical measures I would be pleased to address.