The Division Within
The State of Canadian Aviation Investigations, Part 2: The CASB and the Arrow Air Debacle
This is Part 2 of my series “The State of Canadian Aviation Investigations”. Click here for Part 1, which goes through the Dubin report and explains the origins of the CASB.
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Prologue
It is 1983, and Canada has learned a lot from Justice Charles Dubin’s report into aviation safety. The Liberal government is working on legislation to create an independent board to investigate aviation accidents and incidents. Air Canada would also have a bad year, having the horrific disaster of Air Canada Flight 797, and the incredible event that was Air Canada Flight 143.
143 in particular happened in a weird time of accident investigations in Canada. In June of that year, the first reading of Bill C-163, the bill that would bring the Canadian Aviation Safety Board (or CASB) into existence occurred, but that was just the first reading. According to a legal document (page 8), Bill C-163 was enacted in November of that year, and the CASB would not come into existence until May 1984. The Gimli Glider happened in July 1983, so the ASB was essentially trying to be an “interim CASB” in anticipation of the bill’s enactment. As this was a serious incident, and investigating while going through an organizational change would be a nightmare logistically, that investigation was done under a Board of Inquiry, headed by George Lockwood. This article will not go into Air Canada 143, but you can read Admiral Cloudberg’s article on that.
So what did Bill C-163 exactly do?
Bill C-163
Bill C-163, or the Canadian Aviation Safety Board Act, or CASBA, had its first reading on June 23rd, and was eventually enacted on November 17th. As CASBA is (spoilers) an obsolete law, there are no accessible copies of it online in its final form, nor its revised form in 1985. However, the copies that do exist online are its form in the aforementioned first reading, and also an amended version reported on October 3rd.
I will not go into all of the details, but I will point out a few key ones.
- The board should have no fewer than three members, at least one of whom is full-time.
- One of those members shall be the Chairman, given the role of CEO of the board, and they would supervise the work and the direction of the work and staff of the board.
- Full-time board members have seven-year terms, while part-time board members would have five-year terms (this may have been changed in the final version, as announcements of part-time members say that their terms last one year), but their appointments can be extended.
- The Board’s job is to advance aviation safety via their independent investigations, and should not direct any blame or liability.
- There shall be a Director of Investigation to have exclusive authority to direct conduct of the investigations and to report to the Board.
- Medical examinations of aircraft crew members and cockpit voice recordings shall be privileged, and no one should be required to produce it in any legal case. Statements shall also be subject to the same protections, as would the identities of the people that made those statements.
Finally, the people at the ASB that worked so hard for these protections got what they wanted.
This seemed like a good plan, and a good Act of Parliament. Just one question. What do the Board Members actually do?
The CASB Members
While we think about that question, it is important to list out every board member, when they arrived, their background, and as a preview, their view on Arrow Air’s investigation. Unless specified, they were made full-time members.
- For the first chairman of the CASB, the Liberal government appointed Quebec lawyer Bernard M-Deschênes. The appointment was made in February 1984, with a start date of May 1st, 1984, the beginning of the CASB. For reasons that will be discussed later, he will retire by April 1988, but he supported the majority conclusion.
- To replace M-Deschênes, Kenneth John Thorneycroft, a retired air force general, would be appointed Chairman of the CASB. According the Canada Gazette (which I’ll refer to as “the Gazette” in this section), a publication by the Canadian parliament, he was shown as being appointed by the June 4th, 1988 issue, but he was actually appointed in April 1988. Benoît Bouchard, transport minister, appointed him “as one of his first acts”. As shown in the report, Thorneycroft supported the majority conclusion.
- Rodrick Ross Stevenson was one of the first board members appointed to the CASB. He was a retired Air Canada pilot, and fought to try and remove the mandatory retirement age a few years prior. According to the Gazette, he was appointed to the CASB before June 2nd, 1984, but since he was one of the first board members, he was probably there since the start on May 1st, as the CASB was not allowed to have fewer than three board members, Chairman included. He was one of the four dissenters of the Arrow Air report.
- Roger LaCroix was also one of the first board members appointed, and joined at the same time as Stevenson. He was a retired Brigadier General, and an aide to former defence minister Gilles Lamontagne. While the Arrow Air final report was being made, LaCroix resigned in protest of the majority conclusion, obviously making him a dissenter, though not on the official list of dissenters.
