Air Safety Round Table: Kirsten Stevens

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Kirsten Stevens lost her husband in a floatplane crash in 2005. When the authorities failed to provide answers regarding what had gone wrong, she and the families of the other four victims embarked on their own investigation. What they learned shook their faith in the regulatory system and caused Kirsten to become a vocal advocate for improved air safety.

Remarks

(Video 15:06)

February 28, 2005 was Arnie Feast’s first official day as pilot for MJM Air. He and his passengers, my husband, Dave Stevens, Fabian Bedard, and brothers Doug & Trevor Decock, departed in the float-equipped Beaver at 10 past 10.00 that morning. When they did not arrive at their destination the expected half hour later, the dispatcher was notified immediately. But without a radio in the office, she spent the next hour attempting to contact the pilot by telephone, to no avail. When the chief pilot and ops manager returned from his annual medical about an hour later, she told him the situation. He told her she worried too much, and later departed on another revenue flight. It was not until after 2pm – four hours after departure – that Search and Rescue was notified.

At 6 pm, almost eight hours after the plane disappeared, Dave’s boss called. “The plane is missing”, he told me. “What do you mean the plane is ‘missing’?”, I asked. I simply could not understand. Aren’t all aircraft tracked by radar or GPS or some other means, in this day and age? In 2005?

We were headline news, and as I got off the telephone the story was being reported before my eyes. Not knowing where or when the aircraft had disappeared, searching extended over thousands of kilometres. It was on the third day that Dave’s body was discovered on a nearby island, and the swarm of journalists landed on my doorstep.

But the next day was the Mayerthorpe tragedy, and we were all but forgotten. By both the press and our government.

The Coroner performed Dave’s autopsy the next week, calling me with her conclusions as I headed out the door to his funeral. She explained that he had escaped the aircraft, but had drowned, despite his Mustang Survivfal floater coat, after suffering extensively from hypothermia. I will never know how long he floated out there, cold, wet, exhausted, and alone, waiting for the rescue that never came.

Although witnesses heard the aircraft hit the water and correctly identified the area in which it crashed, the authorities soon gave up the search. The families did not.

I’d like you to keep in mind the Cougar crash while, I’m talking about this, the helicopter that recently crashed off the East Coast. Our story is very different.

We didn’t give up the search because we wanted to know what had happened, and to bring the other boys home, certain they must have been trapped inside the aircraft. Our friends, neighbours and our community rallied, volunteering time and equipment, whatever we could use - and exactly five months to the day after the accident, we recovered the fuselage – the engine had separated from the fuselage due to corrosion. The clock stopped just six minutes after takeoff. And we learned we learned we were wrong. Nobody had been trapped inside. All five men had unbuckled their seatbelts and escaped, leaving their lifejackets still sealed and stowed in the aircraft.

The recovery of the fuselage did not result in any further investigation. We later learned that the TSB had written a brief letter to the Coroner, actually they’d written a letter prior to our recovering the fuselage, and after we recovered the fuselage they changed a couple of things including adding the flight controls and that was just about it. That was going to be the end of their investigation. But they didn’t tell us that, and they didn’t tell the Coroner. We were pretty unhappy with the letter to the Coroner, and of course we were expecting the Coroner to produce a Coroner’s Report. We wanted to make sure they had all the information they required to do an accurate report. So we asked for a meeting with the RCMP, and the Coroner, and the TSB and Transport Canada, all the official bodies who were involved in any form of investigation. Transport Canada declined to come. I guess they didn’t want to answer some hard questions.

Eventually, because we kept insisting, we were sort of promised a $10,000 “reward”, if we were successful in recovering the engine. So we spent about two and a half years, hindered by financial considerations, equipment breakdowns, weather, etc.

But in September of 2007, almost two and half years after the accident itself, Kevin Decock, whose two brothers had been on board, used a camera-baited hook, which he had himself designed and manufactured, on the end of a 1000-foot tether to bring the engine over 850 feet to the surface of the ocean. It seemed nothing short of a miracle. It did not, however, explain, what brought the aircraft down.

After the TSB had completed its examination of the engine, the families, disappointed in the lack of results, contracted the services of R.J. Waldron & Company – a highly respected firm specializing in forensic aviation investigations. It would be several more months before they released their Summary Report and Recommendations which clearly identified the poor condition of the aircraft prior to the accident, and denounced the TSB‘s lack of investigation - suggesting that very failure had possibly resulted in critical evidence being lost forever. Now that firm, which once worked co-operatively with the TSB on behalf of operators and insurance companies, is being shut out of TSB investigations. They are feeling the repercussions of “whistleblowing”. The repercussions of telling the truth.

Easily a quarter of a million dollars later, the families having spent at least, all we know for sure is that every single government agency with an interest in the accident, has failed us. The lack of reporting by the TSB had resulted in a “lack of information” which Transport Canada blamed, along with the pilot’s missing body, for its’ failure to investigate for Canada Labour Code infringements. Disputes over jurisdictional access meant the provincial Worker’s Compensation Board, Worksafe BC, did not investigate the CLC infringements which may have led to the deaths of the four loggers, including my husband. Communication failures meant it was just last week - over four years post-crash, before the BC Coroner’s Service completed it’s report and recommendations.

