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Section 2: Analysis of Program Activities

2.1 Strategic Outcome

The mitigation of risks to the safety of the transportation system through independent accident investigations.

2.2 Program Activities

The TSB has four key program activities, which are the conduct of safety investigations in the following four transportation sectors:

• Marine
• Pipeline
• Rail
• Air

Within each program, personnel conduct independent safety investigations into selected transportation occurrences. They identify causes and contributing factors, assess risks to the system, formulate recommendations to improve safety, publish investigation reports, communicate safety information to stakeholders, undertake outreach activities with key change agents, as well as assess and follow up on responses to recommendations. These activities are carried out by highly qualified investigators who are experts in the transportation operational sectors. They also work closely with personnel who are responsible for executing specialized work in the following fields: engineering and technical, macro-analysis, human performance and communications.

The Internal Services program activity also contributes to the achievement of TSB's strategic outcome. This program activity includes the functions and resources required to support the needs of the program activities of the four transportation modes and to meet the department's corporate obligations, such as human resources, finance, administration, information management and information technology. The activities of the Board, Communications and Legal are an integral component of the program activities of the four transportation modes and hence their financial and human resources are presented within those activities.

2.3 Benefits for Canadians

The TSB exists as an independent investigation authority with the sole goal of advancing transportation safety. Since its inception, the TSB has conducted thousands of investigations across the modes it investigates. Through its contacts with regulators, manufacturers and other investigative authorities, findings from TSB investigations have led to numerous improvements to operational practices, equipment design and regulations throughout all sectors of the marine, pipeline, rail and aviation industries. Thanks to the professionalism and dedication of its staff, the TSB has also made significant contributions to accident investigation techniques and methodologies over the past 20 years. These efforts have firmly established the TSB as a leader in transportation safety around the world and contributed to Canada's economic and social well-being.

For detailed information on TSB activities in the four transportation sectors, see the TSB's 2009-2010 Annual Report to Parliament at http://www.bst-tsb.gc.ca/eng
/publications/index.asp.

2.4 Performance Analysis by Program Activity

The following tables present the expected results, performance indicators and targets for each of the TSB's program activities. Note that all numbers in the performance analysis sections have been rounded.

2.4.1 Marine Investigations

Program Activity: Marine Investigations

2009-2010 Financial Resources ($ thousands)			2009-2010 Human Resources (FTEs)
Planned Spending	Total Authorities	Actual Spending	Planned	Actual	Difference
5,551	5,656	5,526	416	38	3

Expected Results	Performance Indicators	Targets	Performance Status and Summary
Increased productivity while conducting investigations	Number of investigation reports published	Publication of all reports on investigations started in 2008-2009	Target mostly met. The TSB published the reports on 5 of the 6 investigations started in 2008-2009 and 4 reports on investigations started in prior fiscal years.
	Average time for completing investigation reports	Average time for completing investigation reports is less than 456 days	Target not met. The average time for completing the reports was 529 days.
	Number of safety communications issued	Not determined7	The TSB issued: 1 safety recommendation 7 safety advisories 9 information letters
Increased effectiveness of safety communications	Results of Board assessment of responses to recommendations over a 20-year period	Not determined	From 1990 to 2010, 92 per cent of responses to recommendations were assigned a fully satisfactory or satisfactory intent rating.

Performance Analysis

The TSB published 9 marine investigation reports. These reports were completed within an average time of 529 days, or 73 days more than the target objective. Among the 9 investigations completed, 11 per cent (1) were started in 2009-2010, 56 per cent (5) in 2008-2009 and 33 per cent (3) in previous fiscal years.

A comparison of the results from this year and last year shows an increase of 83 per cent in the number of investigations undertaken, 11 compared with 6 and a decrease of 50 per cent in the number of investigations completed, 9 compared with 18. The significant variation in investigations undertaken and completed is due to the Branch focusing its resources in 2008-2009 to clearing the backlog of old reports (over two years old), which was successfully completed. With fewer backlogged reports in 2009-2010, the Marine Branch was able to increase the number of new investigations.

