The Trustworthy Agency
The State of Canadian Aviation Investigations, Part 5: The TSB from Swissair 111 to Today
This is Part 5 of my series “The State of Canadian Aviation Investigations”. Click here for Part 4, which goes through the early years of the TSB (from an aviation view) and the 1994 review.
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Prologue
It’s 10:30pm on September 2nd, 1998 in Peggy’s Cove, Nova Scotia. A small fishing village on the shores of the Atlantic Ocean, people have started to sleep, if they weren’t asleep already. Their lighthouse doing its work preventing ships from running aground. They started to hear plane engine noises, then suddenly, they hear a loud bang coming from the sea. They did not know it at the time, but their community was going to be the epicentre of the most important aviation investigation in Canadian history.
Oblivious to this fact, they do what all good fishermen do: get into their boats and try to help out. What they encounter is a scene of devastation. Wreckage floating on the surface of the ocean, people’s belongings, body parts. It was a horrifying sight that many rescuers are still traumatized by.
They would eventually find out that Swissair Flight 111 had crashed into the Atlantic Ocean, 9 km off the coast. 229 people were on the MD-11, taking them from New York-JFK Airport to Geneva, Switzerland, a popular flight for people in the UN. All died in the crash, making it the second-deadliest air accident in Canadian history.
The Investigation of Swissair 111
The next day, in addition to the many search and rescue/recovery teams that helped getting wreckage, personal belongings, and body parts from the ocean, Canadian investigators from the TSB arrive on the scene, with the investigator-in-charge (IIC) being Vic Gerden, who flew fighter jets with the Royal Canadian Air Force until leaving as a colonel to join the CASB in 1989, where he’d be one of many that moved to the TSB the next year. Larry Vance, who was an inspector and pilot for Transport Canada that joined the CASB in 1984 before being moved to the TSB in 1990, was the deputy IIC.
They had a monumental challenge in their hands. The wreckage that sunk to the ocean floor is 55 metres below sea level, and all they knew was that the pilots said there was smoke in the cockpit and were trying to make an emergency landing in Halifax. They also had to deal with the families of the 229 victims, and also, the aura of distrust.
Remember, this was September 1998. Asides from Air Canada Flight 646 and Propair Flight 420, both happening within the previous 12 months, they had never investigated a major air accident that they officially coordinated themselves. Propair Flight 420 was also the only crash that they’ve investigated that had a death toll above 10 people. On Propair, 11 people died. Swissair’s death toll was over 20 times that. This was an untested agency, and the last time a Canadian investigative agency officially investigated a crash with a death toll over 200 people was Arrow Air Flight 1285, an investigation that broke the CASB due to distrust from 5 Board members that wanted to be too involved.
In this investigation, they would have to do the hardest investigation in their lives while simultaneously trying to regain trust. Suggestions that the NTSB should take over were rebuffed: this was a job for Canada. A successful investigation into this crash, one that seems to have a cause different from any other investigated by Canadians, would be a huge win.
It would come at a huge cost. Air Canada 646’s investigation was going to be complete within the year before Swissair 111 crashed. Now, investigators were going to be pulled from that case to help in Peggy’s Cove, delaying that investigation’s completion until 1999. Propair 420’s investigation, which started 3 months prior, is going to have to play second-fiddle to a world-facing crash. Finally, the actual financial cost: CA$57 million in 2003, with is CA$88 million today.
The details of this crash can be seen in Admiral Cloudberg’s article, so I’ll focus more on the investigation process. The investigation boils down to two main questions: what was happening with the smoke in the cockpit, and why couldn’t the crew land their plane at Halifax?
Getting the Wreckage
The team had the arduous task of retrieving wreckage from the bottom of the ocean. They did this in many stages. First, they had divers and remote-operated vehicles scour the ocean floor, picking up everything they could. About 200 divers helped out in this stage. This was limited by the weather: it was September in Nova Scotia, and the weather could get undesirable for diving very quickly.
Among the things retrieved were the two black boxes: the Cockpit Voice Recorder (CVR), and the Flight Data Recorder (FDR). The CVR records the audio in the cockpit for what the crew says, and also the surrounding sound. The FDR records all sorts of flight parameters. Both of these should be able to withstand the intense forces of a plane crash. If these provide everything the investigator’s need, they would not have to retrieve more wreckage from the sea. Unfortunately, they were dealt with a blow.
The CVR indicated that they smelt smoke in the cockpit. They believed that it was something involving the air conditioner, where it can produce that type of smell occasionally without any harm. However, the smoke does not let up and, being the true professionals these pilots were, they declared a “Pan Pan” call to Moncton ATC. “Pan Pan” is a call of urgency, but not a call of an emergency like a “Mayday” call is; it’s one step below “Mayday”. To them, the smoke is a worrying thing but not a dangerous situation. After the crew suggests a turn to Boston, ATC says that they are much closer to Halifax. The pilots accept that, and they go for an emergency landing. However, their plane is full of fuel for the transatlantic journey, and so they think about dumping fuel to get within their maximum landing weight. After some discussion, they decide that the situation at hand is not urgent enough for an overweight landing that could cause damage to the plane. As they make their turns towards the ocean for the fuel dump, smoke continues to build until the autopilot fails. They have to fly manually. They declare an emergency as a fire breaks out behind them. Then the CVR stops recording.
