What can happen when the investigative branch (in this case the TSB) doesn’t complete an investigation in a timely manner and fails to name a cause and other agencies fail to do their jobs?

Last year (I believe 2001), an amphibious boat sank in Ottawa fortunately with no passengers involved, no loss of life. This year, the very same boat carrying 12 passengers sank again and the tragic result was the deaths of 4 people- two children, their mother and an elderly woman. The passengers that died were constrained by seat belts, or a fabric canopy and therefore unable to escape when the boat sank. The TSB report on the first sinking was not complete. The boat had some work done on it, was re-inspected and cleared to operate by TC (Transport Canada). Emergency river services dismantled their diving teams several years prior to this incident due to budget restraints so many hours passed before anyone with scuba gear to dive were able to search for the victims. The system failed from the investigative branch (inconclusive report as to the cause), to the regulatory agency (total lack of regulations for the operation and inspection of such services) to the emergency services which virtually didn’t exist.

Faults cited in earlier Lady Duck sinking
POSTED AT 11:35 AM EDT Thursday, July 11

By CHRISTINE BOYD and ALLAN WOODS
Globe and Mail Update

The amphibious tour boat that sank in the Ottawa River last month, killing four people, capsized and sank a year earlier because of a faulty valve that allowed water into the hull and other problems, a Transportation Safety Board report released Thursday says.

The report found that the Lady Duck's sinking on June 30, 2001 � in which no one was injured � happened in part because drainage valves were left open, allowing water to flow into the hull.

The mechanical problems could have been avoided if the owners, Amphibus-Lady Dive Tours Inc., had created a checklist for drivers to inspect the vehicle at the start of their shifts and arranged for the Lady Duck to be inspected by Transport Canada Marine Safety before carrying passengers, the report said.

The owner, who built the Lady Duck from the chassis of a Ford F-350 truck and equipped it with both a truck engine for touring the city and a Mercruiser boat engine for going on water, had limited knowledge of marine regulations or standards, the report said.

Had the Lady Duck been tested after construction, the faulty valves and other problems with safety, pumping and firefighting equipment would have been identified, the report said.

The report also found that the company trained drivers orally, but did not give them any written inspection checklists, operating instructions or emergency procedures.

Because the company lacked a formal emergency plan, the man who was driving the Lady Duck when it began to sink was not sure whom to contact and did not that realize a 911 call would bring help from the marine rescue crews of local fire departments, the report said.

The owner also did not report the incident.

"Somebody somewhere seems to have messed up," Doug Wotherspoon, general manager of rival Ottawa tour company Canada Ducks Inc., told globeandmail.com.

The report, which is not intended to assign fault or determine civil or criminal liability, has come into the spotlight after the Lady Duck sank nose-first in the picturesque waterway between the Parliament buildings and Gatineau, Que., on June 23 this year while carrying 10 passengers and two crew.

Four people, including a nun, a mother and her two children, aged 13 and 5, got caught under the canopy of the craft and died.

After being pulled from the riverbed, the Lady Duck was transported to Transportation Safety Board examination labs at the Ottawa airport for investigation.

Transport Canada issued a letter days before the sinking telling all amphibious vehicle owners to check a faulty valve that caused the Beaver Bus, a Kingston craft made by the same manufacturers as the Lady Duck, to take on water on June 15, a week earlier.

"The investigation so far has revealed that the ... one seacock [a valve responsible for draining water from the boat] was open at the time of the occurrence. In a previous occurrence involving an amphibious vehicle manufactured by the same builder [Lady Duck], the TSB noted a similar arrangement ... did not prevent the ingress of water."

The letter concludes by asking all owners to check the valves on their vessels "to ensure that their hulls remain watertight at all times."

Jim Harris, a TSB spokesman, has said that, based on initial investigations, it is not yet clear what caused the fatal sinking in the Ottawa River last month.

