The Teething Years
The State of Canadian Aviation Investigations, Part 4: The Early Years of the TSB (From an Aviation View) and the 1994 Review
This is Part 4 of my series “The State of Canadian Aviation Investigations”. Click here for Part 3, which goes through Air Ontario Flight 1363 and the Dryden Commission.
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Prologue
March 29th, 1990. It has been a year since the Dryden Commission was called, and it’s the expected date of the release of its final report. Unfortunately, Virgil Moshansky pulled an hbomberguy and fell down a deep rabbit hole that requires so much more time than expected.
Nevertheless, the government decides to put the CTAISB Act (or TSB Act for short) into action and breathes into existence the Canadian Transportation Accident Investigation and Safety Board, or the Transportation Safety Board of Canada for short, or the TSB for even shorter.
This series is focused on aviation, but remember that the TSB is also an investigative board for rail, marine, and pipeline occurrences (their combined term of accidents and incidents). Not only does the TSB absorb everything owned by the CASB, they also absorb the Marine Casualty Investigation Unit of Transport Canada (MCI), and the Railway/Pipeline Investigations Directorate of the National Transportation Agency (RPID). In total, about 300 people were reassigned to the TSB.
There were people left behind in this move: the CASB members. The TSB only has room for five Board members, so people knew that four could not make the move regardless. The fact that the TSB is meant for more than just aviation meant that at best, only one or two were able to make the move. The dissenters were not making the move, nor was Chairman Thorneycroft. In fact, in the lead-up to the announcement of the first TSB members, only one CASB member was even speculated by Frank Howard of The Ottawa Citizen to even have a chance of making the move: Bruce Pultz. He was a pilot, did not embarrass the government (he was neither a dissenter nor outspoken about the situation at hand), and even knew President of the Privy Council, Don Mazankowski, who the TSB reports to. Despite this, when March 29th, 1990 rolls around, he is not among the five appointed members. Actually, none of the CASB members even receive a phone call from new Transport Minister Doug Lewis as a final goodbye, according to Val Sears of the Toronto Star.
Instead, the first five TSB members are:
- Chairperson John W. Stants, a former vice-president of Quebecair;
- Wilfred R. DuPont, a former justice of the Supreme Court of Ontario;
- Gerald E. Bennett, a former vice-president of transportation with the Council of Forest Industries of British Columbia and former manager of transportation services with a forestry company;
- Hugh MacNeil, a retired Vice-Admiral and a former deputy chief of staff with Supreme Allied Command, Atlantic; and
- Zita Brunet, a former member of the Civil Aviation Tribunal, and a former air carrier security inspector with Transport Canada.
Frank Howard notes that all five have boardroom experience, which is a nice thing to have if you are appointed as a Board Member, but was not present in some of the more outspoken CASB members. I might also note that you’ll have a hard time finding information of them during their time as board members, which might be important for later.
You’ll also find that a list of every board member in the history of the TSB is not easily available, so I took the liberty of removing a night of sleep in exchange for making this list based on lists of names in the bottom of every report until 2000, and then making use of the Wayback Machine on the TSB’s website, plus other outside sources. I have requested a list from the TSB itself, but it has not arrived as of the writing of this article.
I’ll temper expectations for this part of the series; this part will go from 1990 to 1998 (mostly), and from March 29th, 1990 to December 16th, 1997, there was no major aviation accident or incident where the TSB officially led the investigation. Since I am not focusing on the other modes of transport, I can’t tell if there were major occurrences in those areas either.
However, the TSB helps out in major air crash investigations in many countries, especially when Canadian planes (either the type or airline) are involved. They were especially involved with the investigation of the crash of Nigeria Airways Flight 2120.
Nigeria Airways Flight 2120
On July 11th, 1991, Nigeria Airways Flight 2120, a DC-8, took off from Jeddah, Saudi Arabia, carrying Nigerian pilgrims that just participated in the Hajj. After a fire broke out, the pilots attempted to return to the airport, only to crash under 3 km short of the runway. All 261 people on board died, making it the deadliest crash of a DC-8, surpassing the infamous Arrow Air Flight 1285R.
So what does this have to do with Canada? Well, the DC-8 was wet-leased to Nigeria Airways by Nationair Canada, an airline that existed in the late 1980s to early 1990s. The plane and crew were all Canadian, so this crash was also the deadliest crash involving a Canadian plane. Being so, the Saudis invited the TSB to help out with the investigation.
By help out, I really mean that the TSB flat out did most things. While the investigation was, on the surface, conducted by Saudi Arabia, the investigative team was about 80% Canadian, and even had a Canadian investigator-in-charge, Ron Coleman. In many ways, it was an investigation done by the TSB for Saudi Arabia, as the Saudis had limited experience, to the point where some theorize that the final report, published by Saudi Arabia, was effectively ghost-written by the TSB. Therefore, this report is a great peephole into the early TSB, and how they conducted themselves.
