The Wild West
The State of Canadian Aviation Investigations, Part 1: The ASB and the Dubin Report
Prologue
December 17, 1954. Trans-Canada Air Lines Flight 661 crashes in a field in Brampton, Ontario, having gone too low on approach to Malton Airport, now called Toronto Pearson International Airport. Miraculously, despite the heavy impact, all 23 people on board survived, albeit with injuries. It is considered a Christmas miracle. Investigators got on the scene to find out how this plane crashed short of the runway.
One problem. These investigators are from the Department of Transport. For reasons this article will go into, this is not ideal. However, even at the time, this was not seen as ideal. Dr. Smirle Lawson, Chief Coroner of Ontario, said in an interview reported by The Daily Times-Gazette (a local newspaper for Oshawa and Whitby at the time) and The Globe and Mail on December 21, 1954 that the accident should be investigated by an independent board of aeronautical engineers. He gave quotes, such as “If the investigation is left to transport department officials, the Canadian public won’t get the truth about the crash,” and “My experience with the Transport Department over 20 years has not been a happy one. Investigators from this department bend over backwards to support the Government in office. I have never found them willing to have the facts brought out if those facts might embarrass the Government of the day.”
The probable cause, according to the board of inquiry, was “negligence on the part of the captain.” I will not get into this accident in this article, but perhaps another time. Point is, the bias of investigators employed under the same branch that regulates the industry was already seen as a problem in 1954.
The Dubin Report
Lawson probably was not the first in Canada to suggest this, nor would he be the last to suggest this. However, in May 1981, Justice Charles L. Dubin, nine years before publishing his inquiry into doping in athletics after the Ben Johnson scandal at the 1988 Summer Olympics¹, publishes his first volume of his inquiry into the state of Canadian aviation safety, where he becomes the most important person in Canada to suggest an independent body to investigate aviation accidents and incidents. While volumes II and III are also important, I will focus on volume I. From now on, the vast majority of information in this article comes from his report, and I highly suggest you read it for more details.
Dubin’s work involved 116 days of hearings over the span of a year in multiple communities across Canada. In the context of this article, what he found was eye-opening, and showed the real dangers of having an investigative board within the Department of Transport.
Aviation Investigations at the Time
At the time of this inquiry, the Aeronautics Act implied that the Minister of Transport is responsible for aviation safety. It didn’t exactly say that, but any interpretation of that act would make people think that if there was a crash, they were responsible. Unfortunately, according to that same Act, the Minister of Transport is also responsible for the economics of aviation and the aerospace industry in Canada. As Dubin points out, economics and safety may conflict. In fact, this lesson is not new. The US learned this lesson the hard way, just 3 years after TCA Flight 661.
In 1957, Pan Am Flight 7, during its journey to Honolulu, mysteriously disappeared over the Pacific Ocean. Some wreckage from the plane was later found, and all on board were presumed dead. The Civil Aeronautics Board (or CAB) investigated the accident, as they were the authority that did so at the time, and they concluded that no probable cause could be made with the evidence provided.
To be fair, the plane went down in the middle of the Pacific. There was no way that an investigation could come to a proper conclusion. However, the report does not even mention the poor maintenance practices at Pan Am to keep Boeing Stratocruisers in the air. Claims of Pan Am executives going out on dinners with the top brass of the CAB, who were not only responsible for the safety of flying, but also the economics of flying, put this report in so much question due to the conflict of interest, that the resulting controversy (plus a slew of mid-air collisions) created the FAA in 1958, which is responsible for enforcing safety in the industry, and later created the NTSB in 1967, responsible for the investigations into transport accidents and incidents. Initially under the Department of Transport, which still caused some conflicts of interest, the NTSB was made completely independent in 1975.
At the time of the Dubin inquiry, the responsibility of the Aeronautics Act were delegated to the Canadian Air Transportation Administration, or CATA (also called the Air Administration in the inquiry), a branch of the Department of Transport (now called Transport Canada, and will be referred to as such in the article).
Within CATA, the Aviation Safety Bureau, or the ASB, is responsible for the investigation of accidents and incidents. It consists of four divisions:
- the Aviation Safety Investigation (ASI) division, which does the investigating and prepares the reports;
- the Aviation Safety Analysis (ASA) division, which analyses the data and finds deficiencies in the aviation system;
- the Aviation Safety Promotion (ASP) division, which maintains national aviation safety information; and
- the Aviation Safety Engineering (ASE) division, which provides material failure analysis to the ASI division and to other divisions of Transport Canada, like the Airworthiness Division.