"Why it sank the second time is the big question," Mr. Harris told globeandmail.com. He said several experiments are planned for later in the month to see where the boat took on water.

He said the valve at the centre of the previous investigation as well as the Kingston investigation, appeared to be properly sealed.

Transport Canada approved the Lady Duck for service in a preseason inspection on May 6.

The vessel is unique among amphibious vessels because it has only 12 seats and is below a certain nautical weight � five gross registered tons � and falls into the category of "small vessel" under the Canada Shipping Act.

The legislation permits small vessel captains to operate with only a provincial motor vehicle licence, exempts the crew from safety certification, mandates "random and planned inspections" rather than the yearly inspections required of larger vessels and does not require that the boat have a high-water bilge alarm, which would have notified the Lady Duck's captain that the vessel was taking on too much water.

Marine Investigation Report

Taking on Water and Sinking
Amphibious Vehicle Lady Duck
Ottawa River
30 June 2001

Report Number M01C0033

Summary

At about 1030 on 30 June 2001, the amphibious vehicle Lady Duck took on water while on the Ottawa River during a combined land and waterborne sightseeing tour of the National Capital Region. All eight passengers and the tour guide donned personal flotation devices and were safely transferred to a private craft and a Royal Canadian Mounted Police patrol boat that responded to an emergency message broadcast by the driver of the vehicle. The Lady Duck capsized and sank about 30 minutes later as tour company personnel attempted to drive it out of the water. No injuries or environmental damage were reported as a result of the occurrence.

Full report, including findings and contributing factors at:
Marine Investigation Report ~ Report Number M01C0033

Thanks CD, for the info on this. I read it all, but I'm not sure whether I get it or not.

It sounds like (tell me if I've got it right) the report on the first sinking was not released until after the second sinking. But, according to Jim Harris, the valve that probably caused the first sinking was properly sealed and therefore was not the cause of the second sinking???

I guess it will be interesting to see what is determined with respect to the second (fatal) incident.

Here is another article about these two incidents:

Board: Tour rules inadequate

By STEPHEN THORNE-- Associated Press

OTTAWA (CP) -- Regulations governing amphibious tour operations are inadequate to ensure the safety of passengers, the Transportation Safety Board of Canada says in a report on an accident last year.

The board is now investigating the second accident involving the same vessel, the Lady Duck. It said last year's incident, which involved no injuries, was caused by open drainage valves.

The report said valves on the converted Ford F-350 truck, designed to function as back-ups, did not work.

"The Board is concerned that the safety of Canadian waterborne passengers is ... at risk," said the report released Thursday, 18 days after the Lady Duck was swamped a second time and sank, killing four passengers.

"Current regulatory requirements (Canada Shipping Act and regulations), standards, and guidelines for ship inspectors and owners are complex and not fully compatible with each other," it said.

They "do not specifically address the unique operating characteristics of amphibious vehicles."

Investigators have already determined that the vessel's valves were closed, as ordered last year, when it went down near a dock across the Ottawa River from Parliament Hill on June 23.

Amphibious tour operations across the country were shut down temporarily after the accident while Transport Canada inspectors checked the vessels. Most have since returned to service, though the Duck's owners, Amphibus-Lady Dive Tours Inc., has not.

All passengers were safely evacuated before the Duck went down last year.

The report said grounding effects as the vessel was being driven ashore raised the right side of the partially flooded hull. Floodwater gravitated to the left.

"More water was shipped over the left side, downflooded into the hull, and caused the vehicle to suddenly capsize and sink," it said.

Because the Lady Duck is less than five gross tonnes and carries fewer than 12 passengers, it was not subject to the requirements of the Hull Construction Regulations and the Hull Inspection Regulations.

The vehicle was required to comply with some sections of the Small Vessel Regulations and the Interim Small Passenger Vessel Compliance Program, said the report.

