Honourable members, my name is Norman Chalmers. I'm the president of Pacific Airworthiness Consulting.
I have 47 years of experience in the business of aviation safety and aircraft airworthiness, including 25 years in Transport Canada Civil Aviation in various positions, including periods as acting regional manager. Besides consulting, I write a bimonthly column for Air Maintenance Update Magazine, which is widely read in Canada and the United States.
Today I limit my comments to safety aviation management systems, SMS, as implemented by Transport Canada Civil Aviation.
On my position regarding SMS, first, SMS is a social engineering experiment on a huge scale, with the Canadian aviation industry safety outcomes as the study objective and the travelling public as the victims. Long-term consequences of these changes are unpredictable, because Transport Canada SMS has no precedent or proven models.
Second, SMS is a good idea, essentially the same as total quality management. Safety management systems, if properly embraced by management and workers, can help companies improve themselves in many areas.
Third, SMS is not a regulatory regime. It's essentially a philosophy invented by reductionist university professors who have studied and dissected disasters in the petrochemical industry. These experts include Reason and Hopkins.
Fourth, SMS can not successfully replace regulatory oversight.
Fifth, SMS is a Transport Canada tactic to save money on employee costs, including numbers and qualifications.
Sixth, SMS is a Transport Canada tactic to avoid being sued in court for allowing unsafe aviation operations.
Seventh, SMS was sold to Canadians, yourselves included, using scare tactics, including using the widely distributed worldwide hull loss projections.
Eighth, the lawmakers of Canada have been negligent. They have ignored the warnings of Canada's best people, including Mr. Moshansky in this committee's 2007 meetings and report.
Ninth, Canada has one of the safest transportation systems in the world as a result of the corporate safety culture of companies and the people working in the industry. It is also a result of the effective regulatory requirements.
Tenth, Transport Canada has started to dismantle those requirements.
Eleventh, SMS implementation by Transport Canada will do long-term and enduring damage to aviation safety in Canada.
Twelfth, it will soon be too late to prevent that damage. Canada will face a very difficult time rebuilding the safety infrastructure that is now being destroyed.
Thirteenth, public opinion regarding “safe aviation” and “safety” do not coincide with Transport Canada's definition and are not supported by Transport Canada's actions.
Those are my positions.
On SMS and PVI implementation, SMS is not an “additional layer”, as it was sold to your 2008 House of Commons committee. It was never planned as an additional layer. At the same time as those individuals were telling the Commons committee that SMS was an additional layer, they were telling us inspectors to stop doing audits. Transport Canada leaders were not truthful.
SMS assessments and program validation inspections have almost totally replaced audits and inspections. I know of no regulatory audits in the last five years. The Aeronautics Act regarding SMS does not address all aspects of SMS as implemented, and the act embeds a vague level of safety.
The CAR 107—when I say CAR, I mean Canadian aviation regulation 107—regarding SMS is vague and nebulous, at barely 300 words. This CAR leaves the requirements in the hands and subject to the whims of the bureaucrats at all levels, from senior mandarins to inspectors, and it encourages bullying.
Transport Canada Staff Instruction SUR-001, revision 5, is the primary SMS compliance document. At about 33,000 words, it defines and implements the intent of the act. It is a third- and fourth-level document. To understand SMS, you must become conversant with SUR-001, with which the vast majority of the aviation community is not familiar.
Other areas of Transport Canada infrastructure have been left without support. No credible organization supports the current directions of Transport Canada. PVIs have totally replaced audits on non-CAR 705 SMS companies or organizations. SMS was implemented without any risk assessment or human resources planning. SMS was designed and pushed into place by people with no experience in the civil aviation industry. There was no formal or recorded public consultation. The program bypassed the CARAC process of public consultation despite Transport Canada assurance regarding CARAC involvement. The training for inspectors was and is poor.
SMS is implemented but has little effect on the SMS companies under CAR 705. SMS is implemented for the rest of the non-CAR 705 industry. The implementation has stalled or died.
