SafeSkies Newsletter Vol. 1, No. 10
December 22, 2009
In this Issue
- Latest News from SafeSkies
- Industry News
- Whistleblower Project: Alphabet Aircraft
- Transport Canada Safety Management Information Session
LATEST NEWS FROM SAFESKIES
Welcome to the tenth issue of the SafeSkies Newsletter. We wish our readers a safe and happy holiday, and all the best in the new year.
Please note that the transcript for the November 30th meeting of the Standing Committee on Transportation, Infrastructure and Communities, with respect to the study of Canada's enforcement of air safety regulations and implementation of safety management systems for the aviation industry, has now been published. (See http://safeskies.ca/news/Pushing_paper for links).
On December 2nd, NDP Transport Critic Dennis Bevington issued a press release, again calling for a review, and was featured on CTV's Power Play (see http://safeskies.ca/news/NDP_Critic_Calls_for_Review).
Also on December 2nd, CBC Radio's The Current featured the air safety topic. Interviewees included Justice Virgil Moshansky, Carlos DaCosta of the International Association of Machinists and Aerospace Workers in Canada, and Bill Voss the CEO of Flight Safety Foundation. A summary and link to the audio can be found here: http://safeskies.ca/news/current_air_safety.
December 10th, the last day of Debates in Parliament for 2009, saw the twelfth tabling of the Petition for a Commission of Inquiry (please see http://safeskies.ca/news/Petition_tabled for more information). Debates are due to resume on January 25th, although there is speculation that Parliament may be perogued until after the 2010 Olympics.
The first of our stories for the Whistleblower Project has now been approved. The story is reprinted, in part, in this newsletter. Please visit http://safeskies.ca/content/Alphabet for the full story.
Please note that the next issue of the SafeSkies Newsletter will be on February 1st, 2010.
For information on SafeSkies' projects, and ways you can help, please see http://safeskies.ca/content/how_you_can_help .
Please continue visiting the website frequently and sending your comments, questions and story ideas to Kirsten.Stevens@safeskies.ca .
We regret to once again begin with deepest condolences. On December 10th, a King Air 100, operated by Exact Air, crashed near St-Honoré, PQ. Two passengers were injured while the pilots, Jean-Yves Boutin, 25, and Vincent Bradette, 29, were both killed. The TSB has given the accident a Class 3 Occurrence Classification. Please see http://safeskies.ca/content/2009Q2509 for more information.
As noted in the last newsletter, December 3rd saw the release of the TSB report into the fatal Bighorn Helicopter Bell 206B (operated for BC Hydro) crash of May 13th, 2008. While investigators were unable to determine the cause of the crash, it was noted that "the aircraft should not have been operating at such a low altitude over homes". According to CBC news, investigator Damien Lawson stated, "There is considerable misunderstanding, misinterpretations in the industry about these regulations." Please visit http://www.cbc.ca/canada/british-columbia/story/2009/12/03/bc-cranbrook-helicopter-crash-report.html for the story. The TSB report can be found at http://www.tsb.gc.ca/eng/rapports-reports/aviation/2008/a08p0125/a08p0125.asp.
On December 9th the TSB released their report into the second of two fatal crashes involving an aircraft operated by A.D. Williams Holdings. The report into the March 28, 2008 crash cites a variety of risks, including overloading, maintenance and SMS oversight as contributing factors. Please see http://safeskies.ca/news/SMS_Cited for the Canadian Press article and a link to the TSB report. Note that the first crash, on October 28th, 2007 was given the Occurrence Classification of 5 by the TSB (see CADORS 2007P2160) - there will be no report. Please visit http://tsb.gc.ca/eng/normes-standards/evenements-occurrences.asp for more information on the Occurrence Classification Policy.
In follow-up to the November 29th fatal floatplane accident off Saturna Island, BC, the Canadian Press released an article on December 6th criticizing Transport Canada for failing to act on past recommendations. Please see http://safeskies.ca/news/ATV_Stevens for information and a link to the recent Transport Canada risk assessment acquired through Access to Information.