One huge problem: the plane hasn’t crashed yet. Same story with the FDR. The FDR shows that everything was normal until the last 90 seconds of recorded data, where system after system failed, showing some sort of fire burning through wires. Then it stops at the same time as the CVR. The fire has eaten away at the recorders’ wires. For 5 minutes and 37 seconds, the plane flew without any recorders, radio functionality, nor transponder data. The pilots were all alone. We will never know what they were thinking. This forced the investigators to bring up more wreckage.
The next stage involved using a heavy lift crane from a barge. Then, the use of a scallop dragger to scour the ocean in a grid. Then, a specialized ROV was used to collect more wreckage. Finally, a year after the crash, they used a dredge ship, the Queen of the Netherlands, to scoop up the ocean floor, then sift through the dredged-up seabed to find more pieces of the plane. In total, they found over 2 million pieces of the plane, and, with all of their weights added together, made up 98% of the mass of the plane. This was absolutely incredible work to retrieve the wreckage over a span of 14 months, and then sort it, which was done by December 1999. That’s just getting and sorting the wreckage. Investigators now had to examine it, and what they found was interesting.
The wreckage indicates that there was a fire in the front of the plane, and so they decided to rebuild the front with the pieces on a wire frame. This showed that there was a fire behind the pilots in the upper portions of the cockpit, however, there is no evidence that most (if not all) passengers even knew that there was a fire. Soot was found as far back as business class, but there is no evidence that any passengers even inhaled smoke. The main questions becomes: why did this fire start, how did it build up so bad, and why couldn’t they land?
There was one main culprit for the fire: the in-flight entertainment system (IFE). While common on today’s planes, in 1998, Swissair’s IFEs were some of the first in the world, briefly being available to all passengers before being restricted to first and business class passengers due to economic reasons. It drew a lot of power and would get hot. However, to conclusively find the source of the fire would take years of investigation. They found electrical arcs, a lot of which were too small to see without magnification, but it’s about finding the source of the fire, and the ones they found so far arced as a result of the fire, and didn’t cause the fire.
A Fiery Revelation
One thing boggled the minds of investigators: even if a fire started in the ceiling, there should not be anything that could fuel the fire. They now looked at the cover material of the insulation: metallized polyethylene terephthalate, or MPET, also known as metallized Mylar. As Larry Vance recalled in Peter Pigott’s book Brace for Impact:
We had a good idea where the fire had started, based on evidence from the burnt wreckage pieces and the cockpit voice recorder information. We also were able to piece together the character of the fire from other facts such as the initial appearance of smoke in the cockpit but not the passenger cabin, the absence of fire damage or smoke residue in the passenger cabin, the airflow testing we did in an MD-11, and the known sequence of systems failures recorded on the FDR. We also were confident we knew what provided the source of fuel for the fire — the cover material on the insulation blankets.
But, how could it be? MPET passed the flammability tests mandated by the FAA, right? Yes, but it was a “vertical Bunsen burner test”, where a minimum of three specimens of the MPET-cover insulation blanket would be held vertically over a Bunsen burner, apply the flame for 12 seconds, then remove the flame, at which point the flame has to self-extinguish within an average of 15 seconds, the burn length cannot exceed 8 inches, and drippings from the material cannot flame longer than 5 seconds. It passed this test.
When they saw the unburnt pieces of MPET in the wreckage, and found that this would’ve been the only thing that could’ve fuelled a fire in the ceiling, they tore some of it off, put it on the hanger floor, and lit it with a match. It caught on fire, and propagated, contrary to the FAA’s requirements. So, with this info in mind, they conducted their own, proper tests. Lo and behold, their tests showed that, with the actual ways MPET was being placed within the plane, they could sustain a flame and self-propagate it. These tests were so effective at showing the flammability of MPET that, in one of the tests done at the FAA’s fire testing facility, Don Enns, one of the investigators, claimed that they destroyed the burn test equipment.
In fact, the limitations of the Bunsen burner test were already known, and aircraft manufacturers had already moved on to a “cotton swab” test that was much more consistent and realistic, and McDonnell Douglas, in 1996, advised its customers to not use MPET. HB-IWF, the accident plane, was built in 1991, and no one at the FAA decided to issue an Airworthiness Directive to replace the MPET (and MPVF, another insulation-cover material) on all planes. The worst part is that they knew about previous incidents where MPET and MPVF self-propagated flames:
- November 24th, 1993: Scandinavian Airlines Flight 666, an MD-87 registered SE-DIB that just landed at Copenhagen, Denmark, was taxiing to the gate when smoke was detected in the back. They evacuated everyone on board before a full-blown fire erupted, and even melted through the fuselage. Danish investigators found that improperly-installed wires arced, causing a fire, and MPET helped spread the flames.
By the way, if you are Danish or live near Copenhagen, can you please help me get this report? It’s in the Danish national library, and I can’t get it myself. No copy exists online as far as I know.
- October 10th, 1994: according an investigation by the CAAC of China, ground crew detected a burning smell on a Boeing 737–100. A short circuit ignited the MPVF that covered the insulation blanket.
