The Fly in the Ointment - Martin Doyle
The following is submitted by Martin Doyle, one of our Board Members. If you have any comments please click this link!
The Fly in the Ointment
I recently attended a Transport Canada approved Canadian Air Regulations (CARS) and a Safety Management Systems (SMS) course. May I say, at the outset, I appreciate the fact policy makers too, have family members that fly. However, there is, from my perspective ‘ a fly in the ointment’ in the CARS and SMS for the flying public - particularly dealing with some general aviation operators. Some in the know, might even call it a ‘hornet in the ointment’. I understand the CAR’s have no means of empowering responsible competent Aircraft Maintenance Engineers (AME’s) to remove an aircraft from public service - knowing it does not conform to the standards consistent with the issue of its Type Certificate. From the a/m courses, it’s apparent any decision to use (or not use) an aircraft ‘ beyond’ its Type Certificate approval , is now the prerogative of the Accountable Executive(AE) - by way of the CAR’s and implementation of the SMS. The problem, as I see it is ; “ There are no qualification requirements to become an AE”! (CANADIAN AVIATION SAFETY MANAGEMENT , DAVE DUECK CHAPTER A.5-3 line 16 The CAR’s, combined with the SMS ideal create a disturbing parallel to the conditions of Aviation in Northwestern Ontario ( NWO) prior to the ‘accident that was allowed to happen” (Moshanski Inquiry into the 1989 Air Ontario crash in Dryden Ontario) In other words, I respectfully submit, there was little or no regulatory presence in NWO when that crash killed 24 people from Thunder Bay. May I suggest there are also similarities in this ’ CAR’s SMS’ philosophy in remembering NASA’s ‘CHALLENGER’ disaster when engineers were being exhorted to “take off their engineers hat and put on their management hat” in making the decision to launch. We’re all aware of the differences and results of that thinking! Having regard to the foregoing, I disseminate the following which is a Chapter excerpt from a book I am in the process of writing. The quotes are accurate from daily ruminations for over 30 years. Although the Accountable Executive position was not ‘formally’ identified or ‘approved’ in 1981, as it now is, I humbly submit my perspective regarding what may be a flaw in this new CAR’s/SMS ideal.
(I attach correspondence prior to the DRYDEN disaster substantiating my viewpoint)
CHAPTER 3 A FORK IN THE ROAD
“I’m going to increase your wages another $200.00 a month”. I thought, man, this is a great way to a relationship with this new ‘Accountable Executive’.(ACE) The raise was not requested or expected and with my three young children, a wife, mortgage payments and all the other stuff that goes with a young family, this was good news. He also promoted Glen Watty to Chief Engineer in Thunder Bay who was also pleased with his raise and new status. From a livelihood perspective, things looked great late in the fall of 1979! The great tragedy in our lives at that time was my mother was diagnosed with terminal stomach cancer. I was grateful to the company and co-workers for the support and sympathies extended to me and my family during this extremely sad event. My mother passed away New Year’s day 1980 . The ACE often took his lunch with us in the early part of his management style and initially we welcomed it. He spent a lot of time on the hangar floor , watching, questioning and critiquing. He told me specifically that, unlike the previous owner, we were going to “make money”! I enthusiastically supported this objective! We had company picnics, baseball games, hockey games, and often got together socially. The spring of 1980 Glen and I were sent to Peterborough to do an acceptance on a Saunders ( ST-27) the company was going to lease. I warned the ACE this was not a good choice of aircraft as parts and product support were not that easy to come by for this 20 passenger airplane. Once the airplane was ready in Peterborough, Glen went back to Thunder Bay with Air Canada and it was agreed I would fly back on the ST-27. I can’t remember the name of the pilot who was to ferry it from Peterborough to Toronto but he sure created a memory. During the take-off run we got up to about 70 knots when he decided to abort, mistakenly thinking an external control lock had been left on; although these aircraft were not fitted for such devices. The braking and reverse thrust was vigorously applied. This machine used compressed air to inflate rubber bladders which caused the brake pads to contact the brake drums creating friction . We both pulled hard on the power levers toward reverse thrust, but unlike the PT- 6 engines on a Twin Otter, this machine was rigged so there was very little torque generated. Only a few degrees of negative pitch on