- Frank Russel Thurston was appointed soon after as a part-time board member. A retired aircraft engineer that is an Officer of the Order of Canada, he was appointed before July 28th, 1984 according to the Gazette, though he was probably appointed in May or June, for reasons that would become apparent very soon. He supported the majority.
A bit of political history is needed to know the context of the next two appointments. Pierre Trudeau, long time Prime Minister of Canada, was about to resign on June 30, 1984. Just before he resigned, he gave over 200 people, all Liberals, most who helped him in his long political career, patronage appointments throughout the month of June. He also arranged for his successor, John Turner, to give another 70 appointments in July, some of which were conditional. Many of these conditional ones were then-current Liberal MPs. Trudeau gave Turner the choice of giving them appointments right away or probably a year from then, as giving all of them appointments would remove them from Parliament and lose Turner his majority government. Ultimately, Turner decided to call an election before having a session of Parliament, and so gave these conditional appointments immediately. Frank Thurston was not mentioned in this glut, so he probably got appointed before the glut happened.
- William MacEachern was one of Trudeau’s speech writers and a former Nova Scotian Liberal MLA, and was appointed as a board member in that glut of Trudeau’s patronage appointments. He supported the majority.
- Arthur Portelance was not in that glut of Trudeau appointments, but was appointed in the glut of Turner appointments in July, though Turner claims that this specific appointment was his own idea. Portelance was a Liberal MP at the time. He supported the majority.
Brian Mulroney’s Progressive Conservatives would then destroy John Turner’s Liberals in the 1984 Canadian federal election, partly because of those patronage appointments.
- Bruce Pultz would be one of three board members announced on the November 30th, 1985 issue of the Gazette as being appointed as a board member, though was probably appointed over a month before. He was an air force pilot, and later a flight instructor with his own flight school. He supported the majority.
- Norman Bobbitt, a former military pilot and aeronautical engineer, was also in that group of three. He was one of the four dissenters.
- David Mussallem, another aeronautical engineer, was also in that group of three as a part-time member. He was one of the four dissenters.
- Les Filotas, an aeronautical engineer who is a lifelong friend of then-fisheries minister Tom Siddon, was appointed as a board member around December of 1986. Not only is he one of the four dissenters, he’s considered the leader of the dissenters.
According to a former CASB and TSB investigator, Larry Vance, in the book Brace for Impact by Peter Pigott,
- “the CASB was supposed to have only about four board members in total, plus a chair. The Liberal government had chosen the first four board members [This is incorrect, the Liberals appointed five board members plus a Chairman, though he could have been talking about the board members remaining when the CASB ended, excluding LaCroix]. Then, after the election [in 1984], to balance things off politically, the Conservatives appointed four additional board members. The eight [nine] board members quickly divided into two camps and the whole thing became completely dysfunctional.”
Although Vance is getting his facts a little wrong, he is correct in saying that there were way too many people in the CASB. For context, the current TSB has a Chair and three additional members, with room for one more member*, and the NTSB also has the same setup. In contrast, the CASB, at its peak, had a Chairman and nine additional members. They had way too many people, and that allowed this situation of the two camps occurring.
*when I wrote this, the TSB website showed this was the case, but that spot was actually recently filled
But you might be still wondering, what do they do? That question is the key into understanding the mess that occurred in the CASB.
The CASB’s Start
As stated before, the CASB came into existence on May 1st, 1984, with some parts of the CASBA being enacted on October 1st. They came into existence already busy. Some of their investigators were probably still investigating Air Canada 143 under their Board of Inquiry, and the ASB was a couple of months into their investigation of PWA Flight 501, which the CASB essentially absorbed into their own.
There was also the location of the CASB headquarters. Despite the ASB having been stationed in Hull, Quebec, near Ottawa, the Liberals decided to have the CASB’s headquartered in Montreal. Critics believed that this was done for the convenience of M-Deschênes, who was based there, and whose wife was reluctant to move to Ottawa, according to Peter Pigott in his book. Larry Vance also said in that book that lots of investigation expertise were lost, as few people were willing to make the move to Montreal. Most decided to stay with Transport Canada in other capacities. Now the CASB had to hire a lot of new people.
After Mulroney won the 1984 election, he committed to an election promise to have the CASB based in Hull after all, creating another mess where people who were just hired to work in Montreal did not want to move to Ottawa. I feel the sheer annoyance by the few people that stayed with the CASB during the transition, making plans to move to Montreal, only to move back to Ottawa after a few months. Even today, the TSB is still based in Hull (though Hull has since been amalgamated into the city of Gatineau).