- September 6th, 1995: according an investigation by the CAAC of China, an MD-11 experienced a fire in the Electronics and Engineering bay. Molten metal from arcing wires fell onto MPET next to the fuselage skin, causing extensive fire damage.
- November 13th, 1995: according an investigation by the CAAC of China, during maintenance on a Boeing 737–300, a nut bolt had to be removed with an air drill. Hot metal chips from this action ignited MPVF, and flames propagated to an area of 18 inches by 40 inches.
- November 26th, 1995, an MD-82 in Italy experienced a cabin fire prior to take-off. A broken fluorescent light ignited a fire, which spread rapidly with the help of MPET.
Even after Swissair 111 crashed, two more MPET fires occurred on MD-11s, both investigated by the NTSB. This became such a problem, particularly in China, that the CAAC did their own tests on MPET and MPVF, which showed the dangers of these materials. They even sent a report to the FAA on May 1996, stating that “the insulation blanket installed in the Boeing 737–300, [and] MD-11 airplanes is fire flammable. [The manufacturers] should make a prompt and positive response.” In response, the FAA said that “they intended to investigate the behaviour of insulation blanket materials under larger scale conditions” but that “the type of CAAC testing conducted (igniting at the sewn edge of the sample material) was not required for certification.” Obviously, nothing was done to existing aircraft by September 2nd, 1998.
The key difference between Swissair 111 and these other incidents is that no one died. These fires occurred on the ground, so everyone was able to evacuate. In contrast, Swissair 111 had its fire in-flight, and it slowly spread until it raged all at once. Therefore, only this accident got the world’s attention, and the TSB was using that as an opportunity to show how bad MPET really is.
The Search for the Source
Now the goal was to conclusively prove that a fire that propagated by the use of MPET caused the demise of Swissair 111. The investigators had pressure from everywhere to end the investigation once they had a probable cause. Even when they were retrieving wreckage, Larry Vance, in Brace for Impact, recalls that there was pressure from TSB management that it wasn’t their mandate to “clean up” the wreckage site. But to investigators, not only did they need all of the evidence they could get, but “cleaning up” the wreckage site would prevent any further problems with the fishing industry. They didn’t want to have any wreckage, personal belongings, or human remains from the crash to wash on shore for decades to come. Also, there were claims of diamonds and other valuable possessions, and no one wanted treasure hunters at the crash site. Unfortunately, these diamonds were never found, but the TSB believes these were “industrial diamonds”, worth far less than what was reported, and probably not worth finding in the “ocean-bottom debris unloaded in Sheet Harbour,” which is their most likely location.
The big reason why they wanted all of the wreckage was to push their recommendation A99–07, released in August 1999:
“Regulatory authorities confirm that sufficient action is being taken, on an urgent basis, to reduce or eliminate the risk associated with the use of metallized PET-covered insulation blankets in aircraft.”
This was an interim recommendation made by the TSB during the investigation. This is normal in major investigations whenever there is a safety deficiency noticed. However, there was a fear that financial pressures could make this recommendation ignored as sometimes, recommendations made by investigative agencies are ignored for cost-related reasons, the most infamous of which is that lap children should be banned, and all of those kids should have their own seat. Sometimes, recommendations are only followed in part, and are not satisfactory in the eyes of the recommending agency. The TSB felt that it was in danger of A99–07 being one of those that was ignored for cost-related reasons. Even within TSB management, they called it a “billion-dollar fix” that would never be accepted. This is why the TSB investigators wanted to really show why A99–07 needed to be followed. If there was any doubt in their analysis, then this could be ignored, and it was very possible for doubt to creep in. Doubts about how the pilots didn’t start to land the moment they smelled smoke, forgetting that this exact situation could’ve happened over the ocean, and that the investigation should focus on that instead of the flammability of materials.
So, they kept digging. From their airflow pattern tests on an MD-11, they knew that the fire must’ve started in the cockpit ceiling, just forward of the cockpit wall on the right side. If they could find a source that got the MPET coverings on fire, then they would have their proof to shove in the world’s face.
According to Pigott, it took three years to find the golden nugget: Exhibit 1–3791. This was a wire for the IFE system, and it was not in a great condition. This broken piece of wire was observed under a microscope, and they found an arc 9 cm from its end. When matching this wire to its location, the arc location would’ve been in the cockpit ceiling, just forward of the cockpit wall: precisely where they believed the fire started. It also lined up with a metal bracket that would’ve worn out the wire’s insulation. Crucially, this arc did not show signs that it arced because of a fire; it arced, possibly leading to the MPET covering being set on fire, where it self-propagated precisely where the airflow pattern tests showed it would. To be clear, they are not 100% sure if this exact arc caused the fire, only that it arced before the fire started, and that if it arced because of another arc of an unrecovered wire, that arc would’ve started the fire. Either way, they found conclusive proof that faulty wiring set fire to the MPET.
Jim Foot was the guy that found this arc. When he called Larry Vance to have a look, Vance’s knees went weak. Years of work finally proven with a “speck in the ocean” found. They didn’t tell anyone for the next couple of days, wanting to make sure that it was actually there. They didn’t tell TSB management until they were ready to explain their discovery.
