Air Safety Round Table: Greg Holbrook

Topics:

Greg Holbrook was, at the time of this presentation, the National Chairman of the Canadian Federal Pilots Association. He represented his fellow pilots in this role from July 2000 until the end of June 2009. Between 1998 and 2000 Mr. Holbrook was an Aviation Enforcement Inspector with Transport Canada based in Winnipeg, Manitoba. Prior to that, Mr. Holbrook worked as an Operational Investigator (Air), with the Transportation Safety Board of Canada in Winnipeg, Manitoba. Mr. Holbrook also served as a pilot with the Canadian forces.

Remarks

(Video 25:10)

Good afternoon. I’d like to thank Mr. Bevington and Mr. Julian for taking the time to listen to us this morning, and thank you to the organizers for setting up this event here today.

My name is Greg Holbrook and I am the National Chairman of the Canadian Federal Pilots Association. I am an airline transport rated pilot myself, both rotary wing and fixed wing. My background involves both working as a Transport Canada inspector and a Transportation Safety Board investigator.

My comments here today are prefaced by an interesting little cartoon that I put on the front page, where two police officers are standing by the side of the road holding up a sign, “Honk if you’ve committed a crime”. And the one constable saying to his captain, “Captain, this isn’t working”.

This is essentially the situation we’re in today. Not make light of it, by any means, but to encapsulate it in terms almost anybody can understand. We’re standing by the side of the road watching this happen, and we’re doing nothing to prevent it. There’s lots of talk about Safety Management Systems being proactive and an additional layer, but I’m here today to tell you that it is simply not true.

The essence of SMS

The implementation of Safety Management Systems began before the election of the Conservatives, but is an ongoing effort to dismantle traditional safety oversight. This is not an additional layer. Under SMS, Transport Canada inspectors, who are the individuals that I represent, the pilots who work as inspectors at Transport Canada and who are the investigators at the Transportation Safety Board, and also the pilots who work at NavCanada, they comprise our membership. What we are observing is that the Transport Canada inspectors, under SMS, are becoming increasingly a group of desk-bound system operators. They’ll be inspecting no more than the paperwork regarding the systems that the airlines have put together for themselves. They won’t be looking at the aircraft and the actual operation; they’ll simply be examining the system that the airline documents for themselves. Under the proposed Bill C-7 that has been prorogued and that we understand may re-emerge, there were sweeping new powers that were included in that Bill to make safety information secret and grant immunity to airlines for self-reporting safety violations.

What we’ve seen is that basically reports go into this system and nothing comes out of it. There was talk from Mr. Gauthier about reporting something and years later still not being able to get any response back that something was actually done about it, that it was looked into and that it was taken care of. The companies who have Safety Management Systems are left strictly to their own devices to follow up on the reports. They are able to determine, in concert with their own corporate interests, what the acceptable level of risk is for their operation. It’s not a dictated safety standard; it’s a flexible line that is going to be overridden by the business interests of the operator. That will override the operation in terms of passenger safety, public safety and the safety of their own employees in all respects. This is a plan about making it look good, making it look like there is a system in place to do something, while in fact the actual activities and actions of oversight will not occur.

SMS is not about safety. If we go back to the documentation that Transport Canada put together in their Service Line Plan in 2001, which is available on the public domain (see Reference Material), the implementation and the proposal to implement Safety Management Systems was justified to the senior staff based on saving dollars and reducing the number of employees, and ultimately, reducing the Crown liability or the liability to the Minister of Transport. There was nothing in the justification for the implementation of Safety Management Systems that justified it on the basis of safety. That was all the rhetoric and communication plan that was drummed up after they had decided to do it. It wasn’t done to improve safety, it was done simply to reduce personnel and save dollars.

When we look at the aviation safety system of oversight that we have right now, we have strong parallels between this and other disasters that we are watching in our social safety net and the deterioration of it. We see a consistent pattern across government of oversight reduction in every area, whether it’s food safety, product safety, aviation, transportation safety, it seems to be the flavour of the month with the government and it’s going on insidiously. There is a lot of talk about things being proactive versus reactive. In my estimation what we are doing here is we are creating a completely reactive system that is then going to rely on the ability of the particular department concerned to wage the information war after the disaster happens, to absolve themselves from the responsibility for the job that they never did in the first place. I think that is reprehensible.