Nevertheless, that bad start seemingly gets brushed off, and according to an article by Carol Goar, conducted about 650 investigations a year, and even acquired a fine reputation in international aviation circles. In fact, “its analysts are so highly thought of that they are borrowed by other countries for major investigations.” In my opinion, this only speaks of the beliefs and skills these investigators developed in the ASB, and they were finally able to flourish in independence.
Well, sort of. Despite the CASB being independent of Transport Canada, it still reported to Parliament through the Minister of Transport. This will cause issues, but at least the CASB did not have to worry about Transport Canada editing their reports, nor would they have to worry about being intimidated by them.
But still, what do the Board Members do?
The Good Things the CASB Did
But before we answer that, let’s look at things the CASB actually did that are positives.
As stated before, the investigators themselves were quite capable at their job, and other countries borrowed them for their own investigations, probably when there was an excuse to have Canada involved.
1986 would actually be a year of highs for the CASB, despite the Arrow Air debacle starting to brew in the background. When Air India Flight 182 was bombed out of the sky by Sikh terrorists, the CASB was involved. It was a flight from Canada filled with Canadians, so they had a right to be a part of the investigation in some way. According to Pigott, even though the investigation was under jurisdiction of India and the US, the CASB decided to prepare a report on the matter, presenting it at the Kirpal Inquiry in India on January 16, 1986. It found that there was no structural failure of the 747, but that a bomb took it down. It also condemned Transport Canada “for not having adequately trained security staff at the nation’s airport.” The CASB got even more credibility when the Indian government formally agreed with the findings.
Despite this being a win for the CASB, Pigott said it was an embarrassment for the Canadian government. The CASB basically went out of the bounds of how involved they should be. There were heated discussions between the Prime Minister’s Office, the Department of Foreign Affairs, and the newly established CSIS. The RCMP were not even ready to admit that two bombs, let alone one, had entered the baggage system in Vancouver.
Also in 1986, the Engineering Laboratory staff developed a tool that would revolutionize how flight recorders were to be read: recorder analysis and playback software (RAPS), also known as Recovery, Analysis and Presentation System, which would be a tool for making flight-path animations, providing everyone with a visual depiction of the accident. You could search on YouTube for crash animations based on FDR data nowadays, but in 1986, it was a unique tool that was not commercially available. As RAPS got more updates, many investigative agencies wanted their hands on it, and the CASB (and later the TSB, who absorbed all property of the CASB) provided. 14 international users would have it by 2000, and it was commercialized the next year, according to Pigott.
But those Board Members. What’s their job?
Arrow Air Flight 1285R
I promise that this is the last section before I talk about the Board Members.
Arrow Air Flight 1285R was a flight full of US army personnel, taking soldiers that served in the Sinai from Cairo, Egypt to Fort Campbell, Kentucky. 248 passengers and 8 crew boarded the DC-8, and left Cairo on December 11th, 1985. Since the distance was very far for the DC-8, they had to stop to refuel twice: one stop in Cologne Bonn Airport in West Germany, and another in Gander, Newfoundland, landing there on December 12th at 5:34am local time. During refuelling, witnesses saw the flight engineer inspect the aircraft. However, and this is important: it was dark outside. It would’ve been hard to check for stuff out of the ordinary, especially if it seemed minor and hard to see anyways. The flight engineer found nothing out of the ordinary, and the captain did not request deicing, even though they encountered icing conditions during the descent and the freezing rain conditions outside.
After take-off at 6:45am, the plane struggled to climb, before descending, stalling and crashing into a wooded area about a kilometre away from the end of the runway. A huge explosion occurred, killing all 256 people on board. It is still the worst aviation accident in Canadian history.
Like with PWA Flight 314 last article, I will not go into detail about this accident, but I will give a brief summary. Admiral Cloudberg is going to cover this accident in much more detail in a few weeks, so stay tuned for that*. She even asked me for sources that I’m using for this article, so that article will be a treat to read.
*the article has been released!
