Proper oversight by regulator found lacking
Transport Canada broke its own rules when it cancelled an audit program just months before a fatal plane crash during its transition to a self-policing civil aviation system.
The information was contained in a confidential draft report obtained by Canwest News Service.
The Transportation Safety Board's draft investigation report, dated Aug. 1, 2008, documents the events leading up to a Transwest Air (TWA) crash in Sandy Bay, Sask., on Jan. 7, 2007.
In addition to finding "repeated" and "routine" regulatory infractions on the part of King Air pilots at the regional airline -- to the point where crew were "likely unaware that many were actual policy and procedural deviations" -- the board found big gaps in Transport Canada's role as regulator.
"Although Transport Canada safety oversight processes identified the existence of supervisory deficiencies within TWA, the extent of the deficiencies was not fully appreciated because of the limitations of the current inspection/audit oversight system."
Two flight crew and two emergency medical technicians were aboard a King Air aircraft en route to pick up a patient from the Sandy Bay Health Centre when it crashed into trees near the runway after an aborted landing attempt. The 52-year-old pilot died of his injuries; the other three suffered non-life-threatening injuries.
The board's findings, related to causes and contributing factors, focus on TWA's deficient supervision of the King Air operation and failures of the crew. But the board also identifies several "findings as to risk" concerning Transport Canada's deficiencies. It's one of three crash reports expected in the coming months to single out the department's failure to provide proper oversight during the implementation of the safety management system (SMS). The system is similar to changes being made to Canada's food inspection, where the onus shifts to companies to identify hazards and manage their own risks.
The pilot's widow, Debbie Wolsey, is challenging the findings. In her brief to the safety board, she places blame on Transport Canada's failure to properly regulate the company, to which her husband Rick Wolsey voiced concerns about his 24-year-old crew member.
"It all ties in to Transport Canada not fulfilling their responsibility in ensuring safety in the aviation industry," Wolsey said in an interview.
"I do not want Rick's death to have been worthless. If it has to prove a point in regards to the safety of the aviation industry, so be it," she said.
At the time of the crash, TWA was at Phase 2 of SMS implementation, championed for civil aviation under the previous Liberal government, which introduced SMS to the railway industry in 2001. The draft report said TWA was not yet in a position to identify hazards in any proactive way, and Transport Canada was not slated to conduct an on-site SMS assessment until April 2007.
http://www.canada.com/calgaryherald/news/story.html?id=b3f461b1-690f-4155-9199-6a402d4b520d
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