I will not go into detail, as Admiral Cloudberg has done an in-depth article about this horrific accident. To summarize, two tires blew on the left landing gear during the take-off roll. The crew decided to go ahead with the take-off, and when they lift off, they retract the gear. Usually a normal thing, but in this case, the left gear was on fire from the friction created with the runway. A fire in the wheel-well of a plane designed in the 1950s is a terrible thing. There was no fire-protection nor any fire-detection, and many critical components were able to be compromised by a fire. Hydraulics, electrical wiring, aileron cables, not to mention the fuelling of the fire from the flammable hydraulic fluid and, later, the centre fuel tank. The fire raged so hot that it burned through the floor of the cabin, and a hole was created in the plane. People were falling from the plane from as far as 18 km from the airport over the city of Jeddah. When the crew lowered the gear in preparation for landing, the plane lost its structural integrity and crashed. The question then boiled down to: “what caused those tires to blow?”
That question would be answered by a sheet of paper blowing around the crash site, which happened to be picked up by an investigator. The paper would show that Nationair staff falsified the tire pressures, and would lead investigators down a large rabbit hole of Nationair’s faulty safety practices of this plane in the lead-up to the day of the crash.
When the final report was published, at least one expert deemed it to meet “the highest standards” of accident reports. This was a quote from the 1994 review of the TSB, which was critical of the TSB in many areas, but not in major investigations they participated in outside of Canada. This included this crash, along with Thai Airways 311 (where the investigator-in-charge was also a TSB investigator) and Indian Airlines 605 (incorrectly labelled as Air India). With that, let’s get into the review.
“Advancing Safety”, the 1994 Review
When Bill C-2 (the TSB Act) was made law in 1989, it had section 63, which boils down to this: the government shall appoint one or more people in January 1993 to conduct a comprehensive review of the TSB to access its effect on the safety of air, marine, rail, and pipeline transportation. The final report of the review must be published by January 31st, 1994.
On January 29th, 1993, less than a month before Prime Minister Brian Mulroney would announce that he would resign from the post pending a leadership race, his government would appoint three Commissioners for the Canadian Transportation Accident Investigation and Safety Board Act Review Commission (which I’ll refer to as the TSB ARC).
The three Commissioners are:
- Louis D. Hyndman, who would be the Chairman;
- Johanne Gauthier; and
- Warren E. Everson.
Along with the commissioners, they had their staff, full of experts in transportation safety, law, economics, research, and administration, under the leadership of Executive Director Ted Wallace. Similar to the structure of the TSB, the staff helps the commissioners with their work, but the recommendations only come from the commissioners, not the staff.
Before I get into the details, I just want to note that the timelines throughout each part of my series have often overlapped for a more coherent article (Part 2 stretched into 1990 while Part 3 started in 1989, and Part 3 ended to some extent in 1995 while this Part starts in 1990), but it is important this entire review and final report was all done in between the Dryden Commission’s final report in 1992 and the Dryden Commission Implementation Project’s “Final Response” in 1995. There may be recommendations in this report that could have already been in the process of being complied with (or dealt with in other ways) via the Dryden Commission.
It is also worth noting that the TSB ARC’s final report, named Advancing Safety, would be published before the TSB reached its four-year mark, and besides the major investigations outside of Canada aided by the TSB, it would be almost four years before the TSB could even start a major aviation investigation from this final report’s release. Nevertheless, minor occurrences are still important to investigate, and finding problems in the processes of those investigations would help the TSB in the long term, so the review’s recommendations are still key for improvement. Including appendices, the report ended up being over 230 pages long, containing 66 recommendations to the Chairperson, the Board, and to the President of the Privy Council.
This is a series on aviation, so I will not go into too much detail about the other modes of transport, but I will refer to them when necessary.
The Commission notes that the TSB was created under the dire circumstances described in Part 2, and the Act may have made reactionary decisions to try and prevent those issues from happening. It is also Canada’s first ever independent multimodal accident investigation, so it was expected for the law to have unintended consequences, which is the entire point of this mandated review.
The report is divided into four chapters:
- “History and Context”, which is self-explanatory;
- “Assessing the Transportation Safety Board of Canada”, which “assesses the adequacy of Board products and the TSB’s state of preparedness to handle potential disasters”;
- “Legislation and Policy”, which discusses “the philosophy behind the legislation and some of the concepts and policy issue involved”; and
- “Implementation Plan”, which proposes “a work plan for all parties involved in the implementation of [their] recommendations”.
History and Context
I have covered a lot of history throughout this series, so I will not spend too much time here, but I do want to cover points I haven’t covered.
In Part 1, I covered the Dubin report as it relates to the creation of the CASB, but I did say that he was not the first to suggest an independent investigative board. Advancing Safety points out that in 1972, Brigadier General H.A. McLearn already created a report (which is not easily accessible) that called for “the creation of an Independent Accident Investigation and Safety Board” for all modes of transport, which he wanted established within two years. I do not know why McLearn was tasked with such a report. After looking at what may have happened in Canada around that time, I can think of three things that could have prompted this: the Dorion level crossing accident in 1966, Air Canada Flight 621 in 1970, and/or the creation of the NTSB in the US in 1967.