In addition, there is the Aircraft Accident Review Board, or the AARB, formed in 1976, which reviews the draft reports the ASI division produces, work out if there needs to be changes, takes comments from the involved parties, takes those to the ASI division, where the ASI division then produces a final draft report. No matter what happens, this is most of the final report that is published, whether the AARB likes it or not. If the AARB does not agree with the report, it will outline its views with the appropriate parties, including the ASB, and put its comments in the final report along with the unedited final draft report from the ASI division.
Problems with this System
In CATA’s submission to the inquiry, it claims that the increase of external relations with the public, particularly with public service unions, during the 70s resulted in significant staff resources being directed to this need at the expense of safety management resources, putting the safety system under pressure. Another pressure was the complex relations with the Canadian Transport Commission (or the CTC, the regulator of the transportation market, and in the case of aviation, provide “broader competition without endangering the privileged status of the publicly owned airline, the newly renamed Air Canada”²; now replaced by the Canadian Transport Agency), the provinces, and federal departments, with their “conflicting policies and significant adjustments to air transport operating procedures or facilities.”
These pressures manifested itself in innocent looking ways, such as delays in the release of accident reports due to the delays in them being finalized, to troubling ways in senior management being resistant, and often hostile, to changes in safety. Dubin lists several examples.
His first example happens in 1977, when two civil aviation inspectors within CATA, concerned about the state of aviation safety in Northern Ontario, conducted a fully detailed study, which was highly critical of CATA. In response, the headquarters staff analyzed the report without the consultation of the two inspectors. That analysis, according to Dubin, issued unwarranted criticism towards the inspectors, and disagrees with the analysis’s conclusion that there was “very little evidence” to support the criticism of CATA. CATA’s response to the problems set in the study were based on the analysis of the study and not the study itself.
In a somewhat similar example, after C-FCAS, a Beechcraft 90 that was used for navigational and approach aids by the Airways Branch of the Transport Canada regional office in Dorval, Quebec, crashed on May 1, 1979 after the right wing separated, killing two Transport Canada employees, an audit was done to look at how departmental aircraft were being maintained, which was headed by the Chief of Airworthiness of the Air Administration. This audit was highly critical of Transport Canada’s maintenance practices. Pulling the same move they did last time, headquarters resisted the findings, and audited the audit.
Even during the inquiry, CATA was still hostile to safety concerns. When a civil aviation inspector testified in the inquiry about Airworthiness, which was a testimony highly critical of CATA, senior management in his region of work ostracized him to the point where the Commission of Inquiry had to intervene “to remedy the wrong that was being done to him.”
Seeing the culture of being against any safety changes, one can see how that would translate into CATA’s attitude about aviation investigation reports, especially reports that criticize CATA itself. Reports have the inherent bias towards CATA, as CATA is the one that pays the people in the ASB and the AARB. Even if the investigation finds that CATA’s regulations had nothing to do with the accident/incident, the ASB may appear to not be impartial in their report, as the ASB itself points out to the inquiry. Even when the ASB is critical of CATA, CATA themselves may try to interfere with the report, as Dubin shows in the first “case study” in the inquiry.
Case Study 1: When CATA edited a final report and published it without approval
On December 9, 1977, CF-CFL, a Hawker Siddeley HS 125 operating as a corporate jet departed Moncton, New Brunswick to Churchill Falls, Newfoundland and Labrador. On final approach, the crew notifies ATC that they are two miles from the Churchill Falls airport and can see the strobe lights and the VASIS (a set of lights similar to the PAPI lights). That was their last transmission; they crashed short of the runway shortly after.
Due to the bad weather, it takes two days to find the crashed plane, even though there was a search helicopter over the crashed plane just 15 minutes after the crash. Even more unfortunate, all on board were dead by the time the crash site was found, but two people survived the crash, only to die one to two hours later due to the exposure to the cold. Had there been emergency locator transmitters (ELTs) on the plane, they could have survived, as that helicopter had a receiver tuned to the distress frequency. Frustratingly, the ELTs were removed from the plane because of an Airworthiness Directive involving the lithium batteries, which exploded on other planes.
Clearly, this was cause for concern by the ASB, and one of their conclusions in their report was paragraph 3.1.6:
- “The removal of the aircraft’s emergency locator transmitters seriously delayed the search and rescue activity and may have caused unnecessary loss of life.”