Although the target of 456 days to complete an investigation report was not achieved, the average time to complete an investigation report fell from 796 days in 2008-2009 to 529 days in 2009-2010, a drop of 34 per cent. Additionally, the report into the explosion on the vessel Nils B was substantially delayed due to reasons beyond the control of the TSB. These reasons include a delay in reporting the occurrence to the TSB, resulting in a late deployment and significant delay in gathering initial information (as the ship had sailed) and a two-month delay by designated reviewers in responding to the confidential draft report. If this occurrence is taken out of consideration, the average duration of reports completed was reduced from 796 days last year to 465 days; 9 days below target.

From 1990 to 2010, the large majority of marine safety recommendations assessed by the Board have resulted in positive changes. The change agents took measures to substantially reduce the deficiencies described in the recommendations in 73 per cent of cases (106 of 146) and plan to take such action in 19 per cent of cases (28 of 146).

Lessons Learned

Throughout the fiscal year, the TSB Marine Branch has faced challenges due to fluctuations in human resources. The in-house availability is "one deep" for positions providing specialist input into reports, such as naval architecture. For example, during this time period, the TSB was called upon by the Kingdom of Tonga to assist in a joint international investigation involving Tonga, New Zealand, Australia, and Japan into the sinking of the Tongan passenger ferry Princess Ashika with 74 fatalities. As a consequence of this commitment to provide such support, naval architecture resources were re-directed to this project, which had noticeable consequences on the planned targets of one or more investigation reports. In addition, workplace absences of key personnel due to sick leave had a further impact on available resources.

The TSB Marine Branch has learned that our "one deep" human resources situation should be mitigated by building redundancy in key specialist positions. Additionally, the Marine Branch will continue to seek improvement through the application of updated practices and processes and reflect on lessons learned with each report and adjust as needed. Furthermore, the Branch will conduct an internal review so as to ensure that the organizational structure is aligned with current investigative processes to ensure optimal efficacy.

2.4.2 Pipeline Investigations

Program Activity: Pipeline Investigations

2009-2010 Financial Resources ($ thousands)			2009-2010 Human Resources (FTEs)
Planned Spending	Total Authorities	Actual Spending	Planned	Actual	Difference
451	462	451	3	3	0

Expected Results	Performance Indicators	Targets	Performance Status and Summary
Increased productivity while conducting investigations	Number of investigation reports published	Publication of 1 investigation report	Target met. The TSB published 1 report.
	Average time for completing investigation reports	Average time for completing a Class 3 report is 456 days, and 548 days for a Class 2 report	Target exceeded. The average time for completing the Class 3 report was 374 days.
	Number of safety communications issued	Not determined8	No safety communications were issued.
Increased effectiveness of safety communications	Results of Board assessment of responses to recommendations over a 20-year period	Not determined	From 1990 to 2010, 70 per cent of responses to recommendations were assigned a fully satisfactory or satisfactory intent rating.

Performance Analysis

The TSB published 1 pipeline investigation report in 2009-2010. The average time to complete a pipeline investigation report declined from 542 days in 2008-2009 to 374 days in 2009-2010, a decrease of 31 per cent. The decrease was accomplished through a sustained effort to manage the investigation process from start to finish. This includes early development of a sequence of events (timeline) and identification of the cause, contributing factors and safety deficiencies associated with residual risk. The end result is a more concise, focused report produced within a shorter timeframe.

From 1990 to 2010, the 20 pipeline safety recommendations assessed by the Board have resulted in positive changes. The change agents took measures to substantially reduce the deficiencies described in the recommendations in 70 per cent of cases (14 of 20). In 10 per cent of cases (2 of 20), change agents have taken or plan to take action that will only partially address the deficiency noted in the recommendation. Four recommendations remain assessed as "Unsatisfactory." These unresolved recommendations will continue to be reassessed with the intent of approaching the regulator to discuss areas for potential risk mitigation.

Lessons Learned

The TSB has been able to meet its targets through careful and efficient use of resources. Adherence to investigative procedures and the early identification of metallurgical testing requirements has also contributed to efficient use of resources.