As Advancing Safety notes, this board got established 18 years after that report, not two. I did briefly mention the bill in 1979 that would have somewhat made this into a reality that died when the 1979 federal election was called, and this was mentioned in the report, but without the in-depth look that Dubin did as to why this bill was inadequate. The report also notes that this was the first of three attempts at such a board that died because of a federal election, which would’ve also counted Bill C-142 in 1988. I assume this means that the 1979 bill was attempted again by the brief Clark government before the 1980 election, and by the time the P. Trudeau government got re-established, Dubin was deep into creating his report that would suggest a board only for aviation occurrences, the CASB.
They would also point to two other reports that matched with the conclusions of the McLearn report: one made by a familiar face, and one that was actually mentioned in Part 2 in a completely different context. Bernard M-Deschênes actually examined the “marine casualty investigation function” and published a study on that in 1984, the same year he was also appointed Chairman of the CASB. The other one is the Hickling report made in 1987, which was mentioned in Part 2 as a shocking insight into the CASB’s workings, and whose October addendum was kept secret by John Crosbie. It turns out that these reports also promoted a “multimodal approach to accident investigation and safety promotion”.
The report would also mention why the TSB became independent, which was gone over in length in Parts 1 and 2, and the lessons that were learned in Gander, also gone over in Part 2. When the TSB was finally suggested in 1988 and 1989, the “crisis atmosphere” created by the Gander investigation may have led legislators to deviate significantly from the original visions brought up in the 1972, 1984, and 1987 reports to try and avoid the nonsense that the CASB got caught in. They point to the increased powers of the Chair and the exclusive control over investigations by the Director of Investigations (even though this latter point was in the CASB Act as well), and in general, the TSB Act “seems generally preoccupied with an elaborate balance of power between the Board and investigators, a preoccupation which appears to be inconsistent with a body whose mandate involves neither the finding of fault nor judicial rules of procedure.” They also believe that not only did the changes not successfully address the problems at the CASB, but it created new ones as a result.
Assessing the TSB
One ongoing theme throughout this review is that it feels like the TSB is an aviation investigation agency first, and all other modes are below it in terms of importance. When the TSB was formed from three other agencies (CASB, MCI, RPID), they did it by fitting the MCI and RPID units into the CASB structure. While, in my opinion, this was probably done because the CASB was the only agency of the three that was independent from the mode of transport investigated, it might also push the idea that these other modes are just planes but on sea/on rails/in pipes, even though there are a lot of differences, both physically and culturally.
This is most prominent in the Regional Structure of the TSB. Besides the head office in Hull/Gatineau, there are other field offices in many of Canada’s regions. Out of all of them, only Toronto’s and Vancouver’s has staff for all modes, and for the ones with staff for aviation, the majority of staff in that office is for aviation. Aviation is also the only mode with Regional Managers at the six field offices with staff related to aviation (Moncton, Dorval, Toronto, Winnipeg, Edmonton, and Vancouver). The other modes report directly to the Director of Investigations in the head office. When field offices have been consolidated to place all modes of transport under one roof, they moved to the ones operated by the air units. They point to an example in Vancouver, where they consolidated marine and rail units from the port and rail areas to the air office near the airport.
The report also found this structure unnecessarily bloated with executives between the board and the investigators. An inconsistent spread of jobs in their branches, where one branch has too many workers and another has too little. Jobs done within branches that probably should be done in different branches. For example, the “Safety Analysis and Communications” directorate.
Separated from the accident investigation function, it does safety studies, statistics, and informatics function, which is an understandable separation. However, it also does other aspects of safety analysis that’s “functionally associated” with investigations, including the Accident Prevention Branch, which looks after the safety deficiency analysis and human performance. It does seem odd that the “Accident Prevention Branch” is under a different umbrella than the one that had the investigations, where the point is to prevent future accidents via safety analysis? Even within the TSB staff, there was inconsistency on when the safety analysis begins, whether it was immediately or only after the field investigation is done.
The report also found that the way the TSB classifies occurrences and their responses to them, which can determine whether or not it gets its own report and investigation, are inconsistent and unclear. For example, similar occurrences would generate different types of classifications depending on the workload on the staff at that time. Also, the difference in mode could affect the classification. In the air mode, regional managers, closer to the scene of the crash, determine the level. In the rest of the modes, the Director of Investigations in the Ottawa area determines the level, even if the occurrence happens in Vancouver or St. John’s. They are completely removed from the scene and have a hard time accessing the scope of the occurrence.
One major thing in this section is the focus on the final reports, and the processes on how they get written. Many people believe that, given the nature of these reports, they take way too long to be released. One quote from a person from the Atlantic Pilotage Authority (a marine stakeholder) says it all: “While no one requires CTAISB to leap to hasty or unverified conclusions, it surely does not take 12 months to produce a two-page recital of the facts of a simple incident.” A representative from Canadian Airlines International expressed this same sentiment, but with harsher criticisms: “We find that probably it’s anywhere from two to three years for a report. I know the process and again it depends on the complexity. This one was quite complex from a human factors perspective but when we get the report, we find that the human factors aspect is not really explored. So I’m looking and saying: “Well, what took so long?””
