Transport Canada Shares Blame For Accident

[Understated]

Transport Canada was monitoring the VFR regulations, not enforcing them.
Pilot was a known risk-taker who had been challenged by management for pushing the limits.


Pilot in deadly 2008 B.C. plane crash took risks, flew in bad weather: report (http://www.vancouversun.com/Pilot+deadly+2008+plane+crash+took+risks+flew+weather+report/3562818/story.html)

[Chuck Ellsworth]

History will repeat it's self and there will be a very short period of denial on the part of T.C. with the added drama of some drone from government hand wringing on TV and vowing to make sure T.C. will now seriously enforce the law and all float plane operators will fly within the regulations or be shut down.

Then Brittany Spears will get out of another car with no panties on again and public attention will shift to more interesting subects.

Meanwhile back at T.C. it will be business as usual, they will make an appearance at their offices as needed, push some more useless paper work around and collect their performance bonuses until they can collect their pension plans for a job well done.

Disgusting situation for any so called first world country.

[clunckdriver]

News Flash! The TSB have finaly worked it out that TC is made up mostly of the failures of aviation! {With a few notable exceptions} When will we have a Minister of Transport who will clean house in TC? I was recentley in conversation with one of the few good ones left, his take on TC? "TC is in itself the bigest threat to aviation safety in Canada", end quote. And we were the nation who taught the world to fly, makes me want to weep.

[dhc2widow]

Smells like Davis Inlet but with a much bigger death toll. Hugh Danford must be seething, like I am.

I hope someone sues the hell of Transport - publically, none of this settlement crap - or they will never change, just keep offloading responisiblity through their darling Safety Partnership Program and sweet old SMS.

The "Floatplane Safety Workshop" next month should be tons of fun ...

Much love from your friendly homemaker turned troublemaker.

[cessnafloatflyer]

I'll be there.

[+TSRA]

News Flash! The TSB have finaly worked it out that TC is made up mostly of the failures of aviation! {With a few notable exceptions}

Unfortunately, you're right. I've met some people at TC who are very competent and hard working; willing to put in 10 hours for 8 hours pay kind of people and who realise the importance of safety, but also the importance of being practical, and are able to balance the two such that there is no loss in safety - however, I can count that number on one hand, across three regions.

Most of my encounters with Transport have been with the classic "Those who can, do; those who cant go to Transport" types. You know the sort: fired or laid off because after 200 hours of Line Indoc they still could not line fly a Dash 8/Metro/ATR, etc or because their attitude was just plain awful (PC TPOP anyone? :ugh:)

I actually look forward to the battles with Transport (sick in the head I know - maybe it'll be picked up on my next Medical). The idea that one person could think they know every reg in the book, throwing around their weight, only to be reminded of that one, small one sentance reg, standard, advisory circular, etc that pops that little bubble of theirs. Ahh, its like the feeling of being on a nice sandy beach in the tropics . ;)

As for:
TC is in itself the bigest threat to aviation safety in Canada

I've heard that from a POI I worked with once too.

[Chuck Ellsworth]

What other work place in Canada will protect their top management, even after said individuals were found guilty of breaking the very rules and policies they were sworn to uphold, not to mention ignoring the part of the law that guarantees every Canadian due process under law?

To rub salt in the wounds of the taxpayer these people are still given their " performance bonuses "

Makes me feel nauseous just thinking about them.

By the way what exactly does the Minister of Transport do to justify the position they hold?

[Understated]

Here is the actual TSB report, upon which the Vancouver Sun article was based:

http://www.tsb.gc.ca/eng/rapports-reports/aviation/2008/a08p0353/a08p0353.pdf

[engfireleft]

By the way what exactly does the Minister of Transport do to justify the position they hold?


They support the Prime Minister to the bitter end on every issue whether they agree with it or not and don't embarrass him. Failure to adhere to those two principles gets you kicked out of cabinet. It's the same job description the minister demands from his department.

[Chuck Ellsworth]

Therefore Canada is a one man dictatorship, and top level T.C. employees who have disdain for rule of law are not an embarrassment to the dictator?

[engfireleft]

That depends entirely on how many people know about it Chuck. Nothing substantive happens unless the minister wants it, or is embarrassed into it if he doesn't want it.

I'm not telling you anything you don't already know in spades.

[slatch]

The aircraft in question was chartered by Peter Kiewit and Sons. (US company building a power plant up the coast) Their aviation department, Midwest Aviation, had to review the operation and approve it. Evidently they did not do a good job and a bunch of company employees died because of their and the pilots mistakes.