The ASB submitted their draft report for review with this line in it, and the AARB, as is their job, reviewed the statement and approved it. However, this conclusion was making the rounds in the CATA offices, especially in the Administrator’s office, and Harold Arthur Fawcett, the then Acting Director of the ASB and whom I will discuss in much more detail later on, knew about these concerns. He wrote to the then Chairman of the AARB, H. Ray Foottit, discussing how the conclusion may be editorialized and wondered if the line was actually fine to use, on July 28, 1978.
A few things would happen on August 22, 1978. Fawcett would receive a letter from the Chairman of the AARB, confirming that conclusion 3.1.6 was correct after consulting with the AARB, albeit with a possible footnote that notes that this assumes that at least one of the two ELTs must have survived the crash, a reasonable one to have in both the ASB’s and the AARB’s eyes. At the same time, Fawcett would be called into a meeting with the Director General, Civil Aeronautics (DGCA), Peter Eugene Arpin. Harold Fawcett, as Acting Director of the Bureau, is responsible to the DGCA.
According to a letter sent to Foottit by Fawcett on August 31, 1979, in that meeting, Fawcett had to explain the controversy surrounding 3.1.6. The administrator of CATA (referred to as AATA) wanted it changed. Since the ASI division of the ASB and the AARB were in agreement, the ASI could not change it. Then the meeting moved to the Deputy Administrator’s (DAA’s) office. Fawcett re-explained the situation. After what seemed like a very heated discussion, it was decided that 3.1.6 must be changed. Fawcett, knowing what was happening was in violation of the standards laid out, asked for this instruction in writing, presumably because he knew that he needed the evidence to show that the edited report did not come from his Bureau. Fawcett would get that written instruction as a memorandum from the DGCA. It said to change 3.1.6 to read:
- “On the assumptions that there had been at least one serviceable ELT on board, that it had been activated as a result of the impact or by other means, and that there was the capability at Churchill Falls of homing to the point of origin of the ELT signal, the rescue activity may have been expedited,”
and to make it seem like this report, with the CATA 3.1.6, was approved by the AARB, even though it never was. The edited report was released a day later.
It is clear that CATA wanted their blame to be watered down. The removal of the ELTs was their decision, and at that time, there were no good alternatives. The original conclusion was clear, concise, and was harsh by necessity. The CATA conclusion added so many assumptions, which is different from many other conclusions, and removed the line that some loss of life was unnecessary. They did not want blood on their hands, so much so that they published a report without the approval of the AARB and changed the seemingly unchangeable final report done by the ASB. Not only that, but they deleted the page with recommendations pertaining to this conclusion. The Minister of Transport ultimately intervened and had the original report become the official final report after the AARB expressed their displeasure via letter.
However, the damage was done. As Fawcett puts it in that letter to Foottit on August 31, 1979:
- “I believe what has taken place has been damaging to the Board, Transport Canada and Safety Investigators. Any subsequent reports produced will be viewed with even greater skepticism than in the past. Although past charges of censorship of investigator’s reports have been denied by a number of officials including the Minister himself, it has now been publicly demonstrated as a fact. The credibility of the parties involved and of safety investigation reports have been seriously damaged.
- Without arguing the merits of Finding 3.1.6, it is clear from this case and past experience that the observations of investigators do not always coincide with the beliefs of regulatory officials as to what is taking place in the aviation community. This is not surprising given their differing vantage points. Thus, when a report is issued, the reader must know from which vantage point the circumstances of the accident are being viewed. The reader must also be confident that the writer of the report has no vested interest in the circumstances surrounding the accident and is presenting an unbiased view. The activities of the Board, because it is an independent body, were beginning to develop public confidence in our reports and fewer demands for public enquiries were being heard. I now fully expect to see this development reverse.”
When the Chief Magistrate of the Provincial Court of Newfoundland conducted an inquiry into this accident, they made this similar, but still telling finding:
- “The Aviation Safety Bureau which comprises Aviation Safety Investigators and the Aircraft Accident Review Board, function within Transport Canada. Any organization having the overall authority to investigate itself will invariably be sorely tempted to exonerate itself when the need arises. The only way to remove this temptation and retain objectivity is to ensure as far as possible that the investigative body is independent. It is refreshing to find within a bureaucracy men of such objectivity and integrity as the members of the Aviation Safety Investigation team who appeared before this inquiry.”