The report points at USAir Flight 405 as a reason for making the final report process faster, and also points to another deficiency of the early TSB. As mentioned in Part 3, the Dryden Commission released a second interim report 15 months before Flight 405 crashed, and the recommendations from that report, which would’ve prevented that crash, never got to the FAA because of a major fuck-up, where the commission expected the government to deliver that report to ICAO, which would’ve made it available to regulators and airlines, but it never got there. Somewhat similarly, the TSB ARC found an instance where, during an investigation into a 1990 derailment, the operator did lab tests with the TSB observing. The lab report resulting from that test was finished two and a half months after the derailment, and key information was theirs to use to improve their own safety. Despite the TSB’s final report eventually using this lab report as the basis, it took 21 months from the derailment for its interim recommendation to be released, and 30 months for the final report to be released to the public and to other operators. That is not good for safety, especially when it took 7 months from the “Final Review Committee” approval of the report to the report’s actual release.
One interesting thing that the TSB ARC did was that they had expert opinion on the TSB’s reports, and these experts did not like what they saw. Focusing on aviation, out of the 23 air reports examined,
- 14 reports did not answer all the reviewers’ questions;
- 17 of the 20 applicable reports found an absence of reporting on controllable human behavioural factors (a key point that was alluded to in the Moshansky report);
- 15 of the 21 applicable reports did not address all reasonable hypotheses (a point that may have been a factor in the Arrow Air debacle);
- 2/3rds of the reports had a casual statement that was considered “incomplete” in that it did not address all correctable elements of the occurrence;
- over half of applicable reports were found deficient in the regard of “logic and consistency” in terms of the factual evidence presented or its analysis;
- 15 reports could’ve been improved through more balanced coverage;
- 14 of the 19 applicable reports had their findings to be “inadequate”, and the reviewers “fundamentally disagreed with the findings”, such as machine malfunction instead of “pilot error” being the more likely cause, or the failure to report on crew fatigue;
- a lack of adequate treatment of issues related to Transport Canada;
- though the recommendations in the only 3 reports of the 23 that had them received a positive response, the reviewers felt that there were 6 other reports where recommendations could’ve been made;
- about 75 percent of the reports received overall ratings below “adequate”;
- specific sub-elements were extremely well handled in 20 percent of reports, and were poorly handled in 60 percent of reports;
- the few lab reports that were reviewed were rated positively, even when it corresponded to a final report that was rated negatively; and, most notably,
- the aforementioned Nigeria Airways/Nationair report that got extremely high marks from an expert that also had “significant critical comments” on all but two of the domestic reports reviewed. This report was added in, as it was the closest to a major investigation conducted by the TSB at this point in time.
In all, not a good review for the aviation side of the TSB, though it does show hope, considering the great reports written in part (or fully) by the TSB for international investigations, and also certain areas within the domestic air investigations. The insight into the Nationair report actually reveals something even more troubling: the review says that the investigators are being held back by the processes in place at the TSB, but I would like to add the fact that the Nationair report was made under the supervision of Saudi Arabia, a country which is not known for its transparency, yet somehow had its processes allow the investigators to create a report that ran circles over the ones done under the processes of the TSB.
Many other things were brought up during this chapter, but I’ll summarize parts I felt were interesting:
- When the TSB makes its recommendations, the Minister of Transport, by law, has to respond within 90 days. However, these responses are only made public by Transport Canada “on demand”.
- While Transport Canada usually “accepted” 70 percent of recommendations from air mode investigations, the actual action completed to satisfy a recommendation from the air mode was at 35 percent.
- Recommendations were only directed at the regulator, even though it would be nice for operators to get recommendations as well.
- The TSB staff are “unaware” of what happens to their recommendations because no follow-up procedures exist for monitoring responses.
- The review seems to be obsessed with advocating the use of public inquiries, which is in the TSB toolbox but only used for enormous investigations, as a way of “improving the TSB’s profile and credibility, as well as heightening public awareness regarding transportation safety,” also pointing to the CASB’s use of six public inquiries in five years. I counter this point with the fact that one of these inquiries involved Arrow Air, and that did not do anything when the credibility of the CASB was destroyed later on. No one in the public thought “jee, these accusations of a cover-up and explosion don’t make sense when a public inquiry was called in 1986 and didn’t find anything fishy”.
- The observer’s appointed by the Minister of Transport, having the special privilege of observing CVR recordings and witness statements, was questioned by many in the transportation community, seeing them as “compromising” the TSB’s independence, particularly with the fear that they could be used for disciplinary reasons. Similarly, the fact that “peace officers” (the police) can have the same special privilege, destroying the supposed confidentiality witnesses are promised.
Overall, the report comes to the conclusion that the TSB was not performing fully “when measured against any set of reasonable standards, including its own”, but it did find a high degree of professional competence throughout, and found the laboratory services were “considered to be outstanding”, and when the TSB assisted in international investigations, it was “a source of pride and admiration for the Agency and for Canada”.