[OverUnder]

Here is the TSB Report:

Transportation Safety Board of Canada | | A08P0353 | Controlled Flight into Terrain (http://www.tsb.gc.ca/eng/medias-media/photos/aviation/A08P0353/A08P0353.asp)

I find this portion especially disconcerting (Page 5):

Pacific Coastal management had met with the pilot three times to discuss concerns they had with his decision making. The last meeting, about three months before the accident, was held because management was concerned that he was completing trips in what other pilots deemed to be adverse wind and sea conditions. The company believed that this behaviour was causing other pilots to feel pressured to fly in those conditions and was also influencing customer expectations.

Not to mention this (Page 15):


Some pilots and operators challenge the interpretation of the minimum weather regulation. For example, the regulation refers to a minimum height “above ground level.” Some operators assert that this does not apply in the case of floatplane flights because they operate above water.

Additionally, because the regulation states that clearance must be maintained from obstacles “or” ground, it is argued that one clearance is sufficient rather than both. Finally, when flying over water, some operators contend that they are above an aerodrome and, as such, may fly for extended periods at low altitude as long as they are configured for landing. This is referred to as the infinite runway concept and, although not a factor in this accident, is often used to skirt the intent of the regulations and continue flight in conditions below legal weather minima.

[jonny dangerous]

First of all, the title of this thread is a little misleading in my opinion. Section 3, CONCLUSIONS, in the report might be a reasonable place to find where the TSB determined blame to lie. (As opposed to supplying your own conclusions.) TC seems conspicuously absent in this section as far as culpability lies.

Second, DHC2 Widow, what would the exact nature of the statement of claim be against TC if someone did as you suggested:I hope someone sues the hell of Transport

Negligence? A stretch, even for OJ's lawyers I suggest.

[jonny dangerous]

From the report:Between November 1999 and January 2009, TC’s Aviation Enforcement Section initiated 20 actions in the Pacific Region pertaining to contraventions of regulations concerning VFR Minimum Visual Meteorological Conditions. 15 Of these, no punitive actions resulted.

...

Identifying pilots and operators that fly below VFR minima is difficult unless a customer reports an issue or a TC inspector is present when the violation occurs.

[Willie Everlearn]

C'mon gang, most of this is just hostility toward TC. That aside, to quote Forest Gump (yet again) "stupid is as stupid does". This pilot sounded not only stupid but dangerous (with apology to his loved ones).

I personally don't want more government, more government intervention, regulation, regulatory oversight, prosecutions and court time, followed by remedial training and their associated costs, simply because some "nimrod" decides he's going flying when he should have known better. Let's not advocate a TC Inspector show up for each departure in Canada to review the Wx package and crew qualifications before deciding whether or not to let them go flying.

Frankly, you can't hang this stupid act on TC, or Pacific Coastal. The pilot of this Goose got what he deserved and it should require no gigantic production to remediate.

What angers me in all this is the fact that the innocent people who climbed onto that Goose weren't forewarned or knowledgeable about his reputation like so many others seemed to have been. But then again, I also feel sorry for the 50 passengers who needlessly lost their lives at Clarence Center, N.Y. in 2008. Look at the sh*tstorm that accident has caused.

No thanks.

Willie :ok:

[Chuck Ellsworth]

With regard to this accident Willie is correct, you can't hang a culture of excessive risk taking that is common to far to many west coast float plane pilots on T.C.

[jonny dangerous]

Edited as I went off the plot.

[Understated]

And to keep the record straight, the original poster of this thread, Underated, has posted exactly twice on PPRuNe, both in this thread, having registered Sep 2010.


What's your point? My first post was a reference to the Vancouver Sun article discussing the accident. My second post was a reference to the TSB Report that evaluated the accident.

Delete the thread?

[OverUnder]

Delete the thread?

You very dangerous man! You give us facts. Very, very dangerous.

[burnable gomi]

If you're going to delete a thread because it was originated by a new member you'll have a hard job ever getting new members! The original post was merely a link to a newspaper article. It was hardly a flame, or personal attack that might justify moderation.

I didn't see the thread on AvCanada, but if it was the same, Widow should be ashamed of herself for deleting it.