The damage CATA did is still felt today. Even though the edited report was made unofficial, it still found its way into the ICAO Circular, which is the only readily available copy of the report into this accident. Even at the time of writing, the Aviation Safety Network³ still had the CATA 3.1.6 listed under their “Probable Cause”, sourced from the ICAO Circular. Thankfully, after I filled out a contact form that pointed them to the Dubin inquiry, they have edited the accident page to not only include the ASB 3.1.6, but also explained the situation described in the Dubin inquiry in the accident description. This is something that seems brag-worthy, but I have few people I could brag this to.
This, of course, was an extreme example, and Dubin could not find evidence of any other similar interference from CATA, at least post-AARB. However, since the process of making and reviewing accident reports is just a mere internal administrative process, there’s nothing to prevent it from happening again. If CATA wanted, they could scrap the organizations and do the investigations themselves, as they are the organization responsible.
Case Study 2: When Transport Canada investigating themselves makes the FAA sus
Oh hey, C-FCAS is back to cause more safety problems! To refresh the minds, C-FCAS was a Beechcraft 90 that was used for navigational and approach aids by the Airways Branch of the Transport Canada regional office in Dorval, Quebec. It crashed on May 1, 1979 after the right wing separated, killing two Transport Canada employees. In the midst of the audit and the audit of the audit, the ASB investigated this accident. Yes, C-FCAS was a Transport Canada plane, and the ASB, which is a branch of CATA, itself a branch of Transport Canada, was investigating. Can you see the problem?
While we stew on that problem, the ASE division of the ASB conducted a major part of this investigation, as it was a structural failure of a wing. Their main question: did they follow the Airworthiness Directive from the FAA regarding mandatory inspections of the Beechcraft 90?
For those not in the know, an Airworthiness Directive (or an AD) is an official legal document issued by the aviation regulatory authority, where users of the plane models specified must comply with specific actions to make that plane model legal to fly. ADs are issued with actions to correct the condition of certain aircraft when it becomes known that they contain deficiencies that fall below the safety standards. Most of the time, these ADs are for deficiencies that do not put the aircraft in immediate danger, so they have a time limit of when to comply, whether it’s days, weeks or months. Other ADs are based on how long the aircraft has been used, or how many times the aircraft has taken off and landed (known as a cycle). Some are emergency ADs, mainly for major deficiencies found during investigations that require immediate action.
For the Beechcraft 90, there was an AD to inspect the lower forward outboard wing attachment fittings. The AD specified that these parts must be inspected before the aircraft reaches 5000 hours of use, and then be reinspected every 500 hours.
For C-FCAS, it was inspected at 4907 hours. So far, the AD is being followed. However, the inspection required the use of dye to check for any cracks on the fittings. The documentation related to this inspection did not say anything about this dye test being done, and it was deemed inconclusive purely by physical and documental evidence. The mechanic who did the inspection says that he did do the test, and followed the AD at that time, and the ASB took him at his word. In the ASB’s opinion, even if he didn’t, they concluded that the fitting probably would’ve passed the dye test anyways, as they believed that the cracking hadn’t developed yet.
Despite the opinion of Dubin that this finding was made in good faith, the fact that the ASB, a part of Transport Canada, was making this conclusion about Transport Canada’s maintenance made the FAA and Beechcraft extremely suspicious. How can you fault them? Transport Canada is saying that Transport Canada followed this part of the AD correctly based on the testimony of one person that could have misremembered.
One of their next conclusions about how clear the AD was about subsequent inspections was even more suspicious, because C-FCAS was NOT inspected at 5407 hours, as stated in the AD. For context, C-FCAS ended up crashing at 5464 hours. In the report, the ASB was “persuaded that the Airworthiness Directive was ambiguous,” and that Transport Canada interpreted the 500-hour inspections as not needed if no wing panel skin cracks found, and that multiple operators interpreted the AD in different ways. The FAA and Beechcraft disagreed, believing that there was no ambiguity, and that the investigators were being influenced by Transport Canada.
Furthermore, the ASE division found that there were two cracks in fittings of other Beechcraft 90s way before the 5000-hour mark, and that the fault that occurred on C-FCAS could happen before 5000 hours and could also occur between a successful 5000-hour inspection and the next inspection. This led them to believe that a stronger AD was required for these Beechcraft. However, the FAA and Beechcraft were resistant to the change, particularly because they gave this investigation less credibility due to the conflict-of-interest.