Legislation and Policy
The ongoing theme in this chapter is the way the TSB has interpreted “independence”. In the review’s opinion, the Board has gone out of its way to isolate itself from the transportation industry to maintain neutrality and independence, along with implementing barriers between themselves and the investigators for similar reasons, possibly as an overreaction to the Arrow Air debacle.
In the previous chapter, it talked about the Board’s “public profile”, which I felt was more important to put here, because it mentions that while the Chairperson and members have made several public appearances, “the general transportation community has little understanding of what the TSB is and what it does.” Board members have only appeared on the site of a major occurrence once, and that media relations have been left with the investigator-in-charge or senior staff, and that until a draft report is up for review, “the Board’s role would appear to be minimal.”
This theme of a “low public profile” is presented in this chapter, which is why I mentioned the first five Board Members at the start of the article. They don’t appear much (if at all) in the articles I research from their time. I do find it admirable that they are trying to get out of the way for investigators, but at some point, they have to speak and let everyone know that they approve of the work being done, giving them a public vote of confidence. The theme is so pointed that there is a subsection of this chapter literally called The Passive Board. In here, it discusses the reasonings behind the low profile: they believe that the TSB Act “requires them to sit as “independent judges” between the staff investigators’ interpretation of facts and the Interested Parties’ belief in what happened,” which is considered to be “a fundamental error of perception.” The Board isn’t a court.
This isolation has caused both the TSB staff and the TSB members to be frustrated: the staff was “confined to written communication with Board members,” while the Board members, with their interpretation, “wish could have more contact with staff but feel precluded from doing so because of a necessity to remain neutral and impartial.” These are the unintended effects of trying to avoid an Arrow Air debacle via an overcorrection. There is a way of interacting with investigators that doesn’t involve being fully hands-on. Just having face-to-face conversations with the investigators on what’s going on on the floor would go a long way in boosting morale, with investigators not thinking of the Board as a “Legion of Doom”-style board above all of the investigators that’s unseen.
This separation has also meant that, if a Board member is not on the site of an occurrence, it could take months before they receive a draft report and properly gain the full scope of the occurrence. If they ask the Director of Investigations for a clarification on a section, or to put more work on a certain part of the report to answer the reasonable questions they may have, the evidence may no longer be reliable to reassess. One recommendation I will mention in detail is #64: “The Board members should develop a policy for the role of Board members in representing the TSB at accident sites,” implying that there wasn’t any before!
The review believes that the TSB is missing an advantage they have being an independent Board: being aggressive with what they do, having a strong advocation for transport safety, gaining a strong public presence to gain more trust than being “quiet professionals”. That is the term the review uses for the culture of the TSB: “quiet professionalism”. Proud of their work, but reluctant to share that pride with the public.
Despite all of this, the review does believe that this type of Board can succeed with the right adjustments from their own regulations and changes to the TSB Act. As a big shot against a certain set of CASB members, “the use of technical specialists as Board members invites the danger of undue interference with staff professional judgment,” like aeronautical engineers, I guess.
Some other things that are brought up include the Board’s reluctance to publish a finding “from which blame may be inferred”, even though the TSB Act explicitly says in subsection 7(2) that “the Board shall not refrain from fully reporting on the causes and contributing factors merely because fault or liability might be inferred from the Board’s findings.” This reluctance can limit the amount of safety deficiencies listed out in final reports, and does not advance safety as much as it should.
One final thing that’s worth noting is the “interested parties” (IPs) process. At the time (and now), IPs, such as aircraft manufacturers, could only send “observers” to the investigations, with limited powers. However, IPs could get their opinions about the investigators’ draft report through the IP process. They have 30 days to respond to the draft report with their comments and concerns about it. During the first years of the TSB, they could only express their concerns via writing, even though subsection 24(4)(a) allows them to express them orally as well. This process has been extremely unpopular by both IPs and Board staff. Board staff thought it was cumbersome. IPs “were frustrated that they did not have a real opportunity to explain their concerns to the Board itself.” The forced communication via writing has been especially “alienating.” These IPs might be sitting on their hands for years, hearing nothing from the TSB, and then all of a sudden, be pushed into responding to a draft report via writing within the month. The review manages to distill this frustration from a single quote from an industry source: “You write a short description on how a turbine works!” Another quote, posted below, shows the ridiculousness of the process.
Implementation Plan
This chapter is short, as it is basically accesses the staggered importance of the 66 recommendations (12 are given high priority and should’ve been done within 9 months, 45 should’ve been done within 18 months, and the remaining 9 are “less pressing”. It also justifies having a review of the TSB so soon after its establishment, as they found a lot of problems that need to be fixed, and that having a “longer incubation period would only exacerbate problems.”
Media Response to the Review
The media chomped at the bit that the TSB, the magical agency meant to replace the disastrous CASB, got dragged through the coals. Headlines like “Board too secretive, report concludes”, “‘Passive’ safety watchdog comes under fire”, “On the wrong track”, “Transportation safety agency needs overhaul”, “Safety agency gets failing grade”, and “Changes urged at safety board” were on newspapers when reporters got their hands on this report.