2.4.3 Rail Investigations

Program Activity: Rail Investigations

2009-2010 Financial Resources ($ thousands)			2009-2010 Human Resources (FTEs)
Planned Spending	Total Authorities	Actual Spending	Planned	Actual	Difference
4,931	5,233	5,073	349	34	0

Expected Results	Performance Indicators	Targets	Performance Status and Summary
Increased productivity while conducting investigations	Number of investigation reports published	Publication of 12 investigation reports	Target exceeded. The TSB published 13 reports.
	Average time for completing investigation reports	Average time for completing investigation reports is less than 548 days	Target exceeded. The average time for completing reports was 498 days.
	Number of safety communications issued	Not determined10	The TSB issued: 4 safety recommendations 8 safety advisories 9 information letters
Increased effectiveness of safety communications	Results of Board assessment of responses to recommendations over a 20-year period	Not determined	From 1990 to 2010, 87 per cent of responses to recommendations were assigned a fully satisfactory or satisfactory intent rating.

Performance Analysis

The TSB published 13 rail investigation reports. These reports were completed within an average period of 498 days, or 50 days less than the target objective. A comparison of the results from this year and last year shows an increase of 22 per cent in the number of investigations undertaken, 18 compared with 14, and a decrease of 41 per cent in the number of investigations completed, 13 compared with 22. Over the past 10 years, the Rail Investigations Branch has conducted an average of 15 investigations per year, ranging from a high of 17 to a low of 11. While last year was slightly below average with 14 investigations conducted, this year's increase to 18 is related to two factors:

• Three of the investigations involve long, heavy trains, which is an issue on the Board's Watchlist.
• Four of the investigations involve significant train collisions. This seems to be an emerging trend and, as such, a higher activity level was necessary.

Among the 13 investigations completed, 8 per cent (1) were started this fiscal year, 54 per cent (7) in 2008-2009, 31 per cent (4) in 2007-2008 and one was started prior to this. The average time to complete an investigation report fell from 539 days in 2008-2009 to 498 days in 2009-2010, a drop of 7 per cent.

From 1990 to 2010, most of the 128 rail safety recommendations assessed by the Board have resulted in positive changes. The change agents took measures to substantially reduce the deficiencies described in the recommendations in 75 per cent of cases (96 of 128) and plans to take such measures in 12 per cent of cases (15 of 128).

Lessons Learned

Over the past year, the Rail Branch has focused a significant effort in more efficiently managing the investigation process from start to finish. This includes direct intervention by the Regional Manager in the early stages of the investigation to develop a sequence of events (timeline) as well as early identification of the causes, contributing factors and safety deficiencies associated with residual risk. This assists in producing a more concise, focused report in a shorter timeframe. Better focused reports also have a more significant effect on the change agents which often translates to direct safety action and reduction of risk.

2.4.4 Air Investigations

Program Activity: Air Investigations

2009-2010 Financial Resources ($ thousands)			2009-2010 Human Resources (FTEs)
Planned Spending	Total Authorities	Actual Spending	Planned	Actual	Difference
13,524	13,969	13,525	10011	94	6

Expected Results	Performance Indicators	Targets	Performance Status and Summary
Increased productivity while conducting investigations	Number of investigation reports published	Publication of 60 investigation reports	Target mostly met. The TSB published 50 investigation reports.
	Average time for completing investigation reports	Average time for completing investigation reports is less than 456 days	Target exceeded. The average time for completing the reports was 430 days.
	Number of safety communications issued	Not determined12	The TSB issued: 6 safety recommendations 9 safety advisories 2 information letters
Increased effectiveness of safety communications	Results of Board assessment of responses to recommendations over a 20-year period	Not determined	From 1990 to 2010, 71 per cent of responses to recommendations were assigned a fully satisfactory or satisfactory intent rating.

