The Boeing 737 Max 8 crashes—Lion Air in Indonesia in October 2018 and five months later, Ethiopian Airlines in Addis Ababa —killed 346 including 18 Canadians. Comparisons with the July 6, 2013 Lac-Mégantic oil train disaster reveal a predictable pattern.
In both cases, lower-level regulatory staff opposed regulatory outsourcing measures, warning against “the fox guarding the hen house.” They were ignored or reprimanded for speaking out.
With Canadian railways, the implementation of a safety oversight regime, called safety management systems or SMS, sealed the transition to company self-regulation. And this at a time of looming danger posed by the exponential increase in the transportation of oil by rail. There were multiple critical evaluations of the system including by the Auditor General of Canada, which concluded in a 2013 report: “The Department’s level of oversight was not sufficient to obtain assurance that federal railways have implemented adequate and effective safety management systems.”
In both Canada and the US, regulatory agencies experienced major budget cuts, layoffs and an exodus of trained personnel, eroding their ability to do independent evaluations of company practices.
In both the railway and aerospace industries, safety was increasingly subordinated to shareholder value as Wall Street investment funds—focused on short-term returns—came to dominate corporate decision-making. With Boeing, this was aggravated by competition pressure from Airbus.
Both the Canadian and US governments implemented “red tape reduction” regulatory policies, which force regulatory agencies to offset each proposed new regulation by removing one [two in the US] or more existing regulations which constitute a cost to business— further sidelining safety.
The primary cause of the Boeing crashes was faulty stall prevention software and malfunctioning sensors. The 737 Max 8 pilots’ manual contained no information regarding its new software. This was done to convey [falsely as it turned out] that airlines did not have to engage in costly pilot training with the Max 8. Nevertheless, the Federal Aviation Administration [FAA] allowed Boeing to self-certify its aircraft. Within Boeing, engineers criticized the software whose development had been off-shored to inexperienced low-wage designers. In the words of one Boeing engineer, the 737 Max 8 was, “designed by clowns and supervised by monkeys.”
In Lac-Mégantic, following a railway-drafted loophole in the operating rules, the regulator granted permission to Montréal Maine and Atlantic—a company obsessed with cost-cutting with an appalling safety record—to operate its massive oil trains with a single crewmember. It was granted, and aggressively supported by the railway lobby over opposition within the Transport Canada, including the inspectors’ union. Furthermore, the regulator ignored warnings of its own commissioned National Research Council report stressing the need for numerous safety precautions before allowing single person crews. Canadian Pacific, which was contracted to haul the volatile cargo to the Irving oil refinery, chose to subcontract with this dangerously unsafe company, whose line ran through Lac-Mégantic, rather than choosing a safer but less profitable route in conjunction with Canadian National.
In the aftermath of both disasters, industry executives blamed the pilots and the locomotive engineer. In both cases, the decks were stacked so heavily against these employees, catastrophe was a foregone conclusion.
Canada and the US were the last countries to ground the Boeing 737 Max. In the US a criminal investigation of the FAA is underway. A Congressional investigation into the crashes is also ongoing.
Despite urgings from the victims’ families, Canada has thus far declined to hold an independent public inquiry into the Boeing crashes. Transport Canada was obligated to double check the US certification of the aircraft. Did it exercise due diligence, or did it simply rubberstamp the FAA certification? Why was it not given information regarding the existence of the stall prevention software system on the Max 8? Why was it not provided the risk analysis done by the US Department of Transport experts which determined that the Max 8 had a vastly greater likelihood of crashing than other aircraft?
In Canada, criminal charges were laid against three front-line railway workers; they were subsequently acquitted. No company executives or owners were charged, despite substantial evidence of corporate criminality. No senior government officials or politicians have been held responsible.
Two parliamentary investigations into the Lac-Mégantic disaster had limited mandates. The Transportation Safety Board investigation left many unanswered questions, foremost among them: Why did the final report erase six causes in the original investigation team report related to the decision to allow this delinquent company to operate with a single person crew? The Harper Conservative, and more recently the Trudeau government, have repeatedly refused to hold an independent judicial inquiry into the tragedy.
Responding to the shooting down of the Ukraine Airlines plane in Iran, which claimed the lives of 57 Canadian citizens, Prime Minister Trudeau rightly stated: “The families of the victims want answers. I want answers. That means closure, transparency, accountability, and justice. We will not rest until we get that.”
The 737 Max 8 victims’ families also deserve justice. The Lac-Mégantic victims’ families are still waiting for justice going on seven years after the tragedy.
The pattern of corporate negligence and regulatory failure that that produced these disasters is clear. Repeating the promise, “safety is my number one priority,” unless it is accompanied by concrete government actions that align with this promise, makes recurrence of the pattern a certainty.
Bruce Campbell is adjunct professor with York University’s Faculty of Environmental Studies, former executive director of the Canadian Centre for Policy Alternatives, and author of The Lac-Mégantic Rail Disaster: Public Betrayal, Justice Denied (James Lorimer & Co). This column first appeared on the National Newswatch website on January 28.