Air Safety Round Table: Hugh Danford
Hugh Danford is a former pilot and retired civil aviation inspector. Mr. Danford left his job with Transport Canada after discovering systemic flaws and insisting they be addressed - to no avail.
Remarks
(Video 9:32)
I am here today to speak to the historic and on-going “Lack of Regulatory Supervision” that has resulted in the death of innocent lives over the past ten years. Today I want to make sure that everyone on both sides of the House knows who Damien Samuel Hancock was and how he died when they stand to vote for Bill C-7. I met with Damien’s mother this month and I speak with her informed consent and support.
On March 19, 1999 a Provincial Airlines Twin Otter crashed onto the frozen sea off Davis Inlet killing 22 year old Damien Samuel Hancock. What followed was a cover-up that would draw in several government agencies and senior personnel over the following ten years making Davis Inlet one of the most important crashes in Canadian aviation history. Not since Transport Canada (TC) was found liable in the deaths of six people on October 19, 1984 in the Wapiti Airline crash has there been such a blatant miscarriage of justice by the regulator, Transport Canada. This was crash number five for the captain.
To go back to March 28, 1993, the Regional Manager, Aviation Enforcement (RMAE) wrote in the captain’s enforcement file after his fourth crash: “Previous sanctions have not changed this individual’s method of operating, and I don’t think that this will either. We will hear from this gentleman again.” He was fined $850 and his pilot’s licence remained valid. TC did hear from him again when he crashed onto the frozen sea six years later, killing his co-pilot Damien Samuel Hancock. TC did not investigate the crash as it is mandated to do. Instead, TC closed up the captain’s enforcement file on January 4, 2001 citing “NFA. No further Action.” (see attached)
On July 10, 2001, the Transportation Safety Board (TSB) released Recommendation A01-01 as a result of its investigation into the Davis Inlet crash and the death of Damien Samuel Hancock. Recommendation A01-01 states: “The Department of Transport undertake a review of its safety oversight methodology, resources, and practices, particularly as they relate to smaller operators and those who fly in or into remote areas, to ensure that air operators and crews consistently operate within the safety regulations.”
On July 17, 2001, Transport Canada’s Commercial and Business Aviation branch under Director, Merlin Preuss, was selected to be the OTI (Office of Technical Interest), the main respondent to the recommendation. Although responsible for satisfying the recommendation, this is the last time that Merlin Preuss’ name appears on any document relating to A01-01 or Davis Inlet. (see attached)
On September 20, 2001, a Safety and Security Review Committee was convened by ADM Bill Elliott to formulate a response to Recommendation A01-01. No minutes were kept of this meeting. Conspicuous by their absence were Merlin Preuss, OTI, and Franz Reinhardt, Director of Regulatory Services, or any representative from their individual departments. At this meeting it was decided to offer up a failed study called the “DMR Report” as satisfying Recommendation A01-01. At a cost in excess of one million dollars, the much maligned study was designed to justify reducing inspector levels. It had absolutely nothing to do with Recommendation A01-01. As such this cabal lied to the Transportation Safety Board and thus lied to Parliament.
On October 3, 2001 after being signed off by Bill Elliott, Gaetan Boucher, Art LaFlamme and Margaret Bloodworth, the bogus response to Recommendation A01-01 was forwarded to David Collennette, Minister of Transport for signature. It contained explicit reference to the DMR Report. (See Attached)
On March 31, 2002 the TSB Annual Report was submitted to Parliament. In the TSB’s account of Recommendation A01-01, the TSB mentioned the DMR Report, stating that TC had provided “satisfactory intent” in its response. The information contained in the March 31, 2002 hardcopy edition is significantly different from today’s version on the TSB website. Somebody re-wrote history. At this point, Bill Elliott had moved on to be the Director of Intelligence for the Privy Counsel under Stephane Dion where the DMR Report landed. It is apparent when looking at the rewritten history of Recommendation A01-01 on the website, that the TSB conspired to alter the TC response to A01-01 response, back-dating information to October 29, 2001.
On October 29, 2002, I completed writing the Hancock Report and filed it with Dr. David Bell, TC’s “integrity” officer for the fledgling Public Service Integrity Office (PSIO) headed up by Dr. Edward Keyserlingk. After being stonewalled by Dr. David Bell several months, I approached the PSIO’s Jean-Daniel Belanger to look into my allegations contained in the Hancock Report.
On December 10, 2004, Jean-Daniel Belanger, PSIO Senior Investigator, scripted a response to my allegations regarding the lack of regulatory supervision by TC. Dr. Keyserlingk signed the letter stating that none of my allegations against TC were found to be of merit. In doing so he quoted Policy No. 15 as evidence why TC did not investigate the Davis Inlet crash. Although I had apprised Mr. Belanger that I had written Policy Letter No. 15 myself, and that it was a memo, not policy, he nonetheless used the document to support Transport Canada. (see attached)
On May 14, 2007, I testified before the Standing Committee on Bill C-6 (now C-7) and presented the Hancock Report for the committee’s review. I did not receive any questions or comments from any of the members of the standing committee.
On August 18, 2008 I wrote to Christiane Ouimet of the newly formed Public Service Integrity Canada making her aware of the miscarriage of justice by Transport Canada in the death of Damien Samuel Hancock and of her predecessor, Dr. Keyserlingk’s failure to act or protect me as a whistleblower. (see attached) I received no satisfactory response from her office. Instead I was questioned and intimidated by one of her investigators.
In the final report on Davis Inlet (A99A0036) the TSB sound TC to be a root cause of the accident by its lack of regulatory supervision. This was the last time the TSB has produced such a finding in any air crash in Canada. Previously the TSB found Transport Canada’s lack of regulatory supervision to a root cause of 25% of air crashes in a Tri-National study between the US, Canada and Mexico, known as the TRINAT. The lines are now blurred between the supposedly independent bodies of the TSB and TC. This lack of boundaries TC and TSB is reminiscent of the disbanded Canadian Aviation Safety Board (CASB) that produced the well-known cover up into the facts surrounding the Arrow Air crash in Gander.
I do not feel that the same individuals who contributed to Damien’s death, covered up the facts surrounding his death and lied to Parliament, should be trusted with the future of the safety of the traveling public by introducing the inherently flawed Safety Management System (SMS) via Bill C-7. The changes proposed in Bill C-7 only serve to validate the status quo and do nothing to further aviation safety. It is time to have another judicial inquiry into aviation safety in order to purge the system of unscrupulous behavior by the government of the day and its Crown Servants.
In my supporting documents I have also included pre-course reading material from the September 11, 1999 Basic Aviation Enforcement Course (BAEC). A quick review of the BAEC will make it clear that Transport Canada was not practicing what it was preaching.
The Government of Canada owes a sincere apology to Damien’s family, as well as to the growing number of families it continues to fail. It is the time for the Government of Canada to regulate as it is mandated to do, without political intervention. The inherently flawed SMS will do nothing to further aviation safety but rather create havoc and ultimately lead to more unnecessary death.
Supporting Documents