In summary, the investigators found a few worrying things, but they did not find any evidence of an explosion before impact. No explosive residue on the wreckage, and no pieces of the plane found between the runway and crash site. They did find high amounts of hazardous chemicals in the blood of a bunch of the victims, but they concluded that these victims survived the impact for a very short time, allowing them to breath in the fire and smoke from the crash before they died from their injuries. The only evidence was eyewitness claims from a couple of people on the Trans-Canada Highway the flight flew over, where they saw a glow from the underside of the plane. Also, a few claims of terrorism from Islamic Jihadists from Lebanon. In other words, nothing concrete.
One worrying thing was the CVR and FDR. For some reason, the CVR was not operating properly, and was unusable. We do not know what was said in the cockpit. The FDR was barely usable. It was an ancient foil-tape FDR, and it only recorded four parameters: airspeed, altitude, heading, and vertical acceleration forces. Nothing else that would have been highly useful, like engine power or the pitch of the aircraft.
What little there was, however, was still useful. They found that the plane took longer than usual to take-off with its speed. It led the investigators to look at weight and balance, and they realized that the weight was very underestimated. The average weight of a man was taken as 170 pounds, as per the Arrow Air standard, which included 5 pounds for carry-on luggage. However, the people on board were no ordinary men. These were big soldiers with lots of gear. The investigators found that, after getting their recent medicals, the average weight of a man on that flight with their carry-ons was actually 219 pounds, making the passenger weight about 12,000 pounds heavier than expected.
The weight was still under the maximum take-off weight, but underestimating the weight puts their intended take-off speeds lower than they should be. It also makes any degradation of the aerodynamics of the plane even more pronounced, which brings us to the ice.
As stated, the flight engineer did an external check of the plane, and the pilots found no need to de-ice. The investigators discovered out that a seemingly tiny amount of ice on the wing could drastically decrease the performance of the plane, which was surprising even to them. While a DC-8 with the estimated weight could have safely taken off with a tiny amount of ice, a DC-8 taking off with the same amount of ice could struggle to fly with the actual weight. It got off the ground due to the “ground effect”, however, attempts to climb by pulling back the yoke resulted in a stall.
The investigators worked hard to look into other factors, like engine power, but after years of work, they decided on this probable cause:
- “The Canadian Aviation Safety Board was unable to determine the exact sequence of events which led to this accident. The Board believes, however, that the weight of evidence supports the conclusion that, shortly after lift-off, the aircraft experienced an increase in drag and reduction in lift which resulted in a stall at low altitude from which recovery was not possible. The most probable cause of the stall was determined to be ice contamination on the leading edge and upper surface of the wing. Other possible factors such as a loss of thrust from the number four engine and inappropriate take-off reference speeds may have compounded the effects of the contamination.”
The investigators, having done this hard work, send this report to the Board.
Ok, now to address the elephant in the room. What the hell do Board Members do?
The Board Member’s Jobs
One major thing to point out is that Board Members are not investigators. They appoint a director of investigations, who is given exclusive authority to direct conduct of the investigations and to report to the Board. Interestingly enough, the law did not explain what the Board Members actually do, so there were two camps of interpretations.
By the interpretation of the Chairmen and the four board members that supported the official investigators’ conclusion, the existence of the director of investigations means that the board members cannot interfere with the investigations, cannot boss around investigators to probe a exact aspect of aeronautics, and cannot tell them to “look harder”, at least not directly. They could ask the director for more information, ask questions, and have them explain more clearly, but they can’t just go to the investigation site and boss around investigators. Their job is to look at the findings given by the investigators and make recommendations to the industry to advance safety based on those findings. They should know that these investigators are doing their job.
By July 1988, they feel like their interpretation is correct, considering Bill C-142, which would try and replace the CASB, outlined the duties of the Board Members to something like that.
Objection and Dissension
Some board members do not like this interpretation of the law. They say that they feel like rubber stamps if they are not involved in the investigating. For a couple of them, like Filotas and Bobbitt, they wanted to be investigators but were turned down, and being an “involved” board member would have satisfied that urge. LaCroix wanted to be Chairman, and refused M-Deschênes authority. He even consulted psychics about airline crashes, unsettling his colleagues, according to Carol Goar’s amazing article in the Toronto Star, Safety Board A Sad Spectacle of Discord. Even Ross Stevenson had a habit of going to crash sites and ordering investigators around, clearly violating the “exclusive authority” of the director of investigations.
