OTTAWA – The federal government has failed to fully implement half the recommendations in the last decade from the Transportation Safety Board (TSB) to fix safety gaps in Canada’s air transportation system, according to an analysis by Canwest News Service.
Transport Canada has fully satisfied the board in 26 of the 53 recommendations. In the remaining cases, the government has not taken adequate action to “substantially reduce or eliminate the safety deficiency” for air travellers.
Of the 27 delinquent files, the board has determined Transport Canada’s response to be “unsatisfactory” in two cases, because the board has received “inadequate explanations to convince it that the risks are not worth pursuing.” Both are in response to recommendations related to the Swiss Air crash off the coast of Nova Scotia in 1998 that killed 229 people.
In 10 cases, Transport Canada has committed to fix the safety deficiencies flagged by the board as far back as March 1999, but has yet to do so. On average, the board warned the government of these deficiencies 76 months ago.
The remaining 15 files remain deficient, because the steps Transport Canada has taken to date will improve safety, but not substantially reduce or eliminate the safety deficiency. The board provided the department with these recommendations, on average, 70 months ago.
The analysis does not include any recommendations made since August 2006, because Transport Canada’s responses are not yet publicly available, but some address a long-standing problem previously flagged by the TSB.
Post-impact fires involving small aircraft in otherwise survivable accidents are a “well-known safety concern,” the board noted in a safety-issues report dated Aug. 29. 2006, but a “cost-benefit analysis negated the proposed safety measures.”
Canwest’s analysis of Transport Canada’s responses to air-safety recommendations comes as investigators probe two crashes in the span of seven days.
Board investigators were sent Sunday to northern Manitoba after a fire in the cockpit of a small commuter aircraft forced a crash landing. The crew and three passengers on the medevac escaped before the plane exploded.
The board is also investigating a fatal crash off B.C.’s Sunshine Coast on Nov. 16. The crash of a charter aircraft operated by Pacific Coastal Airlines killed the pilot and six passengers when the vintage, amphibious Grumman Goose carrying workers to a hydroelectric project crashed on a small island; one passenger survived.
It was the second crash fatal crash this year for the Vancouver-based airline. On Aug. 3, another Grumman Goose crashed into a mountainside on Vancouver Island, killing the pilot and four passengers; there were two survivors.
The most recent Pacific Coastal crash came just a week after the B.C. coroner’s office highlighted Transport Canada’s failure to implement a key safety recommendation of the board dating back years.
The B.C. coroner’s office probed the deaths of a pilot and two passengers, including a three-year-old boy, after a single-engine Cessna commercial aircraft operated by Sonicblue Airways lost power on a flight from Tofino to Vancouver on Jan. 21, 2006, and crashed near a logging road near Port Alberni. Five passengers survived.
The coroner’s report noted that regulations in the United States would not have allowed the aircraft to fly in this area unless it was equipped with a terrain-awareness and warning system. Canada had no such requirement, even though the report noted the safety board had previously recommended the installation of those systems.
Transport Canada approved these equipment requirements in 2005, “however, implementation and compliance have been delayed,” the coroner’s report stated.
In its January 2008 report, the TSB determined that the lack of equipment enabling the pilot to locate and identify high terrain was one of the contributing factors to the Sonicblue crash.
Department spokesman Patrick Charette said Monday a new terrain-awareness proposal will be ready for industry to review next spring, and, once the new rules come into force, aircraft will have two years to comply.
In cases where files are stalled, Charette said some of the TSB recommendations refer to areas of jurisdiction not exclusive to Transport Canada. And others require changes to aircraft design, which cannot be done without further study, he said.
None of this washes well with Jonathan Huggett, whose 25-year-old son, Edward, died in the pilot’s chair of the Sonicblue aircraft.
“Had my son had the terrain-awareness and warning system, it would have said, ‘You’re too close to the ground, you’ve got to get out of here.’ Had he all the right gear, it was probably a survivable incident,” Huggett said in an interview.
Kirsten Stevens points to other examples of unfulfilled safety recommendations.
Her husband, David, was one of five occupants who survived impact and escaped from their float plane, but later died after it crashed on waters near , on Feb. 28, 2005.
Her husband’s body was the only one found; autopsy results showed he died of drowning and suffered from extreme hypothermia.
While the TSB did not investigate this crash, the board’s analysis of another fatal float plane crash seven months later involving a drowning death highlighted a recommendation in 1994 to require occupants to wear life-jackets while taking off or landing, but noted Transport Canada believed this “provides no tangible and quantifiable safety improvement.”
The Nov. 11, 2006, report also cited an aviation safety advisory to Transport Canada dated March 2000, “regarding its concerns regarding the apparent lack of progress among seaplane operators to address the issue of underwater escape.”
Another Transport Canada float-plane safety review launched after a series of crashes in 2005 resulted in more recommendations in 2006, but they have not been enacted. The review was “inconclusive,” according to internal Transport Canada correspondence dated May 23, 2008.
And senior managers in the civil aviation unit “agreed that, in the absence of a clear way forward, this file would be put on hold in deference to other civil aviation priorities,” states the document, released to Stevens under Access to Information.
“There are so many recommendations and they’re not acted on, and people are still dying,” said Stevens.
But Charette pointed to fully implemented recommendations, including a new requirement for cockpit voice recorders to have a capacity of at least two hours, up from 30 minutes, and new rules governing runway approaches in poor visibility.
The investigation system
The Transportation Safety Board does not investigate all accidents, but, when it does, Transport Canada must respond within 90 days to any recommendations. The board uses four categories to assess the department’s responses – fully satisfactory, satisfactory intent, satisfactory in part and unsatisfactory.
Fully satisfactory: if action taken by Transport Canada will “substantially reduce or eliminate the safety deficiency.”
Satisfactory intent: if the planned action when fully implemented will substantially reduce or eliminate the safety deficiency. “However, for the present, the action has not been sufficiently advanced to reduce the risks to transportation safety.”
Satisfactory in part: if the planned action or the action taken to date will reduce, but not substantially reduce or eliminate, the deficiency. In these cases, the board continues to follow up to review options to further mitigate risks.
Unsatisfactory: if no action has been taken or proposed that will reduce or eliminate the deficiency. “In the board’s view, the safety deficiency will continue to put persons, property or the environment at risk.”
In most cases, there is a back-and-forth between the TSB and Transport Canada until the board is either satisfied or concludes the department has no intention of fully implementing the recommendation. In both cases, the file then becomes inactive. Other cases remain active files with a “deficiency” label.