The fact that we have august individuals, such as Justice Moshansky, speaking out on the issues, on the lessons learned, and my esteemed colleague over here spoke to the Dryden Inquiry report and his having a sense of déjà vu. In fact Justice Moshansky spoke to the Parliamentary Committee and indicated that very sentiment. That, when I look at the issues and present it to the government today and issues going on in the industry, and he was talking from his aviation perspective, he felt that we’ve come full circle again. He was advocating an inquiry into this aviation safety, in advance of the big accident.

As someone who has been involved in aviation safety for thirty some years, I really have a problem, and I really question why do we always have to rack up the body count before we are willing to do anything about it. Why do we have to have this huge disaster before we do anything, and then there’s this knee jerk reaction to do all sorts of things that may or may not be well thought out, and then put our stamp of approval on it; there, we fixed the problem. We never seem to be able to do this on an ongoing basis, although we relearn the lesson over and over again. We wait until we have a major disaster to do it. We don’t seem to be able to get a proper grip on fulfilling our responsibilities on behalf of the public on an ongoing basis.

As somebody who has been dedicated to the public service for a large number of years, I have a huge frustration with that issue.

When we look at the Auditor General’s Report (see Reference Material) and what their perspective has been on things when they looked at Transport Canada’s SMS implementation, they accurately describe it as a complete replacement of the current system of safety oversight, NOT an additional layer as is continuously proposed by Transport personnel. It’s a partnership with the airlines. They allow the aviation companies to determine acceptable level of risk for themselves. They are determining this level of risk for the public and in return Transport Canada backs off on the regulatory oversight.

In that Auditor General’s Report, you will see a systematic process of offloading to the industry whereby within the next eighteen to twenty-four months the complete aviation industry will be offloaded to the commercial interests to make the decision as to what the acceptable level of risk is for the public. Transport Canada will simply sit back and say, they have a system, they are now responsible.

I find it astounding that, in fact, the legislation hasn’t actually been passed, but yet the implementation is many years underway.

We look at Business Aviation as an example. If you want to look at a clear example of what’s happened and how this has really rolled out, look at what’s happened with the Business Aviation sector, under part 604 of the Canadian Aviation Regulations. They were given ability to oversee themselves and their own operations in 2003. The Minister announced the ability for the Canadian Business Aviation Association to issue private operator certificates, which was previously a ministerial responsibility, and to oversee that whole sector of the industry, they announced it at the end of 2005.

The original document, or White Paper, that was used to study the issue was entitled “Industry Self-Regulation”. When the announcement came from the Minister in the end of 2005, to announce the implementation of this program, it had now morphed into a title that said that this program was the implementation of Safety Management Systems for the Business Aviation sector. If you want to see what the real methodology is about what’s going on, as my esteemed colleague from the Teamsters mentioned, this is self-regulation. This is the companies taking over for themselves to make their own determinations as to whether they are compliant with safety and or government requirements.

The other thing I wanted to mention was that although they took over in 2003 and it was announced publically in 2005, coincidentally it wasn’t until the very day that their Chief Executive Officer was appearing before the Parliamentary Committee in 2007 that an audit was actually constituted by Transport Canada. When questioned in front of the Committee, the CEO said, well, in fact the Transport auditors are in our offices today, interestingly enough. I’ll speak more later about what the results of that audit were, but they certainly weren’t a glowing endorsement of what was going on. In fact Transport Canada did give them a glowing endorsement. It wasn’t consistent with the facts, but they got the endorsement nevertheless.

(For more information, please refer to the presentation by Richard Balnis, and his supporting document “Annotated Index for Canadian Business Aviation Association Access to Information Materials”.)

The Transportation Safety Board is looking into several accidents where they believe that Safety Management Systems are a component of the system that allowed the accident to occur, and the retraction of regulatory oversight from the industry.

Transport Canada is using SMS to frustrate inspections and hide safety information. Incidents related, discovered, referred, reported to Transport Canada, people like Mr. Tayfel or his colleagues, who may phone up Transport Canada and report about a company, if that company has a Safety Management System, an email will simply be sent to the company, and say you have an SMS please handle this report in accordance with your Safety Management System. The answer comes back, thank you very much Transport Inspector; we’ll handle it in accordance with our Safety Management System.

That is the end of it. There is no investigation or follow-up. In fact, we’ve had incidents where our inspectors, in spite of the confidentiality agreements some of them have been asked to sign, but according to the Minister they now don’t have to. Even when Transport Canada inspectors have phoned up companies and said, listen, that’s not acceptable, we want to follow up on this particular occurrence in more detail, the company principles have contacted senior management at Transport Canada and said, one of your inspectors is asking for this information. We are handling it in accordance with our SMS. The inspector was told to cease and desist his inquiries, and that he no entitlement to further bother the company to enquire about information about possible allegations of concern to them.