Even though the investigation believed that an inspection at 5407 hours would’ve found the cracks with the dye test, they did not include that conclusion in the report. While this could be seen as another pressure by Transport Canada, it was just the ASB being resistant to assign fault at all.
This situation just further shows that a great investigative authority must have the trust of the world to be effective, and clearly, the FAA did not trust the ASB to investigate within their department. The lack of trust will play a deep role into the demise of another Canadian air investigative agency, but I will discuss that another time.
There are two more case studies in this volume, but I am going to focus on one more. The third case study involves CF-AIV, which crashed in Coal Harbour in Vancouver while on approach for a water landing (this was a Twin Otter on floats). I will not focus on this, even though the investigation was a complete mess, and led to CF-WAF crashing in a similar manner. The Dubin report is there for all to read, I am just bringing a few things in it to light and providing context for a grander purpose. With that said, let’s go to Cranbrook!
Case Study 4: When investigators shredded their documents as a “fuck you” to the justice system
On February 11, 1978, Pacific Western Airlines Flight 314, a Boeing 737, crashed at Cranbrook Airport after a failed go-around, where the plane attempted to land with a snowplow still on the runway. The plane managed to go-around while narrowly avoiding the snowplow, but not before the pilots deployed the thrust reversers. This go-around interrupted the hydraulic system in the left engine thrust reverser, allowing it to deploy in the air, which the pilots were unable to recover from due to a myriad of circumstances. For more information, I direct you to Admiral Cloudberg’s article. I will not go into the circumstances of the accident, because we need to delve to the chaos that happened behind the scenes.
We begin with the philosophy of the ASI division. The philosophy is simple: they are there to prevent accidents. They must figure out what happened to prevent a similar accident. They hold off on assigning any fault because that would damage their credibility as objective investigators. In their opinion, all information obtained by them must be confidential, as that will ensure that they get the full story, especially when interviewing people directly involved in the accident or incident. In the investigators’ view, the only thing that should be public is the report itself.
When the judicial system gets involved, and their work is not officially considered “confidential”, it is apparent that there will be the butting of heads. This philosophy is so ingrained that one investigator, who was told to give documents to a court, refused so, and was willing to go to jail for failing to give the documents until he was persuaded to just give the documents.
Over the years, the ASI division had been frustrated with the Department of Justice (DoJ), particularly with them “not adequately protecting their interests” and “not assisting them in maintaining the confidentiality of information obtained” during the investigation. In the ASI’s view, this information should be “privileged”, or, in other words, unusable in courts (similar to how conversations between a lawyer and their client should not be usable in court cases. Those conversations are privileged). The DoJ is aware of these views, especially John H. Sims, a member of the DoJ that was seconded to Transport Canada (“seconded” basically means being temporary assigned to a different department) and worked closely with the ASI. Off-topic, but John Sims would eventually become Deputy Minister of Justice from 2004–2010 and was made a Member of the Order of Canada in 2017. Despite the DoJ being aware of these views, they also always explained that, no, not everything had a legal standing to remain confidential, and demanded that files be given.
This context is required for the mess that is going to happen. On August 10, 1978, PWA sued the government (officially “the Crown”), along with senior officials at Transport Canada, reportedly for $15 million. The DoJ, as is practice, acted on behalf of the government and their employees. So, the DoJ had to defend their case with all the documents needed, and filed an affidavit that listed the documents under the control of Transport Canada. Of course, some of those documents were in possession of the ASI. The DoJ, to their credit, did not request documents from the ASI until after the final report was released. John Sims is one of the lawyers in the defence. However, this is where the mess begins.
Transport Canada, to help in gathering all the proper documents, sets up the Contingency Plans & Operations (CPO) group on March 29, 1979, with Charles A. Cowie as the head. Four days later, Sims writes to Cowie, asking him to collect the ASI files requested. Cowie would ask the ASI two days later via letter, but knew that they would be resistant, and were sympathetic to their views. Despite Sims’s expectation that ASI would at least hand over the documents that seemed to have “no conceivable claim of privilege”, and despite him prodding the ASI, the ASI did not give the CPO any documents.
