For a more recent example, see
Aviation Investigation Report A13H0001 - Transportation Safety Board of Canada.
Findings as to causes and contributing factors:
10. Transport Canada's approach to surveillance activities did not lead to the timely rectification of non-conformances that were identified, allowing unsafe practices to continue.
11. The selection of the corrective action plan process as the sole means of returning Ornge Rotor-Wing to a state of compliance resulted from the belief that other options were either unavailable or inappropriate for use with a willing operator. This belief contributed to non-conformances being allowed to persist.
12. The training and guidance that was provided to Transport Canada inspectors resulted in uncertainty, which led to inconsistent and ineffective surveillance of Ornge Rotor-Wing.