For many years the Union of Canadian Transportation Employees (UCTE) has been arguing that Transport Canada needs to be more active instead of reactive when it comes to safety inspections and their overall Safety Management System (SMS). Now, a new report from the Transportation Safety Board of Canada (TSB) into an accident in Alberta confirms that the current system is inadequate when it comes to protecting the travelling public. Here is an extract from the TSB Press Release:
“The Transportation Safety Board of Canada (TSB) investigation (A16W0092) into an occurrence where the nose wheel failed to extend on an Air Georgian flight found several maintenance-related deficiencies that went undetected by the company’s safety management system (SMS). These issues also went undetected by Transport Canada oversight activities.”
On 12 July 2016, an Air Georgian Ltd. Beechcraft 1900D turboprop aircraft was operating as Air Canada Express flight 7212 from Lethbridge, Alberta, to Calgary, Alberta, with 2 flight crew members and 15 passengers on board. When the flight crew lowered the landing gear for the approach into Calgary, they noticed that there was no gear-safe indication for the nose landing gear. The flight circled for about one hour while the flight crew attempted to fix the problem. An emergency was declared and the aircraft landed with the nose gear partially extended. There was minimal damage to the aircraft, no fire, and there were no injuries.
The investigation found that the nose landing gear did not fully extend because of a lack of lubrication to certain landing gear components. These components were not properly lubricated because maintenance personnel were not adequately trained on lubrication techniques and the use of lubrication equipment. The company’s quality control program also contributed to ineffective lubrication activities going undetected for an extended period of time prior to the occurrence.
Safety management and oversight is a TSB Watchlist issue. This investigation found that Air Georgian’s SMS was ineffective at identifying and correcting improper and unsafe practices related to nose landing gear lubrication tasks.”
The Transportation Safety Board went on to say that “If TC does not adopt a balanced approach to oversight that combines inspections for compliance with SMS audits, there is a risk that improper maintenance practices will not be identified, which may lead to incidents and accidents.”
UCTE continues to believe that there is far too much regulatory reliance on SMS which has turned many inspectors into program auditors. It is important to note that the concept of SMS is predicated on the philosophy that companies are regulatory compliant before they become SMS. This is simply not the case for a large percentage of the companies in civil aviation. In addition, while SMS is only required by regulation to be implemented at 5% of the aviation companies regulated by Transport Canada the department conducts its regulatory oversight as if all companies had an SMS.
We also believe that Transport Canada needs to combine inspections with SMS audits instead of just auditing SMS alone. The practice of allowing SMS assessments to replace direct and unannounced inspections is a grave mistake. Giving airlines primary responsibility for safety oversight will lead to more accidents and incidents like the one noted above. Once again on behalf of UCTE qualified inspectors we call for an additional layer of safety and that the audit or assessment function should be completely separate from the direct inspection.
The travelling public deserves and demands better.