On June 29, 1979, Sims met with Harold Fawcett, chief investigator of PWA Flight 314 (and a major character in the CF-CFL debacle), and Dr. François Dubé [“dew-bae”]. Dubé is a very important character in this mess, and important in the ASB investigations. He is a “specialist in aviation medicine.” While employed by the Department of Health and Welfare, he’s seconded to the ASI in major accident investigations. He does medical analysis and assists the investigators in the human factors team. The most dramatic part of PWA 314, where it was discovered that the captain broke his thumb in the seconds before he died? He or his team of medical experts probably found that out.
This meeting, despite an erroneous article by The Globe and Mail by Barbara Keddy on April 2, 1980, was not about the PWA 314, but about an unrelated crash in the Bay of Fundy. Specifically, it was about the requests being made by American lawyers that Dubé should attend a deposition of that crash. Dubé found the file in where there were documents relating to the crash. Sims told him that the autopsy report would have to be presented in the deposition. Dubé and Fawcett took the stance that they always did: no, it shouldn’t.
Sims left the room during the meeting. At this point, the tensions between the ASB and the DoJ has gotten so high, that Fawcett and Dubé decided to come up with a cunning plan: lie. When Sims returned, Fawcett and Dubé told him that the entire file “no longer existed for his purposes.” Sims was infuriated and ended the meeting, calling Fawcett later to demand that he did not destroy any evidence. I wonder if this would give Fawcett and Dubé any ideas?
By July 5, 1979, Sims was told that Don L. Button, acting Director of the ASB at the time, refused to turn over any ASI files relating to PWA 314. A meeting, which I presume got extremely heated, between Sims, Button, Walter McLeish, the Administrator of CATA (also referred to as AATA), and Arpin, the DGCA. The AATA would direct Button to make sure that the ASI files be given to Sims. On the same day, Dubé was told that his personal notes was evidence and to not dispose of them.
After numerous delays, including a particular delay where Fawcett “couldn’t open the combination lock” in his own office where the ASI files allegedly were, the CPO finally got fifteen volumes of ASI files on July 16. By the 18th, Sims realized that he did not have everything. Even though Fawcett initially refused to give any more documents, he gave some more on the 20th. Sims reviewed these and realized that he still did not have everything. He called Fawcett, and specifically asked about the documents that Dr. Dubé had. Fawcett claimed that Dubé already gave him his files and documents, and they were already in Sims’s hands. So, what was really happening with those documents? Well, to use some words that were already used before: the documents “no longer existed for his purposes”.
Rewinding to July 16th, the same day that Fawcett gave his first pack of documents, a member of the CPO, John F. Falvey, visited Dr. Dubé. He then reported to certain parties that they should see Dubé as soon as possible. Why? He was “shredding the documents.” Those parties then reported this to the DoJ.
Back to the 20th, when Sims told Fawcett about the idea that Dubé shredding documents, Fawcett got agitated, and then justified the shredding, saying that it should only be used in the accident investigation and should “serve no further purpose”.
In discussions with Dubé, he claimed that he already shredded those documents in March, when the report was released, and that was a matter of routine. His reasoning? “You cannot subpoena what does not exist.”
This quote represents the toxic relationship the ASB had with Transport Canada and the DoJ. A culture that was so unwilling to hand over things that should, in their minds, remain out of the hands of anyone else that they would rather shred it than hand it over. While these actions are admirable from a certain perspective (and my view, kinda heroic), it could also be seen as horrific in another perspective. Imagine if an investigation comes to a certain conclusion, only for new evidence to pop up after the report is released. If previous evidence is destroyed, they could not examine the new evidence in the context of everything else and cannot come to the most correct conclusion based on all the evidence. Hold that thought.
Dubé also made a weird remark about how “nobody questioned what was the real cause of the accident”. What does he mean by “real cause”, and why does he say it’s “buried” in the report? When questioned, he pointed to a paragraph in page 32 of the report, the last in section 2.2, which involved communications:
- “The failure to report on final approach and the unnecessary talk on company frequency represent an unacceptable standard of cockpit practice and discipline.”
He claims that this was the “real cause” in his mind and the minds of the Accident Investigation team, and that the report did not consider this a contributing factor into the cause of the accident due to the pressure from Pacific Western. My guess is that this probably would have been grouped with Conclusion 3.2, which was “The flight did not report by the Skookum beacon on final approach, as was normal practice at Cranbrook, thereby allowing the incorrect ETA to remain undetected”, or probably its own conclusion. A conclusion pertaining to this comment may have even advocated for the sterile cockpit rule, which was not yet in place with the FAA in the US. Again, even in this chaos, the external pressures on CATA take a toll on the ASB.