[+TSRA]

Yes - lets be exactly like AvCanada and delete every thread that even hints at the possibility of discussion against Transport or an operator who allows their flight crew to operate outside the rules. Who cares if the OP has two posts? - maybe they're smart and they think about what to say first, deciding they have nothing of value to add to a post - unlike 80% of the people over on AvCanada and about 20% of the people here who just shoot their mouth off.

Some of you need to grow a pair, seriously. What is the point in having open forums where people can express their opinion if you are just going to delete every thread you don't agree with?
Granted you cannot be blatantly blasting people as the law still recognizes libel and slander, but come on - none of that is going on here in this thread; and as far as I am concerned, Transport Canada is outside this scope because they are a government department which uses our tax dollars to operate, therefore they work for us (in theory) and are well open to a good, harsh handling by the users.

As for this discussion - Transport, the pilot and the operator are all in the wrong.
For one, the pilot was an idiot for operating in conditions where other pilots and dispatchers were saying no - there is experience and then stupidity - stupidity is disregarding the regulations while not listening to the others around you. Experience is knowing you can do something and realizing there is another day to do it. With his previous history, as written, he should have been grounded;
Two, the operator for allowing a pilot to continue flying with this guys history and for allowing their pilots to weeve in and around the rules as it suited them; and
Three: Transport, for allowing these BC float operators to play loose with the rules. I cannot even fart the wrong way without our POI wondering if there is a safety concern which mandates removing the OC from the wall so explain to me how in the hell is Pacific Region allowing these operators to continue when they are clearly, in my opinion, surfing around the rules?

[Chuck Ellsworth]

so explain to me how in the hell is Pacific Region allowing these operators to continue when they are clearly, in my opinion, surfing around the rules?


Two issues come into play here.

Each region is on their own to regulate in any manner that suits the present person in charge of the region. Ottawa may as well be on another planet as far as how any region acts.

All one needs do is some research on the person in charge of the Pacific Region and all will become clear as to why it is like it is.

[dhc2widow]

After I pointed out a similar fact to DHC2 Widow in another forum, she deleted the thread, rightfully so.

Uh, no, the case you are referring to over there was only similar in that it was a new user that started the thread. The content of that OP was potentially libelous, and was pulled for that reason and not because it was a new user posting news.

I also stick by my comment. TCCA has quietly condoned the rule-skirting that goes on here in Pacific Region for many years ... it is well documented for those who care to investigate.

After Davis Inlet, and TSB Rec. A01-01, TC should have investigated ways to improve oversight of small and remote operations. "Funny" that Rec wasn't referred to in this report.

I can't help but wonder just how much information was removed when all the "interested parties" had their say over the draft report.

[Beechnuts]

This is my first post on this forum .
I do not wish to dis any one be it an operator ,a pilot or TC .I think we are heading in the right direction by discussing the problems that we face in every day Coastal VFR flying.Education and common sense is paramount in having a successful career.
The Operators that have suffered losses in my mind are all good operations .
Please fly safe
Beechnuts

[PPRuNe Towers]

I think the thread should stay and jonny dangerous be deleted:E

Rob

[jonny dangerous]

I was offside. I apologize to DHC2 Widow and the other members of this forum. And as well to the O.P. of this thread. I would appreciate not being deleted.

[xsbank]

"The pilot got what he deserved...??"

What does that mean? The penalty for having a "can do" attitude is death?

IMHO, the pilot was wrong and needed 'retraining' but where was management? Is a talking-to (three times, I might add) sufficient? Apparently management was ineffective and negligent.

What is with this Widow-bashing? Good thing she has a thick skin, at least as thick as those who bash her. I'm bored with it, it has nothing to do with this thread and it might enlighten you lot that she lost her husband in a float-plane crash on the Wet Coast so her opinion about feckless float-plane flying is informed and golden.:=

[+TSRA]

So a "Can Do" attitude is flying below VFR minima and an attitude that places you in the managers office two or three times?

Perhaps instead of slagging the management, you would care to look at both the pilot and the management in the same light, instead of viewing this as a "lost soul who was getting the job done."

You may also care to look at TC who allows this attitude to prevail in the coastal regions.

Quite a number of these smaller operators are a Type C Dispatch - in other words Pilot Self Dispatch - in some cases the management has written into their COM that there will be an authorization process to weight the risk and make sure pilots are making the right calls - I would suggest that this is not what is going on with this or other coastal operators. I would also suggest that many pilots would despise management stepping into the go/not go decision. So until such time that this happens, and should they be operating a Type C Dispatch, then the pilot gets all the blame for flying in weather below minima as far as I am concerned. You want the PIC, then act like it.