the prop blades was achieved and very little engine acceleration. As the end of the runway came up, the air supply to the brakes had been depleted and the Aircraft finally stopped with the nose wheel in the grass at the end of the paved runway. We had to hold the power levers in full reverse until the compressors build up enough pressure for the brakes to function again. Whew! Luckily we only had about 1000 pounds of fuel and the airplane was empty, otherwise the outcome would have been quite different. We eventually got to Toronto without further incident and I flew back to Thunder Bay with a more experienced pilot, Jamie Biggs. Back in Thunder Bay I did my best to rig the PT-6 engines to achieve more reverse thrust although there were no specs or Maintenance Manual directives to do so. With my ‘Peterborough experience’ I was worried there could be an incident or accident if a pilot tried to abort a take-off fully loaded. The Saunders operated out of Sioux Lookout and would occasionally come to Thunder Bay for maintenance since Dave Fiorito, Glen and I were the only qualified AME’s to perform and certify maintenance on this machine. My concern about parts availability were becoming a reality. The tires were so worn the breaker cords were clearly in view around the entire circumference of both main wheels leaving them susceptible to puncture or blow out. Definitely not something anyone would want happening to a tire at takeoff rotation or worse, while retracted in a wheel well. We found out that particular concern was negated during the week the aircraft was being used for continued revenue service with the undercarriage left down since the ‘up selection ’ air lines were leaking so bad the ‘Gear’ could not be retracted! I have never seen tires in this condition used on cars or trucks. We were able to locate two tires before dispatching the Aircraft and fix the ‘up selection ‘ air leaks . Another time when it came to Thunder Bay we discovered the main Cornelius Compressor was seized due to oil starvation. Nevertheless they continually used the Aircraft with only the standby compressor functioning. These compressors also supplied air to the flaps and as mentioned, the brake systems. To continually use the aircraft with only one compressor would not be approved in any Minimum Equipment List (MEL) that I was aware of. We AME’s were getting concerned and wanted to back away from the standards we were beginning to witness . That fall we witnessed the greatest indiscretion to date. Glen almost ran towards me as I entered the hangar. “They’re going to use the Navajo for a medevac!” I was stunned . Three days earlier we had discovered a problem as the result of a new pilot, Brad Martin, complaining about a significant oil leak coming from the right engine. “They can’t use it , it’s got that cracked crankcase!” As I made my way into the hangar I seen the young pilot, Arnie Dusang, with a forlorn unhappy demeanor getting into the airplane. The ACE was standing beside the Piper Navajo . “You can’t use this aircraft; the right engine has a cracked crankcase!” I exclaimed. The ACE and I initially had a good relationship. He had spent time at our home and we socialized together. He was always there for company baseball and hockey games . “Yes we are” he countered,” we got a medevac and we’re going to use it.” For a moment I was speechless as I frantically searched my mind to explain the seriousness of this situation. It came to me, “ Would you put your kids in the family car and drive from here to Winnipeg in the middle of winter with a cracked block?” As he pondered the metaphor, he started to walk away. Thankfully, I thought I had convinced him. Then he turned and said, ” We’ve got experience flying these airplanes with these cracked crankcases. We’re going to use it!” He kept walking. My mouth was open but nothing was coming out. 30 years later I still ruminate over that particular incredulous comment, but more were to come. The medevac was completed with no event . But I knew from my Navy background an aircraft would never be launched off the Aircraft Carrier HMCS Bonaventure with this defect ! With my several years working in the Northwest Territories, one would not be dispatched from Yellowknife to a remote settlement with this problem; medevac or not. This was an unforgiving place for the reckless and to use an engine with a defect like this would be unthinkable with my previous company, Pacific Western Airlines (PWA). Glen phoned Avco Lycoming, the engine manufacturer about the issue. After hanging up, he said Lycoming’s tech rep confirmed that they had previous issues with this particular crankcase problem and recommended the airplane be grounded. Glen asserted “ Nobody here is going to sign out that airplane”! . . . as if we needed to be told. The young pilots, mostly