Rumours swirl about the growing discontent within the CASB, with the investigators’ morale being ground down, especially when Les Filotas was appointed as a Board Member in December 1986, about a year after Arrow Air 1285 crashed. His outspoken challenge of how M-Deschênes is running the Board galvanizes the other dissenting members who have been stewing in their unhappiness of how the Board is run. It gets to the point where the transport minister, John Crosbie, hires an outside firm to find out what the hell is going on. What that firm finds is shocking.
The Hickling report, mostly released to the public in July 1987, finds that a “disruptive group has gone to excessive lengths to force their will on the board. The divisions are so entrenched that, if allowed to continue, the board’s effectiveness could be seriously impaired.” However, there was an addendum to that report in October 1987, and that was kept secret by Crosbie from everyone, including the CASB itself and the next transport minister, Benoît Bouchard. It said a few things, from claiming that the minority group “created a potential conflict of interest by approaching the [transport] minister” and that the “activities of the group are seriously eroding the morale and credibility of CASB as an independent safety organization.” The addendum was so damning that it was even titled The CASB Board, Divided, Divisive, Disruptive. I could not find that specific report, but if anyone knows where to get it, link it in the comments.
It got to point where the director of investigations, Tom Hinton, aka the only person who actually had the authority to boss around investigators, said that that the dissenting group was still abusing the investigators 15 months after the secret addendum was given to Crosbie, according to Paul Koring of The Globe and Mail in January 1989. The abuse took the form of “very close and aggressive questioning, so intensive and aggressive that it appears to challenge the integrity of the investigator being questioned.” Morale was low among the investigators, to the point where a bunch of senior investigators left the CASB. On May 7th, 1988, a senior investigator, according to The Globe and Mail, anonymously said that the dissenters “want to be able to go out and kick metal. The NTSB does that; but I guarantee you the NTSB chairman himself wouldn’t go around asking: ‘Did you check this? Did you check that?’ He wouldn’t dare; those guys know what the hell they’re doing.”
What do the dissenters think of the abuse allegations? Well, in the words of Ross Stevenson, “We are trying to get at the truth. It’s not abuse when people are arrogantly defiant and wilful. We have been frustrated and thwarted in our efforts to learn what is really going on.”
My opinion of this behaviour? Fucking disgusting. How dare they question these professional investigators, working hard despite their abuse. How dare they criticize the investigators and throw them under the bus while the investigators cannot legally answer back.
The dissent’s response to the findings was to threaten legal action, “claiming that the board is not being run according to its enabling legislation,” retaining lawyer Rowland Harrison of Strikeman Elliott. In a November 17th, 1987 meeting between Crosbie and the dissenters, Crosbie lets John Sopinka, who would later become a Supreme Court judge and was involved in the Dubin report, conduct another review of the board. It is also worth noting that Sopinka was also a member of Strikeman Elliott, the same firm that Rowland Harrison was a member of.
According to Filotas, Crosbie said that “this legal action will compromise my department.” Filotas then says that “I don’t want to make it sound like a deal because you’re not supposed to make deals with ministers, but we suggested that John Sopinka be invited to prepare another report on CASB.” Great, a review of the review, sounds so fucking familiar! Must be a Canadian tradition, like gliding a plane that’s run out of fuel.
Sopinka finds the same internal riff, and that the dissenters are in “open conflict” with M-Deschênes on his assumption of “virtually exclusive power” to run the board and block certain investigations, according to Ross Howard of The Globe and Mail in April 5th, 1988. Sopinka also writes that “the “discontent of the board” is heightened by the fact that although there are well qualified members on it, they have too little to do because they are so limited in their role by the rulings of the chairman.”
My opinion? Boo-fucking-hoo. They shouldn’t have been board members then. There were reasons why investigators are hired or not hired, and the dissenters show why they weren’t hired as investigators. The tragedy is that they knew people in government that would vouch for their appointment to the board. It’s also worth noting that Sopinka interviewed all dissenters and Chairman M-Deschênes, but only one other board member, Bruce Pultz, who had no idea of the Strikeman Elliott connections.
Editing note: My original published article stated that Sopinka was the dissenters’ lawyer. This is incorrect. He was merely in the same firm as their lawyer. Note added January 28th, 2024.