Performance Analysis

In 2009-2010, the TSB undertook 33 new air investigations and completed 50 reports. A comparison with last year shows a drop in the number of investigations undertaken, 33 compared with 43 (mostly due to a 12 per cent decrease in the number of reported occurrences), and an increase in the number of investigations completed, 50 compared with 46. Among the 50 investigations completed, 16 per cent (8) were started in this fiscal year, 56 per cent (28) in 2008-2009 and 28 per cent (14) in 2007-2008. The TSB again this year exceeded its target by producing reports in 27 fewer days than the target objective. The TSB also communicated many safety deficiencies it identified through safety advisories and information letters before investigation reports were issued.

From 1990 to 2010, the 235 air safety recommendations assessed by the Board have resulted in positive changes. The change agents took measures to substantially reduce the deficiencies described in the recommendations in 60 per cent of cases (141 of 235) and plan to take such measures in 11 per cent of cases (26 of 235).

Lessons Learned

The Air Investigations Branch is not satisfied with the current uptake on recommendations and will continue to work collaboratively with the change agents to increase the uptake. The Air Investigations Branch will adopt the recommendations of the Chair's Challenge by including more proactive meetings to increase the uptake.

2.4.5 Internal Services

Program Activity: Internal Services

2009-2010 Financial Resources ($ thousands)			2009-2010 Human Resources (FTEs)
Planned Spending	Total Authorities	Actual Spending	Planned	Actual	Difference
7,126	7,009	6,874	5713	51	6

Performance Analysis

TSB's Internal Services program activity includes the functions and resources required to support the needs of the program activities of the four transportation modes and to meet the department's corporate obligations. These activities are coordinated by the TSB's Corporate Services Branch and include the services relating to: branch management and oversight; human resources; financial management; information management; information technology; real property; materiel; acquisition; and other administrative services.

In 2009-2010, the TSB was assessed as part of the Treasury Board Secretariat's Round VII of the Management Accountability Framework (MAF) assessments. The MAF sets out the Treasury Board's expectations of departments and agencies for good public service management. MAF assessments are used to identify management strengths and weaknesses. The observations by the Treasury Board Secretariat related to the TSB management capacity were very positive. The TSB received an acceptable rating in 14 of the 15 Areas of Management against which the organization was assessed. The quality of performance reporting was assessed as requiring improvement. The TSB is taking corrective action by enhancing the description of its performance in the Departmental Performance Report and by providing substantiation and discussion of corrective actions where plans were not fully met.

In addition to ensuring the ongoing provision of quality internal services to its clients, the Corporate Services Branch focused its efforts on three key priorities in 2009-2010. First, the Branch implemented a new business planning process to better integrate human resources planning into the corporate plan. The 2010-2011 Business Plan now includes the corporate risks, challenges, priorities and major projects, as well as the detailed plans of each Branch. These detailed plans include: risks, priority activities, performance indicators, allocated human and financial resources, as well as staffing plans and learning priorities.

Another priority of the Corporate Services Branch was to stabilize its workforce because the Branch had experienced significant turnover in recent years. The Branch experienced some difficulties in staffing its positions, as can be seen by the lower-than-planned spending and FTEs in the table above. However by year end, most positions were staffed or in the process of being staffed.

The TSB continues to work on improving its practices, controls and infrastructure in the areas of information technology, information management, human resources and finance. The project to rationalize and reduce its information technology infrastructure continued to progress on schedule. To date, the department has been able to reduce the number of servers, printers and other information technology equipment through identified efficiencies. The project to develop and implement a full electronic records management system was delayed as a result of vacancies in the Information Management Division. The review of the options for implementing an electronic records management system will continue into 2010-2011.

Progress was achieved in updating and streamlining the internal policies and procedures relating to human resources. However, vacancies resulted in less progress being achieved than desired on the policies and procedures in the areas of information management and finance.

Lessons Learned

The success of the Corporate Services Branch in achieving its priorities is dependent largely on the expertise, the professionalism and the competence of its employees. Many of the positions are "one deep," that is, there is only one person responsible for a specific task or function. The Branch needs to build on the improvements it has made to the strategic human resources planning process in 2009-2010 and perform more anticipatory staffing and succession planning for key positions in order to minimize the impact of vacancies.

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