There’s still a year and a half of investigation and administration for the report after this discovery, but the TSB finally caught the break that no other Canadian aviation investigative agency ever got: concrete proof to gain the trust of the world. Independence from the government to keep the investigation going even at great cost. Independence from possible disrupters that were not investigators. No training wheels by being under a judge or another country’s investigative agency that people can credit instead of the TSB investigators. This investigation was done by TSB investigators for the TSB.
Assessing the Crew’s Actions
However, we have only gone into the fire, and have not gone into the other question: was it theoretically possible for the Swissair 111 pilots to land their plane at Halifax? Were they even alive when the plane crashed?
Before getting into theoretical descent profiles, the report believes that the crew made the appropriate actions considered the limited cues available. This crew did as well as a great crew coming out of Swissair’s training. They could not differentiate between an odour from the air conditioning and a burning fire via just smell, and did their checklist on an air conditioning problem, which would’ve taken 20–30 minutes to complete. By the time they declared an emergency and knew what kind of trouble they were in, they were facing the Atlantic with system after system failing, which would’ve made flying in the dark over the ocean nearly impossible, and would’ve rendered the crew disoriented. The fire was causing molten metal to drop from the ceiling, and the fire was raging behind the crew, an extreme situation for any pilot.
The captain’s seat was found to be in an “egress position,” which would be a position for a person to get out of the seat. He wasn’t in his seat, probably trying to fight the fire and possibly dead before impact, though that is speculation. However, the first officer was in his seat at the time of impact.
In fact, while the FDR and CVR were not recording in the last 5 minutes, 37 seconds, they did find some recorded information in engine 2’s full-authority digital electronic control unit’s volatile memory (FADEC NVM). When the investigators recovered the engines, they found that engine 2 was not generating thrust based on the damage to the blades. What was recorded on the FADEC NVM was that about one minute before impact, engine 2 was shut down via the fuel switch, possibly in response to an erroneous warning about engine 2 being on fire. Disturbingly, it implies that the first officer was alive at least a minute before impact, and possibly at impact, disoriented and trying to find somewhere to land and save his plane. But could all of this have been avoided with an immediate landing at Halifax without any fuel dump?
The investigators believe that that it was basically impossible. With the best descent profile into Halifax, they would’ve had to start their descent just seconds after sending their “Pan Pan” call, a pure coincidence. However, when they sent that call, they thought they were dealing with an air conditioning problem, so there would’ve been no reason to start an aggressive descent. Also, even on that descent profile, the fire still would’ve wreaked havoc on the systems three minutes before landing, making a safe landing impossible. So no, the crew would not have been able to make a safe landing in Halifax, even if they decided to forgo the fuel dump and checklists that they were trained to follow. From the moment the fire started, all 229 people on board were doomed.
When the final report came out on March 27th, 2003, it was 351 pages. They also had videos of their tests online, which you can see if you look up this report online. There was also a press conference, where Vic Gerden, holding a piece of MPET-covered insulation, viciously stated that: “Without the presence of this and other flammable materials, this accident would not have happened.”
This report is praised for the amount of detail they went into to show what happened to the plane. 23 recommendations were made in the report, 20 of which were fully implemented. The “billion-dollar fix” was implemented; no more MPET in planes. Dangers of improper wiring was shown. Dangers of not having fire suppression systems within hard-to-places was shown. This report covered everything, and the world listened. The investigation was so groundbreaking that in 2001, before it was even completed, the International Society of Air Safety Investigators awarded the TSB with the Jerome F. Lederer Award “for its conduct of the international investigation and for its use of non conventional methodologies that advanced the field of aviation accident investigations”`. Finally, a Canadian investigative agency has not only its credibility back, but some of the best credibility in the world. That’s the power of this investigation. In the words of TSB chairperson Camille Thériault, “It’s the biggest contribution Canada has ever made to aviation safety.”
The Headaches During the Investigation
It didn’t come easy though. Asides from the huge price tag, there’s also a story of the investigation not mentioned in the praise it gets. According to an article wired from the Canadian Press and printed by the Toronto Star on November 10th, 2003, a TSB document showed that the investigation suffered from a “chronic shortage of people and technology.” To quote most of the article, it stated that:
“Human resources available and assigned to the (Swissair) team were inadequate to sustain a prolonged complex investigation, which resulted in an insufficient number of qualified personnel available for certain tasks” and that there was an “excessive workload for those assigned to the team, and an inordinate amount of overtime over a very long period.”
It also noted that “some investigation team members were not sufficiently knowledgeable about international investigation standards, protocols and procedures.” The article found that:
“Administrative support to the $56.8 million probe was inadequate, the level of technical help required for the investigation was underestimated, and consulting contracts for outside assistance were beset by delays and difficulties.”
When the final report was being typed, that also suffered from delays, as the “staff hired to produce it were unfamiliar with the technical aspects of a crash investigation.” It also states that:
“The technical accuracy of the report … was at times inadvertently changed during the editing, thereby requiring that TSB investigators invariably re-verify, re-edit and redraft text.”