There is decaying regulatory infrastructure. Having Transport Canada policy-makers and Ottawa staff's total focus on SMS has left other areas of aviation regulation to decay. Implementation and administration of SMS have been taking up almost all the time and effort of the whole staff of Transport Canada.
The Transportation Safety Board of Canada aviation watch-list contains 85 open safety recommendations, some with Transport Canada responses found unsatisfactory. There are regulations and standards that have been technically wrong for years.
The results of Transport Canada Civil Aviation's overall attitudes and actions can be easily found in the reactions of the public safety experts. You will find further evidence in the public service employee survey organizational results. The number of working days lost due to employee absence on medical grounds should be examined, with emphasis on stress leave, in line with the cases I know about.
Long-term results on aviation safety for Transport Canada's new approach, including reliance on SMS, will only be evident in the long term when Canada's aviation safety record changes in relation to the rest of the technologically developed world, which currently shows improvements in safety. If the government is truly interested in aviation safety in Canada and in the effects of SMS implementation, it ought to conduct opinion surveys of Transport Canada's own inspectors and the Canadian aviation industry.
That's it for me. I think I beat the 10-minute deadline.
The Canadian Federal Pilots Association is not opposed to SMS. We have great concerns about Transport Canada's SMS, which has become the sole layer of safety in Canada.
By way of introduction, I've been a pilot for 40 years. The bulk of my experience was with the Canadian military, where I served for 23 years, instructing on jets and patrolling Canada's ocean coastline. I worked at Transport Canada for the remainder of my career training pilot inspectors, managing the approved check pilot program, and in other areas.
Just as I served the Canadian public in the military, I consider the work I now do to be in the public interest.
Our members are 382 licensed pilots who work as inspectors at Transport Canada and the Transportation Safety Board. We also represent 32 licensed pilots who work at Nav Canada.
I can tell you that the number of licensed pilot inspectors is at its lowest. Today we have 50 fewer inspectors than when I last appeared before this committee in November 2009 when Transport Canada promised to hire more inspectors.
One of the first witnesses who appeared before your committee was Auditor General Michael Ferguson. His testimony cast long shadows of doubt over the evidence placed before you by Transport Canada officials concerning rail safety. Among other things, Mr. Ferguson told your committee that Transport Canada had completed only 26% of the SMS audits of rail companies the department said were needed to ensure compliance with safety regulations. This and other comments were in sharp contrast to remarks of Transport Canada officials who testified to you only days before Mr. Ferguson.
I think Mr. Watson's comment, following the Auditor General's testimony, was most appropriate and I quote:
||...I sense that if we were to read between the lines, not only did Canadians expect better from Transport Canada, I suspect you did as well, and I know the government expected better too.
Some of you will be familiar with the Auditor General's review of Transport Canada's aviation safety program. His office conducted an audit in May 2008 and a second one in April 2012. When you line up the audit findings for rail and aviation, the parallels are striking. According to the Auditor General, both Transport Canada's rail and aviation safety programs fail in these areas: the number of inspectors and engineers needed to ensure safety is unknown; significantly fewer inspections are done than planned; the minimum acceptable level of surveillance to ensure safety is not established; and there's no documented rationale for changing the acceptable minimum level of surveillance.
Officials may try to assure you that all of these issues have been addressed, but Transport Canada's rosy forecast is based on a simple sleight of hand. Inspections, once required annually, can now be as infrequent as once every five years. That's one way to stretch your inspection resources, but does it have anything to do with safeguarding the public?
It is important to emphasize that aviation SMS is not intended to be a stand-alone buffer against safety failure, and it never was. This makes perfect sense. Redundancy is an important principle in safety; when one fails, another is in place to ensure that nothing bad happens. Yet today aviation SMS is pretty much the sole safety program, as Transport Canada has all but abandoned direct operational oversight of airlines.
Canada was among the first countries to embrace aviation SMS. In 2005 it was first introduced among the major carriers. There was no beaten path to follow, it was an experiment. As a brand new approach, Transport Canada did not anticipate the implementation of SMS would consume all its inspection resources, and then some. Something had to give and that something was direct operational oversight, which all but disappeared. We seldom, if ever, conduct no-notice inspections, ramp checks, pilot check rides, and other activities that once gave us a window into the state of safety of an airline.