graduates from Confederation College were grateful for our stand. However, it became a collaborated issue with the ACE and Carl Wood, the Chief Engineer with the parent company in Sioux Lookout . Without so much as inspecting the crack, Carl made an entry in the Aircraft Journey Logbook stating, “Hairline crack discovered on the right engine crank case. To be checked every 10 hours. Aircraft is ok for service.” After reading it, we were incredulous. Up until that point the whole purpose of this career had been to correct these serious deficiencies. Now it seemed we were expected to endorse them. The world was being turned upside down and the confusion was surreal. In hindsight, I can only surmise Carl made this entry under duress. With that ‘release to service ‘ entry in the logbook, the onus was on the pilots to fly it or be replaced. Ironically we Engineers were relieved at this logbook entry. Dave Fiorito, sardonically exclaimed , ” Boy, when Transport Canada sees that entry there’s gonna be hell to pay.” In our collective and profound naivety about what was going on with the local authorities our hopes to get out of this quandary proved groundless. There were no authorities! In the meantime, the company continued to use the aircraft for a variety of revenue charters while we lived in fear of becoming testifying witnesses to an airborne fire at worst, or an engine failure at best. With glowing red hot turbocharged exhaust manifolds inches away from the oil leak, this was an absolutely perverse situation for all of us. Sure; one can find comfort in realising twin engine airplanes are designed to fly on one engine. But shut down the ‘good’ engine and feel that comfort fade as power is added to that fractured crankcase. These are things that AME’s are aware of. Finally, we decided to have a meeting with the Accountable Executive about our concerns. Glen and the rest of the maintenance staff requested I be the spokesman since I still had a good relationship with this new owner from Bearskin Airlines, and I was the most experienced AME. Since the faulty engine was the central issue, I opened the meeting and flat out stated.” We can’t conciensously work to two different standards.” The comment was more of a plea in the interests of all of us,( including him). It was not aggressive, but simply offered to alert him that this crankcase issue was way beyond the bounds of normalcy in this business and we were very worried. My intent was to simply enlighten him. The “two different standards” was an implied reference to all the aircraft in our care, prior to the ACE buying the company several months earlier. There was no mistaking his clear, blunt answer as he looked over his shoulder as he turned to leave the office . “ Well Marty, nobodies indispensable!” It was just as well he left since there was no forthcoming answer to this stunning threat. We all just stood there for a moment in awkward silence as we uneasily looked at each other, then went our separate ways. Nobody likes to be evaluated as “dispensable, ” but this comment, under the circumstances was staggering. After over 17 years in the business I could not fathom the concept of being threatened with dismissal for keeping airplanes fit for flight. That was the ACE’s first insertion of intimidating poison in that milieu. Confusion gripped us . I tried to distance myself from what was going on with this company but only with limited success. Several months after that first threat, I found myself in his upstairs office. He must have sensed the pronounced shift in our attitude since that meeting advising us of our “dispensability” . He opened the conversation and said. “ Bearskin would never do anything to compromise safety and we have a good reputation . . .” I knew where he was going and interrupted him . This issue was clearly still in the minds of everyone. “ You can talk to me for a hundred years but you’ll never convince me it’s OK to knowingly and continually fly an airplane with an engine with a cracked crankcase!” , I went on; “ As I’ve told you before, it’s impossible to work to two different sets of standards.” Again, in a tone of pleading ; in the interests of everyone ,again including him. It was his turn. “ And I’ve told you before, nobodies indispensable!” The issue was clearly escalating and coming to a head as this second, painful shot of poison was inserted. As fate would have it, the moment was broken when I was told my wife Lorraine was on the phone and she had an emergency. She was obviously scared and excitedly said my father was showing the symptoms of a stroke. I assured her and immediately made arrangements for a friend of mine, Norman Gibbs, an Ontario Provincial Policeman to get help. He knew where we lived and made arrangements for help. I hurriedly left the ACE’s office and made my way to the hospital