When Falvey was confronted by Dubé’s comment about the “real cause” and asked if he’d been in discussions with Dubé or anyone else in the ASI division about this “real cause”, he was very hesitant to give his answer: “Yes, we had some conversation, and Dr. Dubé said ‘sometimes it’s better if they don’t know the real cause of the accident’”.
After thinking about this line, I still do not know what “they” Dubé was referring to. It could not have been PWA, as he claimed that they were an unrelated pressure into making sure this comment did not get listed as a contributing factor. I don’t think he would have meant the public, as part of his job is to make sure the real cause is published in the report as the real cause. The only people I could think of is the DoJ. The lawsuit started before the investigation was finished, so it is very possible that another pressure was the threat of their documents being taken by the DoJ, so burying the real cause while not having it as part of the cause may have been an attempt to get the DoJ off them, to no avail. The more I look at this, the more I think of Conclusion 3.7: “The lack of a suitable national system of incident reporting, investigation, and follow-up corrective action allowed operational problems to remain uncorrected.” This refers to section 2.7, Incident Reporting, but I wonder if this was a veiled way of saying to the government, “Stop getting in our way. Let us investigate the way we want to.” This is my conjecture and could be totally wrong.
Regardless, the shredding of documents, plus Dubé’s quote that the “real cause” was “buried” and not being its own conclusion, made the report “no longer creditable” to William J. Hobson, senior counsel of the DoJ and in charge of the litigation, and pointed out that even if a fresh investigation was done to look into this “real cause”, the evidence used in the original investigation is gone.
As a result of this shitshow, the RCMP was asked by Transport Canada to investigate these allegations of evidence destruction, and it resulted in Dr. François Dubé, Harold Fawcett, and William M. Howes, the investigator in charge of the PWA 314 investigation team, to be “relieved of their positions and assigned to other work”. Wait, what did Fawcett and Howes do?
For Howes, he was probably relieved of his duties because he did not keep his team in check. Dubin does not believe that he shredded anything, and that his reliance on accident investigators to keep evidence for substantiating the claims put forth in the report, and possibly used in a reopened investigation, was misplaced.
As for Harold Fawcett, he is the Chief Accident Investigator of the ASB. Dubin described him as “a delightful gentleman and an intelligent and able accident investigator”. He was also devout to the philosophy of the ASI division. He also had opinions of how litigants and coroners should obtain information: they should do it themselves. He also believed that if information obtained by him could also be obtained by others, he did not destroy evidence if he destroyed his information. In an interview with the RCMP during their investigation into the alleged destruction of documents done by Dubé, he brought up a good point: accident investigators are not legally trained people, and the responses to questions that could and must be asked for accident investigations may be legally dubious within a court of law. If a cop asked the exact same questions, that person would want a lawyer. There should be no lawyers in aviation investigations. Dubin believes that the heated discussions between Fawcett, Transport Canada, and the DoJ got to a boiling point in Cranbrook, and Fawcett wanted to draw the line. He told Dubé to “destroy your stuff”.
In an interview with the RCMP on July 24, 1979, Dubé was incomprehensible. However, after the interview and after discussion with Button, “he then wanted to tell the truth.” He gave this signed statement:
- “Fawcett told me to get rid of pertinent stuff on the file which the public has no need to know. ‘The biggest bulk of destruction is lately’ — ‘Fawcett called me in his office and said destroy your stuff’. I destroyed most of my stuff as a result of what Fawcett told me, although a lot of stuff had been destroyed before. I was alone with him in his office. I think he might deny it. This occurred at the beginning of July. I did that to listen to the orders of my boss and my own partial conviction. Concerning the latter, I’m referring particularly to the material that’s obtained through the authority of the Coroner and the psychological factors concerning the persons involved in the accident especially the crew, more so if they have no relevance to the accident and will not be referred in the report.”
Dubin manages to put these instructions being given after the June 29th meeting with Sims, where Fawcett and Dubé made their cunning plan to lie. They were so frustrated by the situation that they went nuclear, even though they were legally obligated to give these documents to the CPO.
Fawcett also admitted that in general conversations with other investigators, he would use language like “What are we going to do with this material? We had better get rid of it.” However, he only intended for those people to only destroy documents where copies were available from other sources, similar to his belief that destroying statements from living people did not constitute destroying evidence, as someone else could get the same statement from the same person. He also had the expression of “whatever you don’t have in your possession, you cannot be subpoenaed for”, which is very similar to Dubé’s quote.