Other safety concerns are being cut to this day under the weight of cumbersome SMS. For example, TC is cancelling all comprehensive SMS assessments for airports and aerodromes in favour of doing only more narrowly focused process validation inspections.
When Transport Canada tells you about the thousands of audits and inspections it's done annually, you should keep in mind three important points. First, the numbers are inflated. The Auditor General blew the whistle on Transport Canada's inspection claims with respect to rail. Transport Canada simply cannot conduct up to 30,000 inspections with only 250 front-line pilot inspectors.
Second, the audits and inspections they talk about involve nothing more than reviewing documents and telephone interviews. It's a superficial exercise that allows serious problems to go unaddressed.
Finally, TC expects to see the accident rate increase and adjusted its forecast performance targets to account for it. The increase, if it materializes, will equate to between 40 and 50 more accidents in 2014 than occurred in 2011. You'll find that at tab 3.
Just a few months ago we asked civil aviation safety inspectors about SMS, and nine in 10 aviation inspectors report that Transport Canada's SMS actually prevents them from correcting safety problems in a timely fashion. This is up from 80%, who worried that this would be the case in the early days of SMS.
Give this your serious consideration. These individuals are professionals, as noted by one of the National Airlines Council of Canada witnesses earlier this week, they care deeply about their work and the safety of the travelling public. Virtually the entire aviation inspectorate thinks SMS is better at hiding safety problems than solving them. You have the full survey report.
I want to bring your attention to two specific examples of the consequences of this reality.
Just months before a First Air jet crashed in Nunavut, a Transport Canada assessment found no problems with the airline safety management system; in fact, it was stellar. Yet, the investigation into the August 20, 2011, crash by the Transportation Safety Board discovered many safety shortcomings of the airline, which contributed to the accident, including the fact that the First Air safety management system was not working properly. Twelve people died in this controlled flight into terrain, and it could have been much worse had the accident occurred with a plane full of passengers landing at a major airport.
Today commercial operators in Canada could go for as long as five years without a single SMS assessment or program validation inspection. That's far too long, and well beyond the international requirement for annual inspections.
Transport Canada's own flight operations department is experiencing difficulties, in spite of SMS, according to documents we have acquired through an access to information request. Even with SMS implemented and the best of intentions, Transport Canada continues to fail to meet minimum safety requirements. TC has had two accidents—the last one was fatal—since implementing SMS.
Witnesses from Air Canada, WestJet, Air Transat, and the NACC testified earlier this week that the SMS partnership between industry and regulators safeguards the public. Members of the travelling public should be concerned when at least half of the partnership can't make SMS work and is crashing aircraft at a rate of every three years.
When we rely almost exclusively on superficial SMS audits and program validation inspections, safety problems get missed, with tragic consequences. Transport Canada's aviation safety program desperately needs to change.
For your consideration, we recommend the following.
Give total ownership and responsibility for SMS to the operators.
Have a concentration of SMS experts within a redesigned branch in Transport Canada available to conduct assistance visits to companies. Its mandate would be to help companies with SMS and to promote the benefits of SMS. These visits would be non-threatening, white-hat validations of assessments to assist the industry in the implementation of SMS.
For the majority of inspectors, simplify the auditing method by removing all of the SMS verification actions in favour of conducting more company visits and random no-notice inspections, including monitors, line checks, and office records checks. To improve intelligence gathering, document the results of all visits. Based on intelligence gathered over the year, return to the company to conduct an annual inspection. Using modern sampling techniques, look strictly for regulatory non-compliance in as many facets of the enterprise as time and finances will permit.