It noted that a diagram in the National Search and Rescue (SAR) Manual indicates the National Capital Region (NCR) stretch of the Ottawa River is within the Canadian Coast Guard's area of responsibility.

"Yet no government SAR resources are located in the NCR or the adjacent area. Vessels in this area rely on two auxiliary units and on local fire and police services."

Those same services did not have the diving equipment to save the mother, her two young daughters and a nun who were trapped inside the vessel and died when it sank in 12 metres of water last month.

Tourism is a growing industry in the area, said the report.

Besides numerous pleasure craft, there are 19 tourist vessels operating, including four amphibious vehicles, "representing a significant number of waterborne passengers," it said.

"With such a number of private vessels, commercial passenger vessels, and amphibious vehicles in the Ottawa-Hull area, it is essential that effective marine SAR monitoring and response resources be available in the event of a marine emergency."

The report noted the regulator, Transport Canada, is revising the Construction Standards for Small Vessels, applicable to pleasure craft up to six metres long and non-pleasure craft up to 15 gross tonnes.

"The standards incorporate criteria for inherent buoyancy and stability for pleasure craft but not for non-pleasure craft," it said.

"Just before the publication of this report, (the regulator) indicated that owners of these vessels may not be legally required to comply with Transport Canada's Interim Small Passenger Vessel Compliance Program."

http://www.canoe.ca/CNEWS/tours_jul11-cp.html

What I don't understand is why if the TSB had discovered the cause of the first incident and the problem had been corrected, the final report wasn't released until after the second incident a year later?

quote:

---

Originally posted by Mark Fetherolf:
[qb]It sounds like (tell me if I've got it right) the report on the first sinking was not released until after the second sinking. But, according to Jim Harris, the valve that probably caused the first sinking was properly sealed and therefore was not the cause of the second sinking???[/qb]

---

Hi Mark...

You've got it right. The report on the first sinking was not released until after the second sinking. As well, the preliminary reports in the media here in Ottawa do indicate that the valve responsible for the sinking last year appeared to by closed/sealed.

About a week ago, the TSB held a press conference at the engineering lab and the TV news crews showed the vehicle. The interior has been stripped out to permit investigators access to the "hull". The spokesperson indicated that the investigators plan to take the vehicle back to the water and attempt to re-sink it to determine where the breech is.

A coroner's inquest has also been called. It is believed that the inquest, conducted by Coroner Catherine Rudel-Tessier, will be an exhaustive look at the day-to-day operations of the Lady Duck. No word on when this inquest will begin.