where I was to meet Lorraine and Dad. Thankfully my father made a complete recovery. The next day I advised Glen about the difficult conversation with the ACE the prior evening. Glen just glanced at me, looked to the floor and timidly said, “Well, he’s the guy that signs the paychecks.” Clearly, Glen did not wish to be considered “dispensable. ” A few weeks later he asked me if I would like to take over the Chief Engineer’s position. I declined – not because I couldn’t do the job – but I believed Glen would overcome his fear of being considered “dispensable” if he stood his ground. But we did the best we could under these very troubling circumstances . In August of 1981 Glen asked me to supervise the maintenance functions while he took a brief holiday. There really was no one else so I acquiesced to his request. That week Bearskin had a leased DC-3 brought in to the hangar for a 100 hour inspection and it was to be released within two days - normally enough time for a routine inspection. Dave Fiorito had an endorsement on the machine so he and a Confederation College graduate, Bernie Adamache performed the inspection. Since this left us shorthanded with Glen on holidays I was doing extra duty on the other matters. After the inspection was completed the DC-3 was taken out for a run up to check for leaks and other tests as a normal function after a check. During the run the right engine displayed a pronounced backfiring. Of course it was suspected something had been inadvertently done during maintenance to cause this problem but nothing could be determined. The pilot, Trevor Northcott was adamant there was nothing wrong with the engine and was frustrated at the delay. The oddness of the mechanical problem was difficult to troubleshoot and an opinion from Ashok Patel the chief engineer of Superior Airways, a regular operator of DC-3’s ,claimed , “Those engines all run like that when their cold”. Dave and I knew different! After long and painstaking troubleshooting, it was discovered an upper cylinder exhaust rocker shaft was so worn, that particular cylinders exhaust valve was not opening and that was the cause of the problem. This was a difficult find, and as far as I was concerned, Dave and Bernie had done a very good job. The Accountable Executive wasn’t impressed. The airplane had left two days behind their schedule and he called me into the office. “ The maintenance department here is not very productive”! he lamented. This was clearly in reference to the late departure of the DC-3. “No!” I countered, “This department is very productive! Dave and Bernie should be commended for finding that problem here rather than going to Pickle Lake or somewhere else up north to change that complete cylinder or maybe an engine”. Again, he had no respect , value or understanding whatsoever for what I had just said. I repeated, this time with some force, “ I’ve told you before, we cannot work to two different sets of standards!” He looked up. “And I’ve told you before, nobodies indispensable”! Frustrated, I left his office . Two weeks later he, with Glen in tow, followed me into the maintenance office as I was about to start my evening shift . He handed me a letter and said “ I’m going to lay you off”. I glanced at the note and immediately recalled all the “Nobodies indispensable” threats. After all the attempted intimidation, harassment , bullying, frustration, and worry, the troubling feeling of helplessness for the prior year; my anger towered beyond control. Stunned, I spit out the words! “This is not a layoff”! As I approached him I threw the ‘layoff’ notice to the floor and looked him right in the eye. “ It’s a firing and it goes right back to my stand against flying that aircraft with a cracked crankcase !” I went on; my fury mounting as I furiously stabbed him in the chest with my forefinger. ” You’re gonna kill somebody and when you do, I’m going to be there!” I absolutely believed it was just a matter of time for an “accident” as he was now clearly calling the shots in the aircraft maintenance department. “ You are nothing more than a pimp, and I refused to be your whore!” Poor Glen was standing silently in the shadow of the “guy that signs the paychecks” with that hangdog look. Obviously, he still didn’t want to be considered “dispensable”. I don’t blame him. He too was caught between a ‘rock and a hard place’ and I’m sure he was wishing he was someplace else. I think they both knew the ACE had made a mistake his ego and ignorance were not able to back away from. They shuffled out the office door without looking back. I stood there, alone, livid with this horrific betrayal; not just to me personally , but more troubling, a discarding to what had been my livelihood. I was to learn , in hindsight; if ever there was a justification for the cause of true trade unionism, this