Nevertheless, the Sopinka report results in M-Deschênes retiring the next day, and Ken Thorneycroft being appointed as the CASB’s second chairman. However, his reign as Chairman gets to a poor start when new transport minister Benoît Bouchard, still not aware of the secret addendum, sends a letter to all Board Members, which included this line: “You are expected to give your full and unqualified support to Mr. Thorneycroft", according to Carol Goar. Now that’s a way of the dissenters to immediately hate the new Chairman, and to also get accused of political interference, the thing that the CASB was supposed to avoid! Weirdly enough, that letter got sent to LaCroix, even though he already resigned by that point in time.
The Cost of Division
According to Carol Goar, even all of this mess has not spilt into the reports until 1988. However, I suspect that with the Les in the room, the dissenters had reason to try and build their own reports, because while Arrow Air 1285 was the biggest accident that received two differing reports, two other air accidents also had reports where the dissenters gave disagreements with the investigator’s conclusions.
Editing note: This article originally list two flights that were investigated as the possible reports with dissenting opinions. However, I have since gotten access to both reports, and they were probably not the ones Goar was referring to. Note added December 12, 2024.
I do not know what disagreements were brought up, but the fact that this happened on multiple reports show that the divisions were causing huge problems, not just for the people inside, but for the flying public.
When a final report of an accident is released, you want to see at least four things: what happened, why it happened, how it happened, and how to prevent it from happening again. The last one is particularly key, as these are recommendations to improve the safety of aviation based on how the accident occurred. What happens when some people on the Board drastically disagree with the investigation the investigators give them?
The narrow majority of the nine members, Chairman Thorneycroft, Thurston, MacEachern, Portelance, and Pultz, support the investigator’s report that a thin layer of ice, coupled with an underestimation of the weight, allowed the plane to stall and crash.
However, the dissenters of Filotas, Stevenson, Bobbitt, and Mussallem decided to create their own, dissenting report that completely ignores the years of research the investigators did. While articles written before the publication of the two reports speculated that an engine fire or a mechanical failure caused engine 4 to go into reverse thrust that caused the crash, the actual conclusion given by the dissenters was shocking: “An in-flight fire that may have resulted from detonations of undetermined origin brought about catastrophic system failures.”
Filotas would later say that Arrow Air 1285 was a victim of Jihadist terrorism, and that the detonations was actually deliberate sabotage, citing Lockerbie as a reason to believe that. I believe that his shifting of his opinion, from faulty thrust reversers, to explosions of unknown origin that could’ve involved the Iran-Contra scandal, to Jihadist terrorism, despite him probably not holding a single piece of wreckage, makes him seem like a control freak that is acting out because the CASB does not want him meddling with the investigation, and he would rather destroy the Board than let the Board do its job. I think it could have also been a last-ditch ploy to get a re-investigation run by either his Gang of Four alone, or by the US with his Gang of Four being heavily involved. Giving further evidence to these beliefs is his disgusting actions in 1989: writing to the families of the victims, especially the pilot’s wife. Trying to get emotional leverage, and feeding them disinformation to try and get them to reopen the case because you wanted more power is one of the most abhorrent things I could think of. These families probably think that the Gang of Four are just truth-seekers, not abusers, and Filotas was certainly abusing that privilege to the point where he was testifying in US Congressional hearings, claiming that “It’s impossible that ice would have been a factor.”
In this mess, the majority is just trying to do their job and warn about the dangers of ice on the wings, but what does it say when there is one side that brings up a benign, and somewhat unbelievable explanation that attributes some of the blame to the pilots, and the other side has a flashy bomb story that involves a coverup by the investigators that the media will eat up, and cause an uproar in the US Congress? The dangers of ice get forgotten about, the investigators are viewed with suspicion, and their investigations are no longer trusted.
The reports came out in early December 1988. Transport Canada could have been assured by the Chairman that the majority report was done by great investigators and could have issued huge warnings about the dangers of even the littlest of ice on the wings. Instead, Transport Canada creates a document that disagrees with the official findings, citing a lack of evidence. It becomes a political embarrassment when Bouchard comes out and supports the majority report, and then it leaks out that his own department did their own report in secret that disagrees with the majority conclusion.
They do eventually draft a warning about the dangers of ice and send it out to pilots and airlines. However, they are too late. Five days too late. On March 10th, 1989, Air Ontario Flight 1363 crashes after take-off from Dryden, Ontario. The Fokker F28 was not de-iced for a multitude of reasons, but there was ice on the wings. It wasn’t a lot, but it was enough to stop the plane from climbing, and crashing, killing 24 of the 69 people on board, including 3 of the 4 crew members on board. The warning was sent on March 15th.