Our concern is that should legislation reconstitute itself in Parliament, that even though there was some amendments that thankfully the Standing Committee on Transportation, Infrastructure and Communities (SCOTIC), if that legislation is reconstituted that it incorporate those amendments, but also that we take an opportunity here to have a look at this again.

There is no doubt that traditional oversight is basically being shut down. Significant portions of traditional oversight have already been shut down, and it’s well documented. Those are the facts. The National Audit Program has been shut down. There are documents available showing that Transport was aware that there would increased risk to the industry and to the travelling public for doing that. They decided to do it anyway in the interest of promoting SMS.
The secrecy involved and the confidentiality agreements that inspectors were asked to sign, it’s unprecedented really. This is supposed to be flight safety information that we are all supposed to be sharing to the greater good of the industry.

I totally understand the concerns, that not only our members would have about having their names splashed all over the headlines, but they also feel it is very important that the stories about the incidents come out and that they be properly looked at from all aspects so that the safety information can be brought out and shared openly with all other constituent interested parties.

On the issue of the confidentiality agreements, I just find it incredible that Transport Canada management was aware of it at the time that it occurred and it took two years for a new Minister to finally come out and say, no that’s not on. Much to the consternation of senior Transport management by the way, because their initial reaction was, well, those agreements are simply “not required”. Well, what does “not required” mean? Does it mean that it’s okay to have those agreements? Does it mean that we, as Transport Canada, would ensure that if one of our inspectors found something that they would take no action on it? Or refer the information back to the company, or admonish them for having taken proprietary information off company premises because of what they saw as their fiduciary duty to the public safety?

Those two words, “not required”, give me great cause for concern. They basically revalidate our concern for whistleblowers. Not only for the employees in the industry, for the travelling public, but also for the public servants that are charged with trying to do this job that their management doesn’t really want them to do.

They are out there with the sworn duty to protect the public safety, and if they see an action or a situation that has the potential to compromise safety, they are required to do something about it. Virtually all our members come from an industry background; they come from ten, fifteen years of industry. They are not your typical public servant. They’re second career people. They don’t have an allegiance to a public service pension plan or anything else. It’s not going to amount to much for them anyways. Their allegiance is to the industry and to aviation safety. We find that they are almost completely disconnected from the position of the management that they are working for, in perspective.

We recently did a demographic survey of our members, leading up to negotiations, to try to get a sense of how is the new generation coming along, where are we at. Our average age is 52, our average years of service is eleven, so that will give you a picture of the individuals who we’re dealing with. We didn’t ask any questions on the survey about SMS, but it the comments section there was this unprecedented outpouring of angst and frustration with their employer and what they perceived as their inability to do their jobs on behalf of the safety interests of the public because of the approach and direction their department was taking. They felt, basically, stifled and were, for a better way of describing it, afraid of discipline if they were to speak out in any way, shape or form.

I am aware of several instances where Transport inspectors have tried to assist members of the public with information that quite honestly would be considered public domain, and yet told quite clearly, you’re not allowed to speak to those individuals anymore, do not have any further conversations with them. It’s all about information control now. My members contact me on a regular basis with information, what I call “brown envelope”, I have a “brown envelope file” in my office, and things arrive and they expect me to try and fix the system for them. I can’t do that alone. In fact, what we’re looking at is a system that is going to entrench the ability of management to lock down information, prevent employees from doing what they should be doing on behalf of safety. In fact, dumb the whole system down so that if there is no bad news, you don’t have a problem. It becomes a self-fulfilling prophecy.

I’ll proceed quickly here. Recent developments. You’ve seen the Frequency of Inspection Policy cancelled. You know have assessment of the Safety Management System only. The frequency of those “assessments” can be adjusted depending on the resourcing levels, so there is no hard requirement.

The fact of the matter is Canada’s aviation system is simply no longer compliant with International Civil Aviation Organization oversight requirements. ICAO has, in the last couple of years, strongly entrenched the clear statement that SMS is not a replacement for traditional oversight. It is in fact the foundation on which SMS relies.