On December 16th, Northern News Service ran a story in which the owner of Buffalo Airways, currently being featured on History Channel's Ice Pilots, claims that Transport Canada's version of Safety Management Systems is hurting business. The article can be found at http://safeskies.ca/news/Buffalo_Joe.
On December 17th the Manitoba Court of Appeals unanimously overturned the convictions for criminal negligence against the pilot of the 2002 Keystone Air crash. Some of our readers may recall the pilot, Mark Tayfel, from the Aviation Safety Round Table held in April. Please see http://safeskies.ca/news/Conviction_Overturned for the story from the Winnipeg Free Press.
Finally, an interesting letter was received by the Walrus Magazine in response to Carol Shaben's article, Fly at Your Own Risk. The letter, by Les Filotas, author of the book Improbable Cause, brings to our attention the continuing flaws that exist with the operations of the Transportation Safety Board. The letter can be read in full at http://safeskies.ca/news/Walrus_letter.
FROM THE UNITED STATES
==>FAA Seeks Penalty From Arkansas Firm Over Charter Flights<==
Federal aviation regulators proposed a $4 million civil penalty against a Fayetteville, Ark., firm that carried passengers on hundreds of allegedly illegal charter flights going back to 2005, without the required government certificate and often without a properly licensed pilot.
The punishment proposed for Spitfire Aviation Services LLC of Fayetteville, Ark., one of the largest penalties ever levied by the agency against a charter operator, covers more than 790 passenger flights between November 2005 and October 2007. During that period, according to the FAA, Spitfire didn't have the required operating certificate or FAA-approved operational standards to carry passengers on revenue flights. More than one-third of the flights were flown by a pilot without the necessary license, according to the FAA's statement announcing the action..
See http://online.wsj.com/article/SB125996323129977257.html for the full article.
==>ACSF Publishes Charter Safety Review<==
The Air Charter Safety Foundation (ACSF) has released its first safety review of the Part 135 on-demand air charter industry. The Part 135 Incident/Accident Review is a comprehensive look at the factors surrounding charter incidents and accidents between 2004 and 2008.
In conducting the review, the ACSF analyzed each Part 135 on-demand event reported in the National Transportation Safety Board (NTSB) database and identified non-revenue flights flown under Part 91 that were under the control of a certificate holder. These include maintenance, ferry, positioning and instructional flights among others. Events on Part 91 flights under the operational control of an aircraft owner were not included.
Several interesting data-points emerged in the review:
• Approximately 65% of all revenue flight accidents, and 62% of non-revenue, occurred in visual meteorological conditions (VMC).
• Non-revenue (i.e. Part 91) fatal accidents accounted for 28% of all non-revenue accidents while 25% of all revenue flights were fatal accidents.
• Revenue accident flights involving transportation to/from oil rigs represent, on average for the five year period, 18% of all accidents.
Please visit http://www.amtonline.com/article/article.jsp?siteSection=1&id=9959 to read the rest of the article.
==>Colgan, union differ on cause of fatal crash<==
Colgan Air says the probable cause of February's fatal crash in Clarence Center that claimed 50 lives was the pilots' "loss of situational awareness and failure to follow Colgan Air training and procedures, which led to a loss of control of the aircraft."
The regional airline company, in a 66-page report to the National Transportation Safety Board, also cited as contributing to the crash the lack of low-speed warnings in the cockpit instrument panel on the Bombardier Dash 8-Q400 turboprop.
But the Air Line Pilots Association, the union representing Colgan pilots, said in its 62- page report to the safety board that pilot error did not cause the worst aviation crash in Western New York.
Rather, the pilots union said, a combination of factors caused the crash. And it cited Colgan for failing to adequately prepare the pilots for the conditions that faced them Feb. 12, when the aircraft went into an aerodynamic stall and spun out of control.