Most egregiously, some guy named Les had his opinion printed in The Ottawa Citizen. Like the guy dressed in a hot dog suit, he comes in with his own thoughts, snobbishly starting with Santayana’s quote “Those who cannot remember the past are condemned to repeat it”, which, no, the review was arguing the exact opposite. They remembered his shenanigans so much that it adversely affected operations. Why was he gloating about an agency, which replaced the one he was a part of three years prior, that was not doing great? Then you see that the last line is promoting his book.
I do not have an exact response from the TSB on this review like the Dryden Commission Implementation Project’s “Final Response”. What I can say is that the spirit of this review has been embraced by the TSB over the years, and the TSB Act would be extensively amended in 1998 to comply with recommendations made, which will be talked about later.
Over a year after this review, the first Board members were starting to leave, presumably at the end of their terms, with Bennett and DuPont leaving in March 1995, and MacNeil leaving in September 1995, leaving the Board understaffed with just Stants and Brunet for about a month until Maurice Harquail joined in November. However, July 1st, 1996, Canada’s 129th birthday, would bring in two Board members that would change the face of the Board.
An Unexpected Character Returns!
On June 30th, 1996, John W. Stants retired from the TSB Chair. To replace him, Jean Chrétien already decided in May to choose someone with experience. Someone who was Canada’s Ambassador to France since 1993, before which he filled many Cabinet roles in Brian Mulroney’s government, including Transport Minister.
That’s right, Benoît Bouchard, the person that pushed the TSB into existence, is back, and he’s now the new Chairperson of the TSB! The same man that sent the infamous letter with the statement, “You are expected to give your full and unqualified support to Mr. Thorneycroft”, probably sent a letter to the Board Members that said, “You are expected to give your full and unqualified support to me.”*
*this is also a joke
To be fair to Bouchard, he really did tried his best to fix the CASB, and accepted the report made by the investigators in the Gander accident in spite of the spiteful Transport Canada secret report. Chrétien’s government probably wanted to reward him for “his staunch defence of federalism” as an Ambassador in France during the peak of Quebec separatism (he served from June 1993 to June 1996, which had the 1993 federal election where the Bloc Quebecois separatist party became the Official Opposition, and later the 1995 Quebec referendum that had the “Non” side winning by the narrowest of margins), and offered him a chance to lead the Board he put into existence. He accepted the appointment, and was in the Chair for 5 years from July 1996 to August 2001.
In an address given to the Canadian Aviation Safety Seminar in St. John’s on May 9th, 2000, he mentioned that he had a unique perspective on these agencies, being the Transport Minister that dealt with recommendations by the CASB and being the guy that pulled the plug on it in favour of the TSB, and that Chrétien asking him to be the TSB Chairperson was a “pleasant surprise”. His address would go on to express how the TSB does their work, particularly on an accident that occurred two years prior that I’ll mention later. Also notice that he’s making an address in this type of seminar at all, showing that the review has made great change within the TSB.
In addition to this address, I would like to bring up an anecdote. When I research old newspaper articles, I tried to do a search on some of the early board members from their time on the Board. There are few articles that pop up with “John Stants” or “John William Stants”, and even fewer with the other Board Members of that era. In contrast, just searching [“Benoit Bouchard” AND “Transportation Safety Board”] brings up so many articles, and in most of them, you can feel the power behind his statements, whether it is praising his investigators, making the frank explanations to the media about the nuances of investigations, or putting companies and/or regulators on blast for safety deficiencies. Though a lot of these are Swissair articles, many others were unrelated to that crash, only making my anecdote clearer.
Joining the Board at the same time as Bouchard is Wendy Tadros, a lawyer that held various positions at the National Transportation Agency and its predecessor, the Canadian Transportation Commission. To some people, her name might sound familiar. She eventually became Chairperson of the TSB in December 2005, first in an acting role, before being officially named Chairperson in August 2006, all the way until she stepped down from the Board in August 2014, giving her an impressive 18 years on the TSB. She was the face of the TSB when the Lac-Mégantic rail disaster happened in 2013 and was answering reporters’ questions, and was even in the episode of Mayday/Air Crash Investigation/Air Disasters that discussed Cougar Helicopters Flight 91, a helicopter accident that occurred off the coast of Newfoundland in 2009, during her time as Chairperson, though the episode was filmed after she stepped down from the Board.
Along with the appointment of Charles H. Simpson in December of 1996, another person that would eventually be acting Chairperson at various points in time before he stepped down in December 2005 (which led to Tadros becoming acting Chairperson), the Board became a four-person crew until 1999, which is beyond the scope of this article.
Air Canada Flight 646
I’ve written about the Board itself, and how it was deficient in the 1994 review, but I think that’s enough administrative stuff. How about some plane crashes?
On December 16th, 1997, Canada experienced its first major aviation accident since Air Ontario 1363. Air Canada Flight 646 was a flight on a Bombardier CRJ-100ER, a regional jet, from Toronto Pearson to Fredericton, New Brunswick. 42 people were on board when the CRJ, after the first officer attempted to go-around due to a bad landing situation, unexpectedly stalled due to ice that silently accumulated on the wings during approach, crashing onto the runway and sliding to the right, into a forest beside the runway, coming to a halt when it struck a large tree. Amazingly, despite the slow response by rescuers and the damage to the plane, there was no fire, and everyone on board survived, though 9 were seriously injured.