Apply enforcement action for non-compliance where the findings show that SMS wasn't followed or for a non-SMS company that did not make every effort to remedy the situation. This will entice the company to improve its SMS or to move to SMS to capture future errors. The approach uses positive reinforcement where the system worked, or negative reinforcement where the system—
I want to thank you for the opportunity to present the views of our members on transportation oversight reform. The Union of Canadian Transportation Employees is the national union for most employees at Transport Canada, the Transportation Safety Board, the Canadian Transportation Agency, the Canadian Coast Guard, and many of Canada's airports. Of the 1,350 inspectors at Transport Canada, we represent all but the pilot inspectors in the civil aviation mode.
Our relations with Transport Canada management are positive, consultative, and productive. After all, our members and Transport Canada management have the same objective: ensuring the highest level of safety for the travelling public. We hope that the committee, the minister, and Transport Canada staff know that the paper you have been provided is written with the greatest sincerity and concern for transportation safety.
I recognize that today's session is on civil aviation and as a result we will direct most of our comments to the aviation mode. However, we represent inspectors in all modes and it is necessary to put the aviation mode in the context of the multimodal reality of transportation safety oversight. The committee is directed to focus on the post-regulatory actions necessary following the tragedy at Lac-Mégantic. As a result the major focus is the transportation of dangerous goods, TDG, and the role of the safety management system, SMS, in Transport Canada safety oversight.
The minister has posed questions that form the basis of this review. With the committee's indulgence I will provide short answers to those questions since the details can be provided within our brief. Currently the transport dangerous goods directorate is separate from the other modes of transportation and we believe that TDG oversight should be reintegrated into the transportation modal oversight divisions with continued focus on direct and unannounced inspections. Responsibility should rest with one executive within each mode at Transport Canada. These changes will result in more accountability, less finger pointing, and a more efficient allocation of scarce resources.
Likewise each model directorate manages the implementation and oversight of SMS very differently. There is far too much regulatory reliance on SMS in the aviation mode, which has turned many inspectors into program auditors. This reliance is already present in other modes of transportation and unfortunately is increasing in rail safety. It is important to note that the concept of SMS is predicated on the philosophy that companies are regulatory compliant before they introduce SMS into operations. This is simply not the case for a large percentage of the companies in civil aviation. SMS needs to be an additional layer of safety. It should never be a replacement layer for direct and unannounced inspections by highly qualified inspectors with the power to impose regulations and enforce sanctions.
Where SMS is concerned, the United States takes a very different approach in comparison to Canada. It has far less reliance on SMS for regulatory oversight in all modes of transportation. It also makes a virtue out of whistle-blower protections and even provides significant financial incentives for whistle-blowers. In our view there should be an independent office of whistle-blower protections where transportation workers, both within and outside government, can report incidents without fear of reprisal. There are many positive features in the U.S. oversight system that Canada should pay attention to.
Civil aviation is an oversight division in crisis. Reliance on corporate SMS plans is creating a situation whereby the role of the inspector is to check corporate paperwork. If inspectors leave the office to do an SMS audit, also called an assessment by the department, air operators must be given notice. In some instances the minimum notice period is 10 weeks. This gives the operator more than enough time to correct whatever deficiencies might have been present at the time the SMS audit originated.
SMS audits have replaced direct and unplanned inspections as opposed to being the additional layer of safety. Inspectors believe this is a grave mistake. Giving airlines primary responsibility for safety oversight is paramount to putting the fox in charge of the henhouse.
For a long time now UCTE has gone on record stating that SMS must be an additional layer of safety and the audit or SMS assessment function should be completely separate from the direct inspection function.
Transport civil aviation inspectors are highly qualified industry specialists, many with aircraft maintenance, engineering, and other important credentials. Today, Transport Canada is mistakenly recruiting generalists for inspector positions placing emphasis on skills, such as interpersonal communications and being a team player, instead of industry qualifications, expertise, and knowledge.
Transport Canada has told me personally that they are cloning job descriptions, eliminating references to technical competencies, and pooling candidates. This fact alone demonstrates that Transport Canada has a mistaken commitment to SMS as a replacement layer for direct inspections.
Aviation TDG is another area of concern. Recently, 18 TDG inspection positions were transferred from civil aviation to the TDG directorate. TDG oversight should remain with the various transportation modes and TDG direct inspections should be harmonized with carrier-specific direct inspections.