The following letter was published yesterday in the Globe & Mail:

~~~~~~~~~~~~~~~~~~~~~~~~~

No more lame DUKWs

By STEVE ROBILLARD
Saturday, July 13, 2002 � Print Edition, Page A14

A version of this letter has been sent to federal Transportation Minister David Collenette: The Canadian Passenger Vessel Association supports a full and thorough investigation of not just the Lady Duck accident in Ottawa last month but the whole class of vehicles that carry passengers both on land and into the water.

Further, we ask that amphibious vehicles including converted U.S. Army DUKWs, be categorized separately in all pertinent Transport Canada regulations to avoid confusion with passenger vessels that are designed and constructed only for navigation on the water.

As marine industry professionals we are concerned that these vehicles, because of their dual purpose, may be significantly compromised as marine craft and possibly as commercial road vehicles as well.

Specifically, we suggest that investigators examine the following areas:

(1) Construction standards for amphibious vehicles;
(2) Maneuverability in the water and on congested city streets;
(3) Limitation on weather and sea conditions for operations;
(4) Limitation on water depth and distance from shore for operations;
(5) Maintenance requirements for amphibian operations;
(6) Reporting requirements when on land or in the water;
(7) Co-ordination of jurisdictions between provincial transportation authorities and Transport Canada;
(8) U.S. National Transportation Safety Board investigations into DUKW accidents;
(9) Classification definition for all amphibian vehicles with respect to Transport policies and regulations.

In Canada, the passenger vessel industry operates under more rigorous regulations than domestic fleets in either the United States or the United Kingdom. However, it is evident that these standards when applied to amphibious vehicles have proven insufficient to prevent the loss experienced in Ottawa.

It does great harm to our industry to be lumped in with less than fully seaworthy craft.

president, Canadian Passenger Vessel Association

This is an interesting article that relates to this thread and also has some quotes that apply to sr111:

Families settle lawsuits
Parents of drowned kids wonder if case will make tour boats safer
By Bill Robinson / The Canadian Press

Toronto - The families of two children who drowned on a school outing when their tour boat sank have quietly settled suits stemming from the tragedy two years ago.

Wade Simmons and Henrike Foerster, both 12, died when the True North II sank in rough waters near Tobermory, Ont., in June 2000.

Their families subsequently sued Capt. Hugh Campbell and the True North charter company, the Bluewater District School Board and Transport Canada for damages in the millions.

"I can confirm unequivocally that those two pieces of litigation have been settled," said Marc Gautier, spokesman for the federal Ministry of Justice.

All parties entered into a confidentiality agreement on the terms and other details of the settlement at the request of Transport Canada, the school board and the tour boat captain.

The Simmons reached a deal about seven months ago while the Foersters settled last month.

Thirteen Grade 7 students, two teachers and two chaperones boarded the True North II after spending the night on picturesque Flowerpot Island.

Despite storm warnings, a small-craft advisory and metre-high waves, Campbell tried to make it back to Tobermory.

Noticing too late that waves had begun to flood the vessel, he made a futile attempt to return to the island.

But a large wave crashed down on the boat, ripping off the bridge door and pushing in the wheelhouse window. Water poured in through openings in the main deck, and the True North II rapidly sank just 300 metres from the shore.

An inquest into the sinking, concluded in July 2001, revealed a litany of safety violations.

For example, the boat was barely deemed to be seaworthy despite nearly 30 years of federal inspections by eight Transport Canada officials.

On July 5, 2001, Transport Minister David Collenette vowed to follow the inquest's recommendations, which included new safety regulations for small passenger vessels, in order to prevent another such tragedy.

Debbie Simmons, whose oldest child, Wade, drowned when the True North II sank, said while having the legalities over is a relief, getting on with daily life is a challenge.

"We're still coping, my two other children are coping; it's never really over," Simmons said. "I don't think we've even had a chance to grieve yet."

She said it appears the Ministry of Transport and the tour boat companies are trying to make improvements.

"But more are needed, as recent occurrences have shown," she said, referring to the sinking of the Lady Duck, an amphibious tour boat that sank in the Ottawa River on June 23, resulting in the drownings of four people, including a mother and her two children.

Simmons said the inquest and the civil suit took a toll not only on the two families but on all the people involved.

But the legal action was necessary, she said, to ensure that safety improvements are made.