This investigation was brutal for the TSB. Even though this particular investigation would’ve taken a long time to do regardless, it still took longer than it should have, which was a problem previously criticized back in 1994. It went for so long that Swissair declared bankruptcy a year before the report was released, having its assets taken over by Crossair to create Swiss International Air Lines, which still exists today.
Swissair did make aggressive changes before their demise: when there was the hint that the IFE may have had a role in the crash, they immediately disabled them on their planes and later removed them entirely; they were one of the first to remove MPET-covered insulation from their planes; they installed smoke detectors within the hard-to-reach areas, and even installed cameras so that the pilots could see in those areas, just to check if there’s any fire. Nevertheless, financial troubles that started long before the crash (which prompted the installation of the IFEs in the first place), the crash itself, and 9/11 proved such a burden that these safety changes didn’t prevent their bankruptcy.
Despite the troubles with the investigation, everyone in the aviation community believes that this investigation nailed it and was worth the wait. It advanced safety very far, and it made a mark: “flammable materials do not belong in planes.”
‘That’ Conspiracy Theory
There is one guy that disagrees. I’ll refer to him as T.J. The reason why I’m calling out this guy is because he was an RCMP “arson expert” that believed that Swissair 111 was taken down by arsonists. He was on the RCMP team that helped with the investigation until he told his boss of his claims, at which point he was removed from the investigation. Who were the arsonists? He doesn’t know, no one claimed responsibility. However, he wrote a book in 2017, and somehow got an entire episode of the CBC’s The Fifth Estate (a normally credible investigative show) in 2011 that centred around his claims that the TSB covered up an arson attack because the TSB only investigates accidents, and that they didn’t want to get sued by airlines that were forced to do that “billion-dollar fix” to their planes.
I do not believe his claims. We just saw the stretched resources the TSB had to endure just to complete this investigation. We saw the tests they did that showed that MPET was flammable and could self-propagate a flame, and we found one arc in exactly the right place that shows that an arc started a fire exactly predicted by their tests. We even saw that MPET was a problem before Swissair 111 and could cause a vicious fire. If there really was arson, they would’ve let the RCMP take over. Why on earth would they bare the burden of CA$57 million in 2003 and take away resources from other investigations like Propair Flight 420? Exactly. T.J.’s theories are complete bunk, and the CBC should be ashamed of making that episode. Also, airlines can’t sue investigative agencies for trying to make the skies safer.
You know who else was pissed at CBC? The families of Swissair 111 victims. Articles from after the airing showed that families stood firmly behind the TSB’s investigation, and thought the episode was garbage. Even the Swiss company that collaborated with CBC for this episode decided not to air it Switzerland. During the research of this article, I found “swissair111.org”, a website with a forum attached. At first I was skeptical about this website, with TWA 800 having its bounds of conspiracy theories on similarly named websites. I was pleasantly surprised when I saw the forums were just family members remembering the victims, and even more happy to see a forum topic pinned with the name “CBC Fifth Estate owes SR111 families an apology”.
It’s a complete reversal of the Arrow Air situation, where families in that case were convinced by the dissenters that the investigators were engaging in a cover-up, and it comes down to one thing: the TSB was united in finding the truth and they stood by the investigators, from Benoît Bouchard being at the first press conferences, to new Chairperson Camille Thériault being at the press conference for the final report. Management internally may have tried to make the TSB tone down their investigation, but from the outside, they supported the investigation and its conclusions. The TSB was also committed to keeping families in the loop of their investigation. They were even allowed to tour the hangar where the wreckage reconstruction was taking place whenever they visited Halifax. Once they saw the effort it took to do the investigation, they understood why it took so long. They appreciated the work everyone did to have them grieve appropriately. That’s why trust is a powerful tool for investigative agencies, a tool that Canadian investigative agencies lacked until Swissair 111.
Edit after publication of the article: I have since found out about swissair111[insert common domain] is owned by T.J., and that disappoints me. Don’t visit that website.
The TSB Post-Swissair 111
To this day, Swissair 111 remains the most complex air accident investigation ever done by a Canadian investigative agency. However, accidents and incidents still occur in Canada, and they will investigate whatever occurrences that will advance safety. So, what’s happened to the TSB since Swissair 111?
Chairpersons and later notable Board members
At the start of the Swissair 111 investigation, Benoît Bouchard was the Chairperson, with board members Maurice Harquail, Wendy Tadros, and Charles H. Simpson. Harquail would step down in October 1999, and be replaced by two board members that would serve long terms: Jonathan Seymour, who served for an impressive 12 years until stepping down in December 2011, and R. Henry Wright, who served under July 2008, an impressive 9 years.
Bouchard would step down from his position in August 2001, part way through the Swissair investigation. Simpson would be acting Chairperson until a new one was found. Camille Thériault, former premier of New Brunswick, ended up becoming a board member in December 2001, and would be appointed as Chairperson in July 2002, being the face of the TSB when their most complex report was released. He stepped down in February 2004 to become president and CEO of the UNI Financial Cooperation, a Francophone credit union in New Brunswick, making Simpson acting Chairperson once again.