In this case, the only blame management can have (and I stress in this case) is that they did not pull this guy from the flight line and retrain (as you suggest) or amend their ops manual. Either way the final decision in the Pilot-in-Commands.

We all get the tasks given to us done in one way or another, but the safe way is to wait for the weather to pick up instead of relying on some messed up attitude that "...because I've flown in this area for 20 years, I've seen everything and, and, and..."

[xsbank]

I'm not saying that this pilot's actions were laudable, I just dispute the assertion that he, and by extension, every pilot who has 'cowboy' tendencies, (look around your own flight department) needs to die for it.

This guy was not self-employed, therefore what was the role of the CP and the Ops Manager here, especially as this was not their first accident? Oversight seems to be missing here.

[ChrisVJ]

First, even as a lay person I'd say that the record for float operations on the West Coast is fairly dismal, though I acknowledge up front that the terrain is dangerous, the volume is enormous, and water operations, by their nature, are more dangerous statistically than land ops. If we are to blame someone, then there is plenty to go around.

TC enforcement is sporadic, but then I don't see how it can be otherwise. There can't be a TC rep to watch an operator more than a couple of times a year, it's easy enough to be a good boy while they are around! Also, most of the time they have a whole load of other concerns as well, paperwork, aircraft maintenance, ops manuals, local safety precautions, training manuals and procedures, docks, offices, staff, avgas safety, an endless list. And just how are TC to watch a pilot who himself is two hundred miles from his base? At some point they have to say " We have checked all that we can for this operation and we rely on them to continue operating as they do while we are present."

HOWEVER we might certainly be concerned about the current SMS push. SMS might be a good philosophy in principle but if the idea is that it should largely take the place of regular and irregular inspections etc, it looks like just another way of saving money and I suspect, human nature being what it is, companies will compromise unsupervised safety to the bottom line.

It is not difficult to see how a company might have a word with a pilot about minima while quietly admiring him for 'getting the job done.' Then again, "a word" in hindsight might have been just about anything. I fly passenger occasionally on this coast and it worries me that any company allows a pilot to fly one of their almost irreplaceable aircraft and just as irreplaceable passengers after he has been 'spoken to' more than once. Today we visited a two room schoolhouse a hundred and fifty kms from our administrative centre and I was thinking about how the teachers were operating almost like those of a hundred years ago, responsible on the spot for all immediate decisions. Well pilots around here are in the same position and I suspect it is only accident when head office learns of potential incidents or close calls.

Then there are pilots. Of course they are ultimately responsible but how do we hold them accountable on a daily basis? If you were a passenger and the aircraft flew too close to cloud, did a scud run for the last two kms perhaps, would you report it or just say "Well he must have known what he was doing because we're here safely." If the cloud is six or seven hundred feet down the valley would you get on the plane? Would you watch other passengers get on the plane? You've got four passengers expecting to make a connection at YVR and the route out is a 'maybe.' Do you go?

It is interesting how many on here seem to have just one entity to blame. If progress is to be made then we need to be very realistic and dispassionate about who should do what and how we ensure they do it. If you want more enforcement someone is going to have to pay for it. Yes, TC is pretty inefficient, (and I am a guy who thinks they are idiots often enough too!) but they are not the only ones, just a different kind of inefficiency.

[20driver]

Chris, a very sensible post that will probably get you shelled then deleted.

The mantra is it is all TC’s fault. A particular Lord Voldemer controls an evil empire and leads innocents to their doom . In fact it is much more complicated and involves a lot of dynamics and social interaction that is hard to understand let alone quantify. It is easier just to blame the evil empire.

As an example. Many years ago, before I learned to fly, I was at a small strip in Manitoba trying to hitch a ride. 3 big guys showed up, with bags and tool boxes and squeezed themselves into a hired Cessna for a short hop to start the week at a power dam.

As it taxied out the front wheel of the Cessna was just bouncing along the ground. I was not flying at that point but it was clear that plane was grossly overloaded and out of C of G.

Think of all the players involved. The pilot clearly knew. His employer must have known. It wasn’t about money. Manitoba Hydro has buckets of it and was not going to order people fly in overloaded planes. The pilot cost his employer money as there should have being two trips with more revenue and more hours in the log book to boot.