"Our society dictates that you have to file suit in order for changes to be made (and) to hold these people accountable."

Patrick Murphy, lawyer for the Simmons family, wouldn't comment on the terms of the settlement because of the confidentiality agreement.

Martin Foerster, who lost his daughter Henrike in the tragedy, said now that the lawsuits are settled, he and his family will try to move on with their lives as best they can.

"I'm glad everything's over, but I'm not satisfied," he said. "When someone is dead, how can you be satisfied?"

And he said the inquest and the lawsuits haven't accomplished their goal of saving lives.

"They can make all the recommendations they want, but unless somebody is held accountable, it will happen again and again," he said. "They wanted the confidentiality agreement - not me. Look at what happened (with the Lady Duck) - History is repeating itself."

Two women from Timmins, Ont., who survived the Lady Duck tragedy, have filed a lawsuit against the boat's owners.

http://www.herald.ns.ca/stories/2002/07/31/f204.raw.html


--------------------------------------------------------------------------------

"They can make all the recommendations they want, but unless somebody is held accountable, it will happen again and again," he said. "They wanted the confidentiality agreement - not me. Look at what happened (with the Lady Duck) - History is repeating itself."

My thoughts exactly.

Bilge pumps were failing, Lady Duck report finds

Canadian Press
Thursday, September 19, 2002 � Print Edition, Page A7

OTTAWA -- The Lady Duck was having problems with its bilge-pumping system when the amphibious vessel sank during a tour of the Ottawa River in June, killing four passengers, the Transportation Safety Board reports.

"The investigation has revealed that not all the bilge pumps were fully operational and that there was inadequate maintenance of the bilge system components," Fred Perkins, the safety board's director of marine investigations, stated in a safety advisory.

Moreover, the captain could not properly monitor the pumps due to the construction of the vehicle and the location of the pumps, he said.

A Montreal women, her two children and a nun from St-Hyacinthe, Que., drowned when the Lady Duck sank on June 23. The Lady Duck, a converted Ford F-350 truck that can travel on water and land, also took in water on June 30, 2001, after the bilge valves were left open during a trip on the Ottawa River.

Transport Canada recently issued a ship-safety bulletin reminding operators of the importance of bilge-pumping systems and early detection of leakage in small vessels.

The Lady Duck was relaunched yesterday at a Gatineau quarry for a series of simulation tests, which had been scheduled for July but were postponed due to bad weather. The boat was lowered into the water with a crane and allowed to float for 45 minutes, the same amount of time it was on the river before it sank in eight metres of water.

Based on the results, recommendations will be made to the federal government about new safety standards for amphibious vehicles.

Yes, very tragic. What disturbes me even more is that Transport Canada would certify this contraption. This was not a boat. It was a converted Ford F350 pickup truck. In Halifax, there is the Harbour Hopper. This is a real, honest to goodness amphious vehicle, and is certified with a yearly inspection performed by the Coast Guard. I don't know how the hell this thing ever got into the water. What scares me more, is that this was the second accident. How many do we need before we say no more..??

beanspiller

Hi beanspiller...

Unfortunately, "honest to goodness amphibious vehicles" are not immune from sinking either:

Marine Accident Report
Sinking of the Amphibious Passenger
Vehicle Miss Majestic, Lake Hamilton,
Near Hot Springs, Arkansas, May 1, 1999
NTSB Number NTSB/MAR0201

Executive Summary: On May 1, 1999, the amphibious passenger vehicle Miss Majestic, with an operator and 20 passengers on board, entered Lake Hamilton near Hot Springs, Arkansas, on a regular excursion tour. About 7 minutes after entering the water, the vehicle listed to port and rapidly sank by the stern in 60 feet of water. One passenger escaped before the vehicle submerged but the remaining passengers and the operator were trapped by the vehicle�s canopy roof and drawn under water. During the vehicle�s descent to the bottom of the lake, 6 passengers and the operator were able to escape and, upon their reaching the water�s surface, were rescued by pleasure boaters in the area. The remaining 13 passengers, including 3 children, lost their lives. The vehicle damage was estimated at $100,000.

The Safety Board�s investigation of this accident identified the following major safety issues:

* Vehicle maintenance,
* Coast Guard inspections of the Miss Majestic,
* Coast Guard inspection guidance,
* Reserve buoyancy, and
* Survivability.

The National Transportation Safety Board determines that the probable cause of the uncontrolled flooding and sinking of the Miss Majestic was the failure of Land and Lakes Tours, Inc., to adequately repair and maintain the DUKW. Contributing to the sinking was a flaw in the design of DUKWs as converted for passenger service, that is, the lack of adequate reserve buoyancy that would have allowed the vehicle to remain afloat in a flooded condition. Contributing to the unsafe condition of the Miss Majestic was the lack of adequate oversight by the Coast Guard. Contributing to the high loss of life was a continuous canopy roof that entrapped passengers within the sinking vehicle.