Colgan was in too much of a rush to start new service from Newark-Liberty Airport using the new Q400s, the pilots union said, and failed to adequately train its pilots and provide them the proper operating manuals for the sophisticated aircraft.
Please see http://www.buffalonews.com/home/story/893451.html for the full story.
Whistleblower Project: Alphabet Aircraft (Excerpt)
Shortly after starting I was tasked to do an informal audit of the material safety data sheets (MSDS) on the floor. I found over 50 that were out of date and over 40 materials (paint, adhesives etc) that had no MSDS at all. I also observed two spray painters spraying lead based paints with no fresh air equipment or masks on. I was told that every time a similar concern was taken to the Company President he would get angry and say they did not care about the provincial Health and Safety Act and that no one, including any branch of the government, will tell them what to do. The person nonetheless took my concerns to the President, and was walked out the door about a week later.
Shortly after this incident I was put on my first quality project by my manager. This was to design a defect feedback system. Shortly after inception of the system, the president sent the message to my manager that the defect system was to be dismantled and no more data collection was to take place. I later found out that the president did not like that the defects we had found could be seen by anyone.
The president hired a former Transport Canada Inspector (TCI) to be the quality manager at Alphabet. TCI approached me one day to tell me that the new V.P. of Operations (VPO) had transferred me to the quality department and that I was now working for him. He asked me if I had any internal auditing experience. I confirmed that I had performed some internal audits in the automotive sector but nothing in aerospace. TCI then told me I was now the auditor for Alphabet Aircraft. I asked him how deep he wanted me to go in performing these audits. He directed me to write up everything I found so Alphabet could address all issues. He wanted to fix everything and not to have Transport Canada find anything.
Since I had no training in Canadian Aviation Regulations I requested training, but was refused.
I wrote close to one hundred findings during my employment as an auditor at Alphabet Aircraft, including the use of unapproved drawings on the production floor. All production should have been stopped at this time until everything was cleared up, but it was not. A meeting was called and I was told that VPO said that a way to solve the problem was to get me to stop the audits.
Please visit http://safeskies.ca/content/Alphabet for the rest of the story.
Transport Canada Safety Management Systems Information Session
Building your SMS Based on Size and Coomplexity
Agenda and Links
Meeting Chairperson: Dave Nowzek
Regional Director, Civil Aviation, Pacific Region, Transport Canada
Day 1, November 25, 2009
Presentations available at http://www.tc.gc.ca/civilaviation/sms/info/nov2009/day1.htm
Martin J. Eley
Director General, Civil Aviation, Transport Canada
Proactive Hazard Indentification Workshop
Aviation Safety Management Specialist, TryByte
Getting An Incident Reporting System Up and Running
Chief Pilot, Company Aviation Safety Officer, SMS Programmer, West Coast Helicopters
A Practical and Integrated Risk Management Solution
Aviation Solutions Director, Superstructure Group
Incident Analysis Panel
Moderator: Gerry Pipe
Manager, Corporate Safety Services, Air Canada
Business Strategies to Manage Safety and Quality: CAMC's Perspective
Executive Director, Canadian Aviation Maintenance Council (CAMC)
Day 2, November 26, 2009
How to Develop a Proactive SMS
Director, Standards Branch, Trnansport Canada
Hazard Identification in a Small Operator
Director of System Safety, Skyline Helicopters
Direcotr of Safety Services, Conair Group Inc.
Manual Development: Customizing for Large, Medium and Small Organizations
Aviation Safety Management Specialist, TryByte
Fatigue Risk Management System
Chief, Technical Program Evaluation and Coordination, Transport Canada
Applying a Risk Engineering Framework to Fatigue Safe Systems
General Manager, FaidSafe Business Group, InterDynamics Pty Ltd.
Small Operator Guidance: How do I use it to develop an SMS?
Acting Superintendant, Safety Oversight Operations, Transport Canada
Transport Canada Panel: Questions & Answers
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