Is that report available somewhere?
Thank you.
It's not actually an accident report but much more; Here is the introduction, and below, the ISBN information. The Report is not easy to find:
"This Final Report consists of three volumes: I (Parts One-Four), II (Part Five), and III (Parts Six-Nine and the General Appendices). The table of contents in each volume is complete for that volume and abbreviated for the other two volumes. Seven specialist studies prepared for this Commission ave been published separately in a volume entitled Technical Appendices; he contents of the Technical Appendices are given at the end of this volume."
ISBN # 0-660-14382-8 (Vol 1-3)
Here is the Table of Contents for Vol III, with partial listings for some chapters just to give you an idea:
PART SIX TRANSPORT CANADA
27 Organization
28 Conditions at Transport Canada in the Early 1980s
29 Economic Deregulation and Deficit Reduction
30 The Effects of Deregulation and Downsizing on Aviation Safety
31 Aviation Regulation: Resourcing Process.
32 Audit Program
33 Audit of AU; Ontario Inc., 1988
34 Operating Rules and Legislation :
35 Company Check Pilot .
36 Contracting Out, Waivers, and Spot Checks
37 Safety Management and the Transport Canada Organization
PART SEVEN HUMAN FACTORS
38 Crew Information
39 Crew Coordination and the Communication of Safety Concerns by Passengers
40 Human Performance: A System Analysis
The Fundamental Question
Human Factors
The Organizational Component
The Organizational Component
Lack of Operational Support from Air Canada .
The Potential Disruptive Impact of Mergers and Strikes
High Personnel Turnover Following the Merger
Lack of Organizational Experience in Jet Operations
Deficiencies in System Operations Control Practices
Lack of Standard Operating Procedures and Manuals for the F-28
Leadership of the F-28 Program
The Informal Culture at Air Ontario
Flight Attendant Training
PART EIGHT LEGAL AND OTHER ISSUES BEFORE THE COMMISSION
41 The Aviation Accident Investigation Process in Canada
42 Aviation Incident and Occurrence Reporting and the Issue of Pilot Confidentiality
PART NINE CONSOLIDATED RECOMMENDATIONS