NTSB Marine Accident Report - Sinking of the Amphibious Passenger Vehicle Miss Majestic

Regarding the Lady Duck, the TSB report into the first sinking contains information on the vehicle licensing and inspection and states, in part, that:

"As an amphibious vehicle of less than 5 in GT carrying not more than 12 passengers, the Lady Duck is not subject to compliance with the Hull Construction Regulations or the Hull Inspection Regulations made pursuant to the Canada Shipping Act.

The Lady Duck is an amphibious passenger vehicle with a valid provincial automobile licence for highway operation and is explicitly excluded from the marine licensing requirements of Part I of the Small Vessel Regulations (SVR).

Marine Investigation Report - Taking on Water and Sinking Amphibious Vehicle Lady Duck, Ottawa River, 30 June 2001 - Report Number M01C0033

Rather then blame TC, though IMO all these agencies have a huge responsibility to do a far better job than they are presently doing,(because lives depend on it), I think we should look more towards individual responsibility. The reason I believe that is that it really isn't practical for a government agency to keep up with all these modes of transportation whether it be a large jet or a small boat to the degree it is necessary to keep people safe. In the case of these vessels (not sure if that's what one should call a ford truck used for water transport) I think we should hold the operator of said vehicle responsible as they are the ones who are earning the income and should be concerned about their reputation to the public that they are accountable for. A little integrity wouldn't hurt either. If the boat operator, or the airline CEO, is aware that there are hazards on their particular type of craft, and they fail to do the necessary repairs or alterations and human beings are harmed or killed while using their mode of transportation, the best deterrents, in my mind, are criminal charges which would discourage other operators from ignoring same. There will always be individuals, whether it be a small boat operator who ignores a repair or an airline who insists on installing an entertainment system that is so powerful it causes a fire and the deaths of 229 people for the purpose of making a profit and I doubt any agency can totally prevent that from happening. Few of us would argue that a drunk driver when he gets in a car, and kills someone that happens to cross his path shouldn’t be charged criminally for causing death or harm and yet we, as a society, continually allow the transport industry to literally get away with murder. Let’s start holding accountable those that don’t maintain their mode of transport. I can’t think of a better way of getting the message out there that it isn’t ok to have callous disregard for human life then to start putting those individuals who knowingly don’t do the right thing, in jail. In the case of Swissair for example, they knowingly kept operating the IFEN despite reports of system failures that were causing blackouts and the overheating of their aircraft and yet failed to take action against it. Let’s stop blaming the ‘cops’ and go after the criminals.

*Do want to add a disclaimer- I do not know enough about the particular boating incidents we are discussing to say whether the operators of these boats knew whether they had problems prior to the tragic events that ensued.

Having said that I want to apologize Beanspiller if it appeared that I opposed your comment because that was not my intention. I too am surprised that they would certify that thing as worthy of being on the water. It was involved in two incidents, the second one having resulted in tragedy and that is inexcusable.

Chris thanks for the information.

Barbara

quote:

---

Originally posted by BF:
[qb]...I think we should look more towards individual responsibility...[/qb]

---

Hi Barbara...

In Canada, there are proposed amendments to our Aeronautics Act and Regulations that are intended to do just that.

Originally, the proposals to amend the Aeronautics Act contained the following:

It is proposed that the Act be amended to make persons (individuals and corporations) liable for offences committed by their employees and agents, acting in the course of their employment or within the scope of their authority, unless they can establish that the offence was committed without their knowledge or consent and that all due diligence was exercised to prevent its commission.

It is proposed that the Act be amended to make directors, officers and agents of a corporation liable for offences committed by the corporation, where those directors and officers directed, authorized, assented to, acquiesced in or participated in the commission of the offence.