In May of that year, a controversial appointment would be made by Prime Minister Paul Martin. He appointed his friend, Jim Walsh, to the board. This became even more controversial when he was investigated and charged with fraud done during his time in the Newfoundland and Labrador legislature. He was put on administrative leave in July 2006 when he was named in a list of people that allegedly committed fraud, but did not resign, and collected his salary as a TSB member until his term was up in May 2009. He was eventually convicted on charges of fraud and breach of trust, and served jail time.
Back to December 2005, Simpson decided to step down from the board and from his role as acting Chairperson, where Wendy Tadros took the role. Her role as Chairperson became official in August 2006, and she stayed in that role until August 2014. Including her time as a board member, she spent 18 years on the board. A year after Tadros was officially made Chairperson, Kathy Fox was made a board member in July 2007. When Tadros finally stepped down from the board, Fox became the Chairperson of the TSB, and she is still in the same role to this day.
However, not for very long. She planned to retire in August 2023, but with no successor on the horizon, she stayed on for one more year. This means that come August 2024, the TSB will have its first new Chairperson in 10 years. Applications are actually open for the position on their website, so if you want the position, go right ahead and apply!
It is also worth mentioning the other current board members: Paul George Dittmann, appointed in May 2017, Kenneth Potter, appointed in June 2019, Yoan Marier, appointed in September 2020, and the newest board member, Leo Donatti, just appointed in December 2023, recent enough that he was not on the TSB website when I published the first two parts of this series.
Notable Aviation Investigations and Reviews
Since March of 2003, the TSB has investigated numerous accidents that have occurred in Canada, conducted the first ever investigation of an aviation accident by a foreign agency in U.S. soil, and even reviewed a controversial Australian investigation and the ATSB itself.
There is also the TSB’s involvement in (and TSB’s criticism of) the Iranian investigation into the shootdown of Ukraine International Airlines Flight 752 on January 8th, 2020, which had 63 Canadian citizens on board and a total of 138 people travelling to Canada via Ukraine, but I won’t get into that in this article.
Some notable investigations include:
- MK Airlines Flight 1602, a Boeing 747–200 freighter that crashed on October 14th, 2004 after a botched take-off in Halifax that was caused by, after an investigation where the CVR was unusable, incorrect take-off speeds taken from software that could be glitchy, and the fatigue of the crew, killing all 7 on board;
- Air France Flight 358, an Airbus 340–300 that overran runway 24L at Toronto Pearson on August 2nd, 2005 in bad weather, but ultimately caused by a botched landing and a “feeling that a go-around was impossible” due to the weather ahead during landing, which caused an overrun of an unforgiving runway, which itself had a limited overrun area that allowed the plane to break apart and injure numerous people, but miraculously not result in a death in the 309 people on board;
- Cougar Helicopters Flight 91, a Sikorsky S-92A was that transporting workers in the oil industry, “ditched” (really, in the words of Wendy Tadros, was actually a crash, not a ditching) in the Atlantic Ocean off the coast of Newfoundland on March 12th, 2009 after the gearbox suffered a catastrophic loss of oil, resulting in the gear that controls the tail rotor to fail ten minutes later, and also gave a misleading picture to the crew, who observed that everything else was fine, leading them to not properly configure the helicopter for an autorotation, resulting in the deaths of 17 of the 18 people on board;
- First Air Flight 6560, a Boeing 737–200 Combi (a combined cargo and passenger plane useful for flights in the high Arctic) that crashed 2 km east of the runway in Resolute, Nunavut on August 20th, 2011 due to poor Crew Resource Management (the way pilots communicate with each other to make sure everyone is in the loop and results in fewer mistakes, a system that has been refined since the 1970s/80s), an inadvertent disabling of the autopilot, and a compass that was inaccurate due to the crew not updating it frequently in the high North, where that type of thing is required, misleading the captain, leading to the deaths of 12 of the 15 people on board;
- Air Canada Flight 624, an Airbus 320–200 crashed short of the runway at Halifax on March 29th, 2015 due to the poor weather, poor standard operating procedures, and poor monitoring of the plane’s position by the crew, injuring 24 of the 138 people but did not result in a death; and
- West Wind Aviation Flight 282, an ATR 42–300 that crashed shortly after take-off from Fond-du-Lac, Saskatchewan on December 13th, 2017 due to wing contamination, killing one person of the 25 people on board, and exposing extremely inadequate de-icing procedures in remote Canadian airports, something that should’ve been fixed after Moshansky’s inquiry into Air Ontario 1363.
In addition to these investigations, the TSB was given the unique opportunity to investigate a mid-air collision that occurred in U.S. soil, involving only U.S. general aviation planes. On May 28th, 2012, a Beechcraft V35B Bonanza, registered N6658R, flown by Mike Duncan, the chief medical officer for the NTSB, and a Piper PA-28–140 Cherokee, registered N23SC, flown by Thomas Proven, an FAA crash investigator (according to Peter Pigott), collided in mid-air over Warrenton, Virginia. The Beechcraft broke up in the air, killing Duncan and his flight instructor, while the Piper managed to conduct a forced landing in a pasture, giving Proven injuries.
When the NTSB and FAA found out who were actually on the planes, they decided to give the investigation to the TSB to avoid the clear conflict-of-interest, which launched their investigation the day after the crash. While this was a case of see-and-avoid being limited, the fact that the NTSB gave it to the TSB, while probably being the most convenient agency, is also a testament into how robust the TSB is. I don’t think the NTSB would’ve given a similar case to the CASB in their most battered years.