SMS is not about doing less, it costs you more, it costs you more people, it costs you more time, there is more process and you have to maintain what you’ve done before and add SMS on top. So the concept of an additional layer is true – if you were to actually do it. ICAO says you absolutely have to retain your traditional oversight and the fact of the matter is, Transport Canada is simply not doing that and has no intention of doing it. They say that we are leading the world. Well, no kidding. But the world is sitting back watching and waiting for us to fall off the cliff. While the idea of Safety Management Systems from an academic perspective is a good one, it needs to be promoted in addition to and not as a replacement of traditional oversight.
(See Transport Canada’s SMS does not meet International Aviation Standards for more information.)

Recently we’ve seen in-flight inspections on international flights cancelled. That’s just the latest iteration of multiple initiatives to either shut down or retract from inspection programs.

You now have a partnership framework that came out at the beginning of this year that will allow for the outsourcing of the remaining sectors of the aviation industry which will ultimately culminate at the end of next year with aircraft manufacturers being able to oversee the certification of their own products.
There is nothing that will be left in this system that will not be farmed out.
The final thing, as recently as last night we became that the chairperson of the SCOTIC said that the government has ambitions of bringing the Bill back to Parliament and hopefully prior to the summer.

We really need to rethink this whole initiative. We have a unique opportunity here. The experience and the concerns that have been voiced around this room today are very clear in their singular message; that what is happening here is not a good thing. We are all concerned that the travelling public is going to hold us accountable when this all falls apart.

We’ve got a unique opportunity here, in that you have a department that has implemented a program prior to the issuance of the legislation to enable it. There is lots of information available, and lots of rhetoric too, about what’s going on. If I could provide one piece of advice, don’t listen to what people say, look at what is actually occurring. That is the key thing to focus on.
Thank you very much for your time and attention today.

(end of video)

Question FROM Peter Julian

Peter Julian Asks

I just had three questions:

You mentioned the issue of companies forcing the inspector to back off, essentially, on the concerns that they were raising. Do you have any idea how many times that has happened in the last year?
Secondly, you talked about the shutting down of the National Audit Program. The last time we had a conversation, at the SCOTIC, the government was phasing it back. But do you have an idea when the last audit was conducted in commercial aviation?
My third question is around what, hopefully will reverberate out of this room right from the Hill, the issue that Canada's aviation is no longer being compliant with ICAO. That is absolutely earth-shattering when one thinks about the consequences. Is there any indication, in any formal way or informal way, that ICAO is concerned about how far back Canada has fallen?

Greg Holbrook Responds

The first question, if I have it correctly, is the number of times that inspectors have been asked to back off? I can't quantify that in total, because I only know of the couple of incidents that I heard anecdotally, members calling me up and advising me, or situations where emails have been forwarded to me for my information. Obviously emails between inspectors and their managers where they've been instructed. I'm aware of a few incidents in particular. But the mere fact that that is occurring, and the fact that there is an exchange of emails between an inspector and senior management where the senior manager advises both the inspector and the operator, yes you are correct, that is our policy, the inspector is to back off. And to find that management is advising directly, is carrying on conversation directly with industry to the detriment of the inspector to do what I would think would reasonably be their normal duties - I found that absolutely astounding. So, it is not so much the quantum, as it is the issue itself. It is so unprecedented, that I think that alone speaks to a huge concern that we should have; what is the philosophy of the department, what are they actually doing, and why do they even exist if this is the kind of methodology they use for supposedly carrying out an independent oversight of the system on behalf of the public?

To answer your second question; the shutdown of the National Audit Program? My understanding is that happened about two and a half years ago, about 2006. So the last audit that would have occurred would have been in 2006. Since then there was a period where nothing happened and now what they are doing is they are doing SMS assessment where they go in and they analyze the company's Safety Management System. As long as their system meets all the tick-boxes for the management system as prescribed by Transport, then that is satisfactory. But they are not checking out the actual operation itself. That is where the lack of balance occurs.

To speak to your third question; is ICAO concerned or looking into Transport Canada's Civil Aviation system compliance? I don't know whether they are. Transport Canada is supposed to be audited by ICAO on an ongoing basis. I'm not sure where we are in the audit schedule; however that information could be obtained. I am aware that Transport Canada management has been advised on a couple of recent initiatives that should they continue to shut down this program that they would no longer meet ICAO requirements. So I know that management has been advised of that, but in trying to obtain those documents through Access to Information, obviously the parts that the inspectors showed me have been blanked out for "policy" reasons when we get the actual ATIP document. So, anything that talks about ICAO non-compliance is blacked out when you get it from Access. For all your information, concerned people, it is a big bureaucracy that uses bureaucracy to hide accountability for itself.