These divisions killed them. That’s the cost of the divisions within.
Even when Air Ontario 1363 crashed, board members were still divided. According to Paul Koring, on April 4th, 1989, the CASB issued interim recommendations that “Transport Canada should consider requiring Canadian airline pilots to make a “last-chance inspection” of wings for icing just before take-off.” Three of the four dissenters refused to support the recommendations.
One was not in Ottawa at the time, Stevenson and Bobbitt abstained from approving the recommendation, and one straight up boycotted the meeting. The reasons Stevenson gives for abstaining? The recommendations are too premature, and wants to know if the engines were working properly, a buildup of slush on the runway, engine anti-icing turned on, blah, blah, blah. I think it is way past time for “premature” when ice crashed a plane, no one listened, and then ice crashed another plane. I think that’s “postmature”, and Stevenson should’ve just yelled at a cloud instead of at his investigators.
Judicial Inquiry and Review
In the days after Air Ontario Flight 1363, the CASB sends its investigators out. However, with the controversy into Arrow Air’s conclusions still fresh, Benoît Bouchard steps in, and calls for two judges to clean up the mess. Justice Virgil Moshansky was called to conduct an inquiry into the crash of Air Ontario Flight 1363, with the CASB investigators working under his rule. His inquiry was comprehensive and detailed, something that will be discussed in the next part. However, the very fact that he was called to do an inquiry removed the CASB Board Members from the equation, effectively killing off their role in creating any recommendations from the investigator’s findings, and also preventing the dissenters from their standard meddling.
Justice Willard Estey, a former Supreme Court judge, was called to conduct a review of the Arrow Air investigation. When Estey’s review is published in July 1989, the CASB is finally united: they hate his review. It found that there was insufficient evidence for the majority report, and even less for the dissenting report. However, he also states that any reopening of the investigation would be futile, considering the lack of physical evidence remaining.
Everyone in the Board believed that Estey was essentially asking for investigations to find a cause, not probable or possible cause. People believed that Estey was looking at the CASBA from a strict legal view, not an aviation investigation view, where investigators do not have to go to the extent to prove someone guilty, but merely enough to gain useful recommendations to prevent similar accidents.
Either way, the Estey review closes the mess that was Arrow Air Flight 1285. Conspiracy theories live on, mainly through the work of Les Filotas and his book on the matter, but in the end, lessons were not learned fast enough to prevent other ice-related accidents. I have a hatred for misinformation about air disasters. Whenever a person is wrong, I have to urge to correct them, no matter how minor. With these series of events, the more I looked into it, the more infuriated I got. I could not believe that the Gang of Four/Five managed to portray themselves as “truth-finders that don’t care about feelings”, when in fact, they are, in my opinion, “control freak abusers that don’t care about feelings”. They did not have the job of investigators, yet decided to act like them. They assumed purely from their (possibly flawed) knowledge and acted so snobby about it, believing that their ideas were right first, and then forcing people to look into their ideas despite it being completely wrong.
The Dismantling of the CASB
At this point, like the CVRs in Arrow Air and Air Ontario, the CASB is unrecoverable. Even before it became unrecoverable, politicians were already thinking of replacing the CASB with a board that investigated more than just aviation. Dubin thought that 1981 would have been too early to try and do this, but other modes of transport in Canada did not have the same independent investigative board that aviation had. Talk of a combined “Transportation Accident Investigation Board” (or TAIB) had been going on since 1985, but when the nastiness behind the Arrow Air investigation was revealed, politicians now had a reason to replace a board that only came into existence in 1984. It also didn’t help that the government was politically embarrassed by their Air India report.
It would take two attempts of legislation for the Transportation Safety Board (or TSB) to come into existence. Bill C-142 had its first reading on July 8th, 1988 to create the TAIB, however, the 1988 Canadian federal election was called before it could become law. Any bill that hasn’t been made law when an election is called dies.
After a few months, and the Air Ontario 1363 crash, parliament reintroduces the bill as Bill C-2, the Transportation Accident Investigation Board Act, with its first reading on April 7th, 1989. After being amended, by June 8th, 1989, it was renamed the Canadian Transportation Accident Investigation and Safety Board Act (or CTAISBA, or TSBA for short), finally coming into Canadian law on June 29th, 1989. The Canadian Transportation Accident Investigation and Safety Board, or Transportation Safety Board of Canada for short, eventually came into existence on March 29th, 1990, finally killing off the CASB. Even though the CASB offered its members a seven-year term, it did not even last six years.
