BRIEF by the Honourable Virgil P. Moshansky, C.M., Q.C., F.R.A.e.S, presented at the hearings of the House of Commons Standing Committee of Transport, Infrastructure and Communities, at Ottawa, ON, on Thursday, April 6, 2017. _____________________________

[DEFCON]

The lessons the Government has never come to appreciate.

 

https://www.ourcommons.ca/Content/Committee/421/TRAN/Brief/BR8974984/br-external/MoshanskyVirgil-e.pdf

 

Madame Chair and committee members. I thank you for the invitation to appear before you. Some of you may know of me as the Commissioner of Inquiry appointed by the Government of Canada under the Inquiries Act to investigate the causes of the crash of an Air Ontario passenger jet aircraft at Dryden, Ontario, on March 10, 1989. in which 24 passengers and crew members died. As a condition of accepting appointment as Commissioner, I insisted upon and received a twofold mandate. Firstly, to inquire into the contributing factors and causes of the Dryden crash, and secondly, to make recommendations which I deemed appropriate, in the interests of aviation safety generally. This allowed me free rein to probe into and report upon safety deficiencies discovered within all aspects of the Canadian aviation system. I appeared before the Standing Committee as the sole witness at a near full day hearing on February 28, 2007, at which time I lauded Transport Canada for introducing the concept of Safety Management Systems (SMS) but warned against failure to maintain an effective Regulatory Oversight system, as is mandated by the International Civil Aviation Organization (ICAO), a specialized agency of the United Nations. ICAO promulgates Standards and Recommended Practices (SARPS) which Contracting States are bound to implement by, inter alia, the Chicago Convention. My Commission became a full-blown inquiry into every aspect of aviation safety in Canada. It took three years to complete, including two years of many 10 to 15 hour hearing days. By comparison, superior trial courts normally sit about 4.5 hours per day. Many serious ancillary aviation safety issues were examined and reported on pursuant to this wide mandate, which, for example, allowed me to conduct a major seven-month investigation in 1991 into the serious aircraft ground de-icing problems existing at Toronto’s Pearson International Airport. This resulted in precedent setting aircraft ground de-icing recommendations which have been adopted worldwide. Over 600 witnesses were interviewed and 165 were called to testify at the Dryden Inquiry, under oath and subject to cross examination, as in a court of law, many being international and Canadian aviation experts with impeccable credentials in diverse disciplines. Over 35,000 pages of evidentiary transcript and over 1400 Exhibits were considered, which produced a four volume Final report of near 2000 pages, plus two Interim Reports. While I most certainly commend this Committee for focusing its attention on an examination into aviation safety issues existing within the Canadian aviation system, I respectfully submit, ....

[Vsplat]

Amen.  Thanks for (re) surfacing this.

An expensive lesson we just seem destined to paying for again.

Vs

[Don Hudson]

The Moshansky Commission of Inquiry Report may be found & downloaded (by chapter/volume) at http://epe.lac-bac.gc.ca/100/200/301/pco-bcp/commissions-ef/moshansky1992-eng/moshansky1992-eng.htm

Cheers,

Don