Again, Admiral Cloudberg has an article on this crash, but to summarize: the landing restrictions based on the weather conditions were lax, the first officer was making the landing despite his limited experience and the landing conditions, the warnings about ice accumulation reaching a dangerous level were suppressed by the plane below 400 feet, precisely when they reached that level, and the engines being at idle before the go-around meant that it took eight seconds before they would get to full power. All of these combined to create the situation of a stall when the first officer pulled up as per go-around procedure, which unexpectedly gave a stick shaker indication, quickly followed by a right wing stall.
The TSB would hammer the regulators for allowing such an approach in the weather conditions even legal despite the conditions being below the minimums stated for the approach, among the other issues presented. Seeing how the TSB produced a beautiful, 106-page report that was released only 16 months after the accident shows the improvements in place, and it would have been released within a year after the crash if a certain enormous accident did not take away resources from this investigation.
Propair Flight 420
Propair Flight 420 was not that enormous accident. However, according to some cursory research, it seems to be the first aviation crash officially investigated by the TSB where the death toll was at least in the double digits.
This was a flight that occurred on June 18th, 1998, going from Montreal-Dorval (now Montreal Trudeau) to Peterborough, Ontario on a Fairchild Metroliner. The plane was a small turboprop, with a maximum capacity of 19 passengers. On this day, it was carrying nine passengers, all General Electric engineers, commuting to GE’s Peterborough facility. With the two pilots, that made 11 people on board.
I won’t cover this accident in too much detail right now. Cloudberg has no article yet, so I could cover this at a later date (assuming she doesn’t get to it first). However, it ends up being similar to the Nationair crash mentioned at the start of this article. A wheel-well fire occurs a few minutes after take-off. This fire damages the hydraulics, and spreads to the wing itself, slowly deforming it during the emergency return. The crew shuts down the left engine, believing the fire is coming from the engine itself. They divert to the slightly closer Montreal-Mirabel Airport. When they extend the gear, the left one does not extend. Nevertheless, they are 5 seconds from a successful emergency landing. They are over the runway threshold when disaster strikes: the fire has eaten through so much of the wing that it folds up on itself. The plane drops from the sky while rotating 90 degrees to the left. The plane crashes and slides upside down into the dirt, ending up in a watery ditch. Despite fire crews arriving to the crash site within seconds (they were watching the plane as it was making its landing), they could not save anyone. All 11 people are killed from the crash, making it the deadliest crash to occur at Mirabel Airport.
The TSB investigated this crash for four years, possibly due to the stretched resources relating to the enormous crash that happened later in 1998, but also due to the lack of a Flight Data Recorder, which was not required for planes as small as the Metroliner, and the amount of damage to the plane making it difficult to find what even happened structurally.
Thankfully, they were able to solve it via the Cockpit Voice Recorder, ATC witness statements, an observation of the left brakes, lab tests on the flammability of hydraulic fluid, and collecting data on other Metroliner incidents.
The basic summary is that the left landing gear rims were rubbing on the partly engaged parking brake (which is the assumption, they don’t exactly know if it was the parking brake, but it’s the most likely scenario given the Metroliner’s history), getting the rims very hot from the taxi and take-off. When they retracted the gear, the wheel-well got extremely hot from the gear, as the heat had nowhere to dissipate, and the heat kept on building inside until it melted some of the hydraulic lines, allowing flammable hydraulic fluid to leak out and literally fuel a fire when it contacted the hot rims on the gear.
Note that this was just how the accident happened. The TSB also had to deal with the victims’ families, trying to answer to the best of their abilities of what happened while also trying to comfort them. In the Mayday episode discussing this accident, a TSB investigator described how he told the widow of the captain that he performed as well as anyone could perform given the circumstances. Just his retelling to the camera was so emotional that he had to dab his eyes from the tears.
When Mayday covered this crash, it also got me very emotional. In fact, this crash still gets me emotional to this day. The crew, as the TSB found, did everything to the best of their abilities. Despite the myriad of failure encountered by the pilots, they still managed to get their plane within 5 seconds of landing. Yet it still wasn’t enough. For the cruel cost of 5 seconds, 11 people lost their lives. While tragedy loomed in Montreal, 130 km away in Ottawa, the law was being dramatically changed for the better.
The 1998 Amendments
Coincidentally, also on June 18th, 1998, after a first reading in September of the previous year, Bill S-2 assented to law. It was a bill that would extensively amend the TSB Act to finally implement recommendations made in the 1994 review into the law.
Bill Tucker, who was Direction General of Investigation Operations, would give a speech at the International Transportation Safety Conference in Rome, Italy on October 10th, 2000. In that speech, he described the amendments as “increased independence from the regulators and the courts, increased emphasis on the identification of safety deficiencies, and some administrative tidying.”