was it! The ACE exercised his option of forgetting and denying these past events. I don’t ! And so, I left, knowing the maintenance standard was now under the complete control of an individual with an unrestricted mandate to “make money” ; absolutely no experience or background in the aviation industry; and a remaining maintenance staff who, I’m sure, did not want to be thought of as “dispensable”! For the next several weeks I was somewhere between panic and heartbreak over what had happened . Thankfully, my brother-in law got me a temporary job at an aggregate plant in the community while I began to embark on a life changing journey to correct this horrific event in our lives. I wrote to the Transport Canada officials in Winnipeg, and a Member of the Provincial Parliament expressing my concerns over the conditions this company was practicing with regards to Aircraft integrities . I believed the reality of a fatal accident was high. Eventually I received a copy of a letter by the incumbent Minister of Transport, Jean Luc Pepin. Transport Canada could find no justification to my concerns and I could only classify their reaction as a ‘whitewashing’. With my firsthand knowledge, and after reading sections of The Commission of Inquiry into Aviation Safety in early 1983, (over a year after the wrongful dismissal) and Chaired by the late Mr. Justice Charles Dubin, I realized what a difficult hornets nest I had been buried with. Justice Dubin revealed: “Transport Canada’s regulatory and enforcement attempts are viewed with considerable contempt and distain as being a joke”, and further, “Aviation in some areas of Northwest Ontario appeared to be in a state of anarchy”. ( Vol. II pgs. 341-363) Logbook falsification, flying unsafe aircraft, and employee intimidation were a common practice. Fabricated ‘lay-offs’ were also used among certain operators towards employees expressing safety concerns. My former employer was specifically mentioned and had “ guaranteed “ Transport Canada in 1979 they would stop these practices if they would be permitted to keep their operating certificate! With tongue in cheek, I say, unless that was a limited time guarantee, it occurred to me it made much more sense to simply discard me than deal with the ramifications and difficulty of revisiting that so-called “ guarantee”. Being buried and being dead are two different things. I was faced with: accepting the regional employment standards the ACE had established with Transport Canada’s awareness ( collateral with Labour Canada’s third rejection of my wrongful dismissal grievance.) In an attempt to right this wrong, I embarked down a “road less taken” and discovered, as a ‘layman’, a life changing adventure . Thunder Bay was my home and I refused to buy into this local “anarchy.” In the course of the Wrongful Dismissal and Punitive Damages lawsuit I was eventually obliged to file, (at Labour Canada’s suggestion) the ACE stated his recent entry into the industry in 1979 was the result of buying shares in the company from his brother, who then made him president of the defendant company . When asked if he had any technical expertise he testified under oath during ‘discoveries’ : “No I am not an engineer. I am not licensed. I am not qualified as an engineer nor am I licensed or qualified as a pilot. My basic experience is management.” He further confirmed, “I have taken a pilot’s training course that I never completed. I have no desire to fly. I have taken courses related to management and management, basically, whether it is aviation or any other industry that you may want to be involved in, is the same.”
TO BE CONTINUED . . . .
Although many other relevant truths were deflected and denied, the Defendant ‘AE’ eventually acquiesced, to both the claim for Wrongful Dismissal and the Punitive Damages. This occurred a year after a Pretrial on December 7th 1985, in Thunder Bay, in which Mr. Justice John Wright validated the Punitive Damages claim: cognizant of what an AME was; that we were sometimes caught between a rock and a hard place; the wellbeing of the flying public, and his personal awareness of the’ Dubin’ Report. My concern is the CARS now ignore the worth of any qualifications on the part of an ignorant Accountable Executive in a Safety Management System. And so, I offer these circumstances to reveal, in my humble opinion , the “fly in the ointment” with reference to the new CARS, the SMS, and the empowering prerogatives of the Accountable Executive. I submit ignorance, profit, intimidation and regulatory ‘deferral’ were the main features in Northwestern Ontario prior to the “accident that was allowed to happen”. I fear these shadowy factors have now been unleashed on the rest of the country with the new CAR’s and SMS in the naïve, costly and deadly belief economics trumps physics .
Martin J. Doyle