Probably the most interesting saga of the TSB was when they reviewed a controversial accident report by the ATSB, Australia’s investigative agency. On November 18th, 2009, an IAI 1124A Westwind II, registered VH-NGA, operated by Pel-Air was conducting an air ambulance flight from Apia, Samoa to Melbourne, Australia via a refuelling stop in Norfolk Island, a territory of Australia between New Zealand and New Caledonia. The weather deteriorated in Norfolk Island during the flight, and the pilots did not carry extra fuel to divert to an alternate airport. After four failed approaches into Norfolk Island, the pilots were forced to ditch 6 km west of the island in the dark and with bad weather. Luckily, all six on board survived the ditching and were eventually rescued, but the initial final report, released in August 2012, pointed the finger entirely on the captain for not ensuring that the plane had a safe amount of fuel. The investigators also decided not to recover the flight recorders to aid in the investigation, as they felt that the cost would’ve been too great to retrieve them from the bottom of the ocean.
The ATSB’s work was criticized in an episode of Four Corners, an investigative journalism documentary show, released shortly after the final report, causing an inquiry to be called by the Senate, and when the inquiry’s report was released in May 2013, it found that the final report was deeply flawed and extremely unfair to the pilot, and criticized the decision to not recover the flight recorders. In response, the ATSB requested that the TSB do an independent review of their methodologies and investigative processes.
The TSB was asked to do this in July 2013, and they took this job seriously. The review itself reads like a final report, looking at how the ATSB does its job, and comparing the Norfolk Island investigation with two other investigations of similar size that were of much better quality. When the report of the review was released in December 2014, they found that while the ATSB methodologies and processes in general were great and exceeded international standards, the Norfolk Island investigation itself did not meet the ATSB’s own standards. This finally prompted the ATSB to reopen the investigation a few days later, in which they retrieved the flight recorders and got more information than in the first investigation, and released a monstrous 521-page second final report in November 2017. While they still blamed the pilots’ decision to not take more fuel, they also blamed the lax guidelines provided by the company and the regulators, which the pilots actually acted within, the looser regulatory requirements around air ambulances, and the fact that neither air traffic controllers in Nadi nor Auckland warned the pilots about the deteriorating conditions in Norfolk Island.
I think the fact that the TSB ended up being asked to conduct two unusual investigations by the NTSB and the ATSB only shows how trusted this agency has become in the international community. Maintaining that trust is the job of the TSB, and they have accomplished that in numerous ways.
Expanded Outreach and Publicity
One of the earliest ways the TSB attempted to do this not only predates Swissair 111, but also predates the release of the 1994 review report. From 1993 to 2005, the TSB published a magazine series called Reflexions, where Air, Marine, and Rail/Pipeline would each have their own separate issues. Originally quarterly, the series became yearly just after the turn of the millennium before ceasing publication. These magazines were to give summaries of certain, notable occurrences that had their reports released before the issue’s publication, and would also list the investigations started and the final reports that were recently released.
In the age before widespread access to the internet, it was a great way for people to know what was going on within the TSB. However, according to Johanne Ostiguy, a TSB employee that was involved the initial production process of Reflexions, most of the subscribers were organizations within the transportation industry to distribute within their ranks. While this was a great way of spreading awareness of the consequences of unsafe and dangerous practices, most people in the public had no idea what Reflexions was, and so were not aware of what the TSB was doing, or even was. Also, Ostiguy points out that “the summary information it contained was not aimed at encouraging regulators and industry stakeholders to take measures to address the safety deficiencies identified by TSB investigators.” Essentially, it was a good pre-wikipedia wikipedia article, but it did not contain the detail that would pique the interest of a regulator. However, I think that the point of Reflexions was supposed to be a more public magazine that just never got the publicity it needed to be useful.
During the Swissair investigation, the TSB got a shiny new tool: a website. The Internet Archive has screenshots of tsb.gc.ca from as early as November 1999, though it could’ve been around earlier than that date. During the Swissair investigation, there was a section of the website dedicated to it, though the screenshots are limited in showing what was there. It had a page for updates, documents, a list of Board members (which was very useful for me), and even a page of where to see reports, though the limitations of these screenshots meant that I couldn’t go into detail, and couldn’t see how accessible they actually were.
When the final report for the Swissair investigation was released, there was a link to it right on the front page of the website. It linked to the synopsis, the report itself, the supporting technical information, and an explanation of the structure of the report itself, which must’ve been a huge help for people not familiar with air accident investigation reports. It also points out that a person could have a copy of the report on a CD-ROM, which is quite the interesting format if you wanted an electronic report with the supporting technical information outside of the internet.
Over the years, as all websites do, it improved with the times, making Reflexions obsolete, and enabled a new, simple way of communicating to the public. In March 2010, they launched their Watchlist, “a list of safety issues investigated by the TSB that pose the greatest risk to Canadians”. This gets updated every two years, adding more issues they’ve investigated and believe Transport Canada has not acted on appropriately, or remove stuff they believe have been dealt with. It’s similar to the NTSB’s “Most Wanted List”, which was recently retired.