You will see in our submission that we highlight additional principles that are important to not just civil aviation but to all modes of travel.
Ministerial delegations of oversight power should not be allowed except for select functions such as new builds and retrofits. Where delegations exist, conflict of interest rules must be put in place and enforced.
The inspector to overall staff ratio is far too low. There is no conceivable reason why inspectors should only represent 58% of the total staff complement within the Transport Canada safety and security directorate, and only 23% of the staff complement at Transport Canada itself.
The length of time to act on Transportation Safety Board recommendations is much too long. Time limits to implement recommendations should be imposed and inspectors should be a key component of all Transportation Safety Board follow-up working groups.
Safety incidents should be publicly available through a separate database for all modes of transportation.
In conclusion, many of our comments today are relevant to not only civil aviation but all modes of transportation. Direct inspections should always be the principal mode of oversight. TDG should rest with different transportation modes under an accountable executive within the department. SMS audits and regulatory inspections within each mode should be completely separate. There needs to be an independent office for whistle-blower protections.
I need to emphasize that these ideas are not my own. I am presenting the input of our Transport Canada experts, the inspectors who do the work, day in and day out. Transport Canada's primary responsibility is safety and not being a cheerleader for industry.
Thank you very much, Mr. Chairman.
Thanks, ladies and gentlemen, for being here this morning.
I hardly know where to begin in the wake of the testimony. It's frankly unbelievable. It's shocking to hear what we're hearing from front-line inspectors, from folks with 30, 40, and 50 years...with 100 years of combined experience on the front lines—former pilots—because it flies in the face of everything we've been hearing this week from the government, from the government's Transport Canada officials, and from the airlines.
Mr. Chairman, it's hard to know where to start except maybe to ask.... Maybe I'll start with Mr. Slunder.
Mr. Slunder, you were talking a moment ago about the poll, or the survey, that you conducted with your own members, with all of the inspectors. On several occasions in this committee, the government members have tried to dismiss these findings, because they have this problem with organized labour. They can't see past their bias against organized labour, which is very unfortunate, because I think that's dangerous for Canadians. For the front-line folks who are doing this work each and every day, who really care about what they're doing, and who are seized with these matters, and bringing, as you have here in all these briefs, some really positive recommendations for change, I don't know why the government is fixated on its anti-labour, anti-union ideology, but it's really dangerous for Canadians.
The minister was asked in the committee of the whole whether she had seen your survey, and she said she had not. She had not seen it. She had not read it. She was there with her deputy minister and ADMs. They had not seen it nor read it, apparently, but she went on to repeat the same claim that you have debunked here when you talk about “30,000 inspections with only 250 front-line pilot inspectors”.
Can you help us understand what would possess a minister of the crown to put out numbers that are clearly not right?
Thank you to our witnesses for appearing today.
Just for the benefit of some background for the public who are listening in, there have been substantial increases in air traffic over the last number of years, and they are forecast, of course, to continue growing at the rate of about 4% per year through 2025, according to the extent of ICAO's forecast on air traffic. Yet the number of accidents in the modern era are in fact at their lowest. I appreciate that incidents still happen. Even on the natural course of increase you would expect accidents and incidents to go up as well. That's noted in the Auditor General's report, that Transport Canada appreciates this is in fact the case and that is why we have to get this correct.
One other clarification, it almost seems from witnesses that somehow there's an implication that SMS is Transport Canada's idea. It's not Transport Canada's idea. It's ICAO's idea, and its member states are all moving towards implementation of safety management systems. We just happen to be the first and the most mature along the implementation of safety management systems. I think that has to be clear. The International Labour Organization even supports management systems where occupational health and safety are integrated into a full system.
So in principle this isn't a new idea. It may be new to implementation in the aviation sector, recent to the aviation sector. So I think just for context of our discussion, that's important.
By the way, just for clarification, to the UCTE, how many inspectors do you actually represent? That wasn't clear in your brief. Of a global number you said you represent most of them. Out of those 1,300-plus or 1,350, how many do you actually represent?