Using the June 8th version as the closest to the original TSBA (as the TSBA has since been amended many times, and I wasn’t able to find the original law at the time of writing), here are a few notable differences:
- The Board has a limit of five full-time Board Members, one of whom is a Chairperson. Governments can’t just chuck more members in there to make it “politically equal”.
- The Chairperson is the CEO of the Board like in the CASB, but they have exclusive responsibility for managing personnel matters, financial matters, property matters, and any other aspects of the internal management of the Board. So, clear as day, the Chairperson is the boss of the Board Members.
- Even though the function of the Board is not to assign blame, they have to report all of the causes and contributing factors, even if people could infer blame from them. This was actually reported as another problem, but most people did not notice with the Arrow Air debacle around.
- There shall be multiple Directors of Investigations, one for Air, one for Marine, and one for Rail and Pipelines.
- Unlike in the CASBA, the TSBA has actual guidelines for Board Members. No more legal ambiguity; they have actual duties, none of which include doing the actual investigating, though they could make the Director of Investigations to do more investigation into aspects of an occurrence. So now the actual investigators are protected by the Board Members. They only communicate through the Director. They also come up with the causes and contributing factors based on the findings, identify safety deficiencies, and make recommendations.
- Instead of reporting through the Minister of Transport, the TSB now reports through the Minister holding the title of “President of the Queen’s/King’s Privy Council for Canada”, a job which is basically a ceremonial one that does nothing. Any lasting questions of government interference is gone.
With all of these clarifying laws in place, you would think that the TSB would fly (or ride or float) free, being the majestic investigative board that most other countries aspire to have! I thought so too. However, the TSBA also said that there should be a review of this law, starting in 1993, and will release a report by January 1994. That review did not turn out so great for the TSB, but that will be discussed another time. The current state of the TSB will also be discussed another time, but in a few words: currently, it is amazing at its job, and I hope their assistance will be useful in the JTSB’s investigation into the January 2, 2024 ground collision at Haneda Airport.
Conclusion
I really wanted to make this article, as I have always been fascinated by the CASB’s short but impactful life, to the point where I wrote an article for my university’s mathNEWS publication about it, but in lesser detail (as I had a strict word limit and not much research other than memory, Wikipedia, and other basic sources). When I dug into this topic, I got so much information that I did not fully realize, including the fact that I had to make an article about how and why the CASB became necessary before making an article about how and why the CASB became an agency that it needed to be replaced.
I also realized that the CASB died because of five people and an ambiguous law that did not define their role. Everyone else in the CASB did a great job, and seeing a lot of people with the title of “TSB investigator that started with the CASB” makes me feel bad about the CASB. It should have lived longer, or at the very least been given a much more dignified death. However, the destructive actions of a few managed to kill a safety board and 24 people. That is unacceptable to me. The one positive that came out of the mess is that Canada learned more lessons, and constructed the TSB so that this mess could never happen again.
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Thank you so much for reading! If there are any errors, please comment below. However, any talk about the explosion theory will result in insults by me.
I may have gotten emotional at times describing some of the people in the minority group. I’m sorry to the family members of these people. However, I think it was just a manifestation of my rage reading those articles, and I do not regret showing my feelings towards them. I stand by my words and opinions.
The next part of this series involves the inquiry that surrounds Air Ontario Flight 1363. It was a massive inquiry that was more important to the TSB than I ever expected.
Part 4 covers the 1994 review, along with the early history of the TSB up to Swissair Flight 111.
Part 5 covers Swissair 111, and its effects on the TSB from then until now.
Admiral Cloudberg has a great article on Swissair 111 already, and I don’t want to step into her territory. If she didn’t ask me for my sources, I would feel bad for going over the Arrow Air accident. Since this article’s release, she has since revisited Arrow Air 1285R. It is an amazing read, and credited me for giving her my sources.
Here’s a list of sources. Some of the most detailed articles were written by Ross Howard, Carol Goar, and Paul Koring, so shoutouts to them for covering the CASB in detail at the time. Also, Peter Pigott’s book “Brace for Impact” is a good read. If you want to actually see the articles, comment below, and we’ll arrange a way for me to share them.