As social media started to become mainstream, the TSB joined at various times. Their two Twitter pages (one for each language) were made in March 2012, and their Flickr page, made for posting photos, was made around 2012 as well, with their first photo post being in June. They also made a YouTube channel in 2012, where they post press conferences, modelling how an occurrence happened, and other advocacy videos. As a recent example, when the West Wind report was released, they also posted a video that summarizes their key points. Remarkably, the TSB didn’t create its Facebook page until 2020, but they have been making similar posts on Facebook as on Twitter, along with videos. Every time there is an investigation to be done, a recommendation made, or a report released, they will post it on Twitter and Facebook to this day.
In December 2012, the TSB decided to start their blog, The TSB Recorder, which would have articles written by investigators, board members, or other employees of the TSB about various things, from their job and experiences, to just their own personal thoughts about how investigations should be. It’s an incredible source of information that, unfortunately, the TSB stopped doing in 2018, and took offline around 2022. Fortunately, Library and Archives Canada archived those articles, and you can can see them here. It really is a shame, as it was a fun insight into the people actually working there.
Though the TSB doesn’t have a high follower base, they are there, waiting for the public to look for them, and will be there in the event of another, world-facing investigation. Gone are the days of “quiet professionalism”.
The TSB Now And In The Future
Today, the TSB is involved in numerous investigations: of the active ones under their control, 51 in aviation, 16 in marine, 16 in rail, and 0 in pipeline. In addition, they are always there to help an international investigation whenever they can be involved. Just this January, Japan Airlines Flight 516 collided with a Japan Coast Guard Dash 8 when the Dash 8 lined up on the runway at Haneda Airport without permission, and, unlike the many recent instances of runway incursions, JAL516 landed on the runway and hit the Dash 8 directly. Since a Dash 8 was involved, the TSB sent a representative as the state of manufacturer under the rules laid out in ICAO Annex 13. They continue to connect with the public on Facebook and the remains of Twitter. When there’s a news conference of a serious investigation, they’ll post it on YouTube, like they did with the helicopter crash of C-FYDA in Griffin Island, Nunavut, a crash I might cover in the future. Finally, when anyone sends a question through their contact page, they’ll respond as soon as they reasonably could, like they’ve done with me.
What’s in their future? I hope nothing extremely major. If they have to investigate such a crash, then something has gone seriously wrong. From my research, the closest they got to using their power to call a public inquiry was the Swissair 111 crash, but they later decided that it wasn’t needed. They have never held a public inquiry, unlike their predecessor CASB, that did six in five years, and that’s probably because there hasn’t been the need for it. If they’re using that tool, something serious has happened.
Leaving that possibility aside, in their Strategic Plan for the period of 2021–2022 to 2025–2026, they say that they plan to review the TSB Act. It’s been 30 years since the 1994 review was released, and though the TSB Act was extensively amended in 1998, and has since been amended a bit over the years, there hasn’t been an extensive review since 1994. It might be time to do that, and find out what needs to be done with the 30 years worth of information, plus the external changes in the world since then. The best should only strive to be better, and the TSB, despite being one of the best investigative agencies, should strive to be even better.
Final Conclusion
When I started this series, I may have been way over my head. What started as an article of the CASB’s time on earth turned into a big, five-part series on Canadian aviation investigations since the late 1970s.
I learned how the CASB was birthed from top investigators giving the Department of Justice the finger.
I learned how the CASB was supposed to be a good agency, but for a critical flaw in the Act that created it that gave Board members the opportunity to butt in and disrupt the investigators to the point of the collapse of the agency itself.
I learned how the Moshansky Commission was a unique opportunity to observe an investigation while the investigation was happening, and how it was much more than an investigation of a plane crash in Dryden.
I learned that the TSB had enormous teething problems that were caught by the 1994 review, and how the TSB took those recommendations to heart and changed the Act to deal with them.
Finally, I learned how Swissair 111 really did change the way the TSB was looked at internationally and domestically, and how the TSB continued to improve with the times.
To end, I’ll list the last names of some people that were important in making the TSB into what it is now. Fawcett. Dubin. Boag (the IIC of Arrow Air). M-Deschênes. Moshansky. Hyndman. Bouchard. Gerden. Vance. Tadros. Fox. All these people, plus the numerous Board members over the years that gave the TSB stability, the numerous investigators that showed why the TSB has its reputation, and the countless employees that made and make the TSB run, make the TSB great. Thank you.
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If you’ve made it though all five parts, thank you so much. I can’t believe people actually enjoy what I’m writing. This was quite the journey.
Special shoutout to Peter Pigott and his book, Brace for Impact. The book was crucial in getting most (if not all) of those quotes from Larry Vance and some of the pictures, and was a huge help in this part and part 2.
This isn’t the end of my articles. I think it’s only the beginning! The articles I plan to write will be of the same format as my Air Tindi Flight 223 article, explaining a plane crash, similar to Admiral Cloudberg, an inspiration of mine. I will attempt to cover ones she does has not covered, to avoid any clashes.
I’ve started a Patreon and Ko-fi! You can support me in those places if you want.