One big change was that the Minister of Transport used to be able to send an observer to an investigation “in order to obtain timely information to the responsibilities of that minister.” This observer had the special power to access CVR recordings, witness statements, and the identities of those witnesses. However, as pointed out in the 1994 review, this violated some of the independence of the TSB, and as a result, this privilege was removed. This is important, as the Minister of Transport could have theoretically been influenced from what their observer heard and hand out disciplinary action based on that, even though that is not allowed. I believe the law might allow the Minister of Transport to send an observer, but only on the same level as observers sent by ministers “responsible for a department having a direct interest in the subject matter at hand”, which has no special privileges.
Another big change was that “peace officers” (police) also had the special power to access CVR recordings, witness statements, and the identity of those witnesses, provided they had a warrant. Again, the 1994 review pointed out that this destroyed the confidentiality that witnesses were promised, and thus, this power was removed in these sets of amendments.
One other thing that was removed was most of protections given to ATC recordings, as these are recordings of an open radio frequency. It wouldn’t make any sense to keep those protected if anyone with the right equipment can make their own recordings. Today, it’s as simple as tuning into an ATC frequency online and making an audio recording.
These amendments also added section 15.1, which allows the TSB to make “agreements with the provinces relating to the investigation of transportation occurrences coming from within the legislative authority of the provinces.” My interpretation is that this is allowing the TSB to investigate accidents within localized public rail transport, like the TTC’s subway or GO Transit Trains, provided they have an agreement with the province.
Finally, section 63, the thing that made the 1994 review legally necessary, was removed. Asides from all that, sections were made more legally clear, and the term “commodity pipelines” was replaced with “pipelines”.
Amendments to the TSB Act would continue over the years, and you can see when repeals and amendments happen on the Act itself. 1998 pops up a lot in those repeals, and when I saw Tucker’s speech that mention this in detail, I had to go into it.
1998 ends up becoming a pivotal year. Asides from my own birth, the TSB and the government are making the changes needed to improve the TSB, and they do so just in time. The TSB’s greatest test in its history was about to occur.
The Crash of Swissair Flight 111
On September 2nd, 1998, Swissair Flight 111 was carrying 229 people from New York-JFK Airport to Geneva, Switzerland, a popular flight for people that worked for the UN. The MD-11 was flying normally until the pilots smelt smoke in the cockpit. After initially thinking it was something unremarkable from the air conditioning, they decided to declare a “Pan Pan” to ATC in Moncton (“Pan Pan” is a call for urgency, but is a step below “Mayday” and is not a call for an emergency). After the crew suggested diverting to Boston, ATC saw that Halifax was much closer, and so the crew started to divert there.
The smoke would quickly build up into a huge fire in the cockpit, taking out many systems on board. The plane ended up slamming into the water off the shore of Peggy’s Cove in Nova Scotia. All 229 people on board died, making it the second-deadliest air accident to occur in Canada, after Arrow Air Flight 1285R.
As the plane crashed in Canadian territorial waters, the TSB was, by ICAO Annex 13, responsible for the investigation of this crash. Flashbacks to Gander 13 years ago went through people’s minds. Can the TSB actually do this? Can they be trusted? Should they just delegate the investigation to the Americans or the Swiss? Can they fully rebuild the reputation of Canadian investigators that was torn to shreds by the troublesome dissenters?
One of those dissenters, Norm Bobbitt, had unnecessary (and possibly hypocritical) advice for investigators, particularly from someone who was in the camp that verbally abused them. In an article by Anne Marie Owens for “The Ottawa Citizen” published two days after the accident, he said that investigators should “gather all the evidence and refuse any pressure to rush to conclusions about the cause of the tragedy.” I bet they wished to refuse the pressure from you and your friends, but okay. I’m sure they were going to do that without your words. I would not be surprised if they rolled their eyes reading that, if they read it at all.
After four and a half years, the TSB would prove that, yes, it is trustworthy, and it can investigate accidents of that size. However, covering that story is for the start of Part 5.
Conclusion
When I first started writing this series, I did not even think that the TSB would have teething problems. Its first seven years of existence is not really talked about in the grander scheme of things, so I always assumed that things were fine. On the one hand, it could just be a result from the lack of major occurrences within Canada, and thus would not really need to be talked about much. On the other hand, the 1994 review is an important report that still impacts the TSB to this day, and it doesn’t get a mention in almost any place that talks about the TSB. That’s why I made Part 4 centre around that, even if it was a boring thing to read, and why I made a Part 4 at all. It corrected many things in the TSB, some of those things that probably should’ve been corrected in the CASB days, but many distractions made those laws unchecked until there was already an irreparable rift. The TSB is what it is today because of that review in 1994.
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If you made it this far, thank you! I had a tough time reading the 1994 review, which naturally made this a tough write. It was boring to read, but I had to do it to gain the full picture of the TSB.
Part 5 is the end of this series, going from Swissair 111 up to present day, and will discuss the TSB’s future.
If you followed me after reading Admiral Cloudberg’s amazing article on Arrow Air Flight 1285, thank you so much. Seeing my name credited was a joy to see.