The report itself was riddled with inaccuracies and misinformation. Many of those recommendations had been made before - by the TSB, even by TC themselves, but not acted upon. Recommendations that might have saved the lives of all on board, and certainly would have saved the life of my husband. Other recommendations were clearly made by someone with little understanding of the aviation industry, such as suggesting that a life raft should be carried on single engine float planes.

We had held out so much hope that the Coroner’s Report would bring us some sense of closure. We felt very let down.

The feeling of having been failed by the governing agencies - those whose job it was to protect our loved ones, to investigate their workplace deaths, to take quick remedial action and make immediate recommendations - and follow through with them - to prevent future such tragedies. Policies, procedures, and the misunderstood rules of jurisdictional access have all played a part in prolonging our grief, in denying us closure.

Who was accountable for these failures?

I cannot change what happened. I cannot bring back Dave, or any of the men lost on that fateful day. But I decided there was something I could do. Something I had to do.

I started researching, reading, talking and listening to people working in the aviation industry. Many of you here already know me … I know you!

I built a website and wrote letters. To unions, to government officials, to anyone I thought might listen.

Slowly, people started paying attention. Aviation workers, accident victims and their families, workers from other industries often transported by air - started coming to me for advice, for guidance, for help.

Our accident seemed to be a perfect example of every hole in the “Swiss Cheese Model” lining up, even highlighting issues related to federal and provincial jurisdictional access which may not have been previously identified. We started a petition, demanding that this accident be used as a starting point for a public inquiry into the the oversight of small and remote operations. Without even publicizing, we have collected over 1500 signatures, many of whom are professional pilots.

You have heard my fellow speakers decry Safety Management Systems, decry the governments purposeful step back from oversight in order to reduce costs and the burden of liability. You have heard about the lack of whistleblower protections, the public’s right to know and our flawed and overburdened Access to Information system, you have heard the calls for an immediate and subsequent periodic reviews of Transport Canada’s safety oversight.

MJM Air did not operate under a Safety Management System - but they did have safety related rules. Rules that they did not follow and which may well have resulted in my husbands death and the deaths of all the men on board that day. Broken rules and no repercussions. Safety Management Systems would not have changed that. The paperwork said everything was done according to regulation and standards. But the paperwork was a lie, and the existing system did not identify those lies, even after the fact.

Do we need to have more deaths before we clean up the existing system? How will “another layer of protection” help in an already dysfunctional system?

Aviation workers, especially in small and remote operations, which by the way is where many new commercial pilots go in order to get the hours so they can get the “good job”, are already provided far less stringent OH&S standards than any other high-risk industry. When they voice safety concerns, they are all too often ignored. If they try to bring in a union, to help fight for their rights, they are too often fired, and subsequently black-balled - unable to find work in the industry. I can provide many examples of companies where this exact scenario has played out, just in the last few years, even just the last few months.

I know there is a small group of pilots who, perhaps discouraged by the lack of regulatory initiative, are trying to form a professional college whose goals are to promote safety standards, training standards, technical issues and accredit Canadian pilots from the youngest commercial pilot to the Airline Transport Pilot near the end of his career. They are the aviation experts who wish to fill an obvious void - the void into which safety concerns fall due to the lack of filter, if you will, between Transport Canada and the owners and operators. Their goals, if adopted, will go a long way to ensuring Canada has the best trained pilots and a safer industry.

But other things need to happen too.

One of the things that we learned about was the TSB’s Occurrence Classification Policy. This didn’t seem to exist ten years ago, and I’m not sure of the exact its exact date of inception. However, at some point the TSB introduced this policy by which they decide the level of investigation they are going to put into an accident. Our accident was a “5”, which means that it’s the bottom of the barrel. It means that it is only investigated for statistical purposes and information. There is no public report, and if you go to the TSB website, you won’t even find more than a mild mention that this accident even happened. Five men died.

The TSB Occurrence Classification Policy needs to be re-examined and improved, so that whenever a pilot - or worker from another industry - is seriously injured, or killed, there is a mandatory investigation for cause and contributing factors. The other governing agencies – Transport Canada, Worker’s Compensation Boards, Coroner’s Services, police - all require the expertise of the TSB and Transport Canada to do their jobs effectively. They cannot interpret the CARS. Most of the aviation industry can’t interpret the Civil Aviation Regulations. Management factors must be examined as recommended in Safety in Air Taxi Operations (SATOPS) study which was done back in 1998 by Transport Canada.

Finally, there is a growing need for a Program to act as a communications facilitator between the many governing agencies and the survivors and victim families of aviation accidents. Transport Canada and the TSB once began to work towards a “National Compassionate Assistance Program”, at the insistence of a mother who had lost her son, Jane Abramson, and then dropped the ball when Ms. Abramson thought they had picked it up. Knowing the confusion created by so many agencies working at cross purposes and with overlapping mandates, I can’t help but thinking of the families of those killed in the Cougar helicopter crash, an how confused they must be by everything that is going on around them. The lack of communication both with them and between the agencies, trying to understand all the different jobs, whose job is what …

All these ideas fit together and by incorporating these recommendations, we may well be able to, not only prevent future deaths, but reduce the trauma and grief caused by a dysfunctional system.

My faith in our Canadian government has been shaken. I would like to get it back. The next time I hear someone say “Canada has the safest aviation system in the world”, I’d like for it to be true.