It is proposed that the Act be amended to make "accountable executives" that are required to be nominated by regulations made under the Act, liable for offences committed by the corporation, organization or undertaking they represent, unless they can establish that the offence was committed without their knowledge or consent and that all due diligence was exercised to prevent its commission.

Proposals to amend the Aeronautics Act - Enforcement

I see that these original proposals have been changed somewhat to the following:

It is proposed that the Act be amended to make "accountable executives" that are required to be nominated by regulations made under the Act, jointly responsible for offences committed by the corporation, organization or undertaking they represent, but only to the extent that the offences relate to the establishment and maintenance of management systems that are prescribed by regulation.

Revised and Consolidated Summary of Proposals

I believe that this change has come about due to the introduction of Safety Management Systems (SMS) into our Regulatory structure. SMS, in a broad sense, is intended to bring together all of the existing safety-related programs in a company (flight safety, maintenance, occupational health & safety) into one all-encompassing management system with a clearly identified accountable executive. One of the fundamental changes with the introduction of SMS are the changing roles and accountability of management and the regulator.

Here are two additional links relating to the introduction of SMS in Canada:

Some Features of Safety Management Systems

Safety Management Systems for Flight Operations and Aircraft Maintenance Organizations

The first batch of amendments to our Regulations introducing SMS were presented in March, 2001:

Commercial Air Service Operations - NPAs relating to Safety Management Systems

Christopher, Thanks very much for that information. It's good to see that people are finally seeing how important it is to make those accountable that endanger the public's lives. Let's hope that these kind of acts are enacted in other countries as well. I can't see a better case for it's use than sr111 and the IFEN. Those involved in the design and installation of this so-called 'entertainment system' in my mind are nothing but common criminals. There is no way I will ever believe that they didn't realize that what they were installing went against simple rules of good wiring practices. I believe they knew that the MD-11 wasn't able to support this powerful system but pressures from swissair (they wanted their toy- safety be damned)and their own managers caused them to do the wrong thing. If only one person had had the integrity to speak out this site wouldn't exist today. Why is it that at least to my knowledge Hollingsead's role as the installers never has been questioned and brought to light? Pretty strange if you ask me. Anyone that would install something like this on a jet carrying large groups of people clearly doesn't belong in this business. Furthermore it has become obvious that the airline itself knew it was dangerous- causing blackouts as well as making it necessary due to it's huge power usage to adjust cabin temperatures from the heat it generated. It was even reported a while ago by a reporter that one of the seats may have caught fire prior to the crash of sr111. It's absolutely disgraceful. Just think of this- those involved are still around and they obviously have no integrity whatsoever and maybe we should be concerned that some of them are still in the aviation business. I think that if they haven't already done so, the US and Switzerland should do serious inquiries into sr111. Despite Bouchard's words that most people in the aviation business are good and do the right thing, it is glaringly obvious that sr111 is the exception.

The proposed amendment to the Aeronautic Act referred to by CD has perhaps a more chequered past than evident from the bare facts presented in this forum, unfortunately.

During the consultation phase, ATAC and the Airlines in particular, objected to the accountable executive principle most emphatically. 'Vicarious liability' became the rallying cry - and despite the determination of some senior TC officials, I see that the lobbying to remove the accountability has been successful.

Think about it - on the pretext of being held liable for something that they might not have been able to actually know first hand, the senior executives were able to dodge the bullet and now are only responsible for setting up a management system that should prevent accidents from happening.

Now, as an exercise for the reader, I would like to suggest attention be directed towards the hypothetical scenario outlined in Mark Fetherolf's post in 'A Brave Person Has Finally Spoken Re:sr111'on this board. As the scenario is reasonably possible, I wonder whether - an accountable executive in the hypothetical company could be found. No, I suspect that the required data management systems would all be in place. And despite the fairly clear liability of the senior executives in at least creating the atmosphere where despite reservations, most employees would have to conform , look the other way, or resign - the newly created SMS will have been completely unable to prevent a fairly predictable root cause.

We had the opportunity, but not the determination.