During the inquiry, Fawcett concluded by saying this:
- “…I still feel the same way, and I think we have to have some very definitive legislation to enable us to carry on with this job, and I think that lack of legislation had a great deal to do with what led up to the Cranbrook situation.
- Notwithstanding that, I would like to say, sir, that any decisions that I have made, that either harmed any individual or caused this Commission to have to involve itself in a lot more detail than it would otherwise have had to, I regret very much. I am sincerely sorry.”
Dubin believes that Fawcett should be a part of a possible “new independent tribunal”, as he had great talent as an accident investigator, and merely acted the way he did because the ASB was in the wild west of investigations. Dubin did not think the same for Dubé. He believed that he would not be able to follow instructions not to his liking, and that his work should be limited to aviation medicine and not a part of any aviation investigative team.
Conclusion
Seeing this madness unfold, Dubin saw the real need for a tribunal “independent of any department of government”. We saw the madness that could result when the board is within the control of Transport Canada. Before I end this article, it’s worth looking at Bill C-40 (of 1979) briefly, because Canada nearly had a weird compromise solution.
Bill C-40 never became law. It died when the 1979 Canadian federal election was called, but what it called for was fascinating. Its title was “An Act Respecting the Establishment of the Office of the Commissioner of Transportation Accident Investigation”, which sounds like an establishment of a Canadian NTSB, but it was not. In its form, it would only investigate accidents and incidents where people died, or result in injury that, “in the opinion of the Commissioner, involves a serious likelihood of the loss of life.” The ASB would still exist for accidents and incidents that weren’t covered by this office. Requiring two sets of investigators would’ve put a strain in the pool of investigators available in Canada. Also, any investigation by the ASB would not be taken as seriously because of its position as a branch of Transport Canada, and could snowball into an accident that requires investigation by “the Office”. Furthermore, even accidents that do not result in injury could still have vital lessons to learn, and having those lessons in different parts of the government seems needless and inefficient. This office couldn’t investigate accidents like TACA 110, AA 96, Air Canada 143, or Qantas 32, as these accidents, even though they could have killed people and had serious lessons to be learned, had no serious injuries (if at all).
Dubin saw this too and believed that all incidents should be investigated by the same group that investigates accidents. He even came up with a name for this hypothetical independent tribunal: the Canadian Aviation Safety Board. He even notes that the word “Safety” is signifying what this board should do: advance safety. We will talk more on how focused they were on this goal another time.
Harold Fawcett: A Hero
Unfortunately, I do not think Fawcett ever made the jump to the CASB. It’s possible that he might have, but I think this situation may have ended his career, though I could not find any evidence for either option. Harold (Hal) Fawcett may have damaged the ASB’s reputation, but he also strengthened the case for Canada to have an independent board to investigate aviation accidents and incidents. He was willing to protect his sources and witnesses from the courts, and he deserves credit for Canada now keeping their evidence involving people, particularly the CVR transcript, private and privileged when collected in a transportation investigation. For that reason, I consider him a hero. He died on May 21st, 2001, and was never properly recognized for his actions.
In an obituary posted online ten years after his death, it talks about Hal’s role in improving aviation investigation in Canada via his campaign to make these investigations independent, resulting in the CASB and now the TSB. There are also three comments that talk about what a great man he was. One is from a person that knew him after retirement, who he went fly-fishing with in the Mississippi River. One is from a person that worked at the ASB during this very Dubin inquiry who agreed with the obituary. The third comment is from his granddaughter. According to her, he was a wonderful grandfather.
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This is a subject I really wanted to write about, and the Dubin report was an absolute bombshell of a find. This was originally meant to be an article purely focused on the downfall of the CASB, but the reasons behind the founding of the CASB itself was so important, and so packed with information, that it needed its own article.
This series has five parts.
Part 2 is focused on the CASB, its brief rise and its ugly downfall, particularly Arrow Air 1285’s investigation.
Part 3 is focused on Air Ontario 1363, and its effects on aviation safety within and outside of Canada.
Part 4 is focused on the early days of the TSB, from 1990 to 1998, particularly on the 1994 review of the TSB.
Part 5 is focused on the TSB from Swissair 111 to today.
Feel free to correct any errors in the comments. Thank you for reading.