The people at the airport and the dam site would have known the plane was overloaded but did anyone drop a dime and call TC or inform Manitoba Hydro? I doubt it because no one gave it a second look. The passengers in the plane would have known but rather than wait for second trip it was, I’ll just squeeze in. There was no crash that day and the same scenario plays out every day all over the north. Someday you get unlucky and then the hand wringing starts.

The pilot who always gets it in is lionized, “he’s a real pilot”. The pilot who sits and waits is often shunned by customers and employers and ends up down the road. Pilots get the message pretty quickly.

It’s not a simple issue. A new regulation isn’t going to change things when the existing rules are being broken. A new dynamic is needed and that will only start to happen when the customers start demanding it.

There are a lot of players involved but ultimately cash rules and the customers control the cash. When they can differentiate service providers based on quality and safety things will change.

[dhc2widow]

I wish I had more time to respond.

I agree there is plenty of blame to go around, but wasn't everyone on board this aircraft working (or travelling to work at the behest of their employer)?

If that is indeed the case, the only suable party is Transport Canada, thanks to the Meredith Exchange. No employee/employer can sue anyone else who is covered by (provincial) Worker's Compensation, either employee or employer, anywhere in Canada.

The way it was explained to me, even if I had declined my WorksafeBC Pension, I would not have been able to sue, for example, my husband's employer, the air operator or its employees (including the pilot or his estate), the AMO or its employees, a Canadian aircraft or parts manufacturer or its employees, etc. Because my husband was deemed to have been working and was covered by Worker's Comp.

If I had declined my pension, I could, however, have gone after TCCA. But five and a half years ago, when I had to make that decision on the heals of my husband's death, I had no idea the truth of this industry or I would have made a quite different decision.

Further, the "Little Crown" (or Provincial Crown) seldom goes after the "Big Crown" (Federal Crown), so there is little or no chance that WorkSafeBC would go after TCCA for the, say, 1/3 liability (my opinion, reference Wapiti).

You have to try to understand, lawsuits aren't always about money. Sometimes they are about making a point, so that the truth comes out, and people care and government acts.

[OverUnder]

You have to try to understand, lawsuits aren't always about money. Sometimes they are about making a point, so that the truth comes out, and people care...

Music to my ears.

A few pilots, a very few, have actually been known to start legal proceedings because that is the only way to effect change. In many situations, initiating legal proceedings is the only way to make the existing laws applicable and enforceable.

Doing so, however, almost inevitably comes at an incredible price, in far more than monetary terms. None of their (former) friends will ever accuse them of being altruistic. At least not around here, anyway.

[Chuck Ellsworth]

Widow has seen the documentation of my legal battle with T.C.

Widow also knows I won and was promised a settlement of $250,000 tax free from the top bureaucrat in Transport Canada.

The finding of wrongdoing by TCCA was in my favor and was made about four years ago, to this day I have not seen one penny of the money they owe me.

But I did get to publicly name several of T.C.'s top management and describe them as morally corrupt.

As widow stated, money is not everything.

However I could sure use what they owe me.

[STC]

The pilot in command is ultimately responsible for his actions and the safety of his passengers. Using this incident and the TSB report to place blame on the regulator will get nowhere.

Are we any more lenient on a bank robber because he found a breech in security? Are we any more lenient on a murderer because he was able to get away with it the first five times?

This pilot knowingly broke the rules repeatedly. He gambled with his passenger's lives. Not TC.

Stop trying to blame your shortcomings or indiscretions on the regulator.

[Willie Everlearn]

He deserved what he got as a result of his own stupidity.
His passengers didn't.

This guy ignored the rules, not TC.
If this guy was known to behave like this, breaking the rules on a regular basis, then how is that TCs fault?
Couldn't his colleagues have done more to protect him from himself?
Does that mean all operators who knowingly turn a blind eye are not at fault either?

Three parties here, TC, the operator, and the pilot. All three sound like they're negligent in their duties and responsibilities. Flying has always been an inverted pyramid of responsibility with ultimate responsibility falling to the PIC.
This guy was negligent and fully responsible for the outcome of this flight.
Ignoring the rules is just stupid in my opinion. That's what he did. Ignored the rules and put his passengers lives at risk. That was stupid and we can't fix stupid.

If you ever give your passengers the option of going with you or staying behind due to the risk, then you already have your answer.

If you're flying with someone who takes these kinds of risks, don't pass it off as "Can Do". Turn them in.

At least doing so might save some lives.

Willie :ok: