ARCHIVED - Transportation Safety Board of Canada - Report

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Chair's Message

For over 20 years, the Transportation Safety Board of Canada (TSB) has investigated thousands of transportation occurrences. No matter where things go wrong—on our waterways, along our pipelines or railways, or in our skies—we make sure Canadians know what happened and why. But our work doesn't stop there. Our mandate is to improve transportation safety, not just report on it, and that means we are committed to ensuring that our voice is heard and understood by regulators and the industry.

To accomplish all of this, we need to make strategic use of the human and financial resources available to us. That means making sure that we as an organization, along with the products we deliver—including our safety communications, recommendations, and media outreach—are as good as they can be.

Overall, we have been successful at meeting most of our targets. This year, for example, more than two dozen of our recommendations received our highest rating of "Fully Satisfactory." Our recent safety Watchlist has also helped spur concrete action with industry and regulators. As a result, we have taken a significant step toward our goal of 80 per cent implementation for all recommendations. At the organization level, we also completed the implementation of the Multi-Modal Training and Standards Division, and we met or exceeded some of our targets for report publishing.

However, there is always room for improvement, particularly with goals as ambitious as ours. Delays on some projects were attributed in part to staff turnover and vacancies, but we feel we are on the right course, and those goals not met this year are, for the most part, being carried forward. At the organization level, these include a stakeholder consultation and improved records management, as well as continuous improvement in our modal investigations.

Ultimately, Canadians need to have confidence in our transportation system, and that confidence, which is built on trust, can only exist if there is progress. That means we can never stop pushing for improvements, for increased uptake of our recommendations, and for increased organizational efficiency. Every year we set our goals higher, striving to do more, and now, as we enter our third decade, we will continue to do exactly that—so that Canada's transportation system becomes as safe as it can be.

Section 1: Overview

1.1  Raison d'être

The Transportation Safety Board of Canada (TSB) is an independent agency created in 1990 by an Act of Parliament (Canadian Transportation Accident Investigation and Safety Board Act). It operates at arm's length from other government departments and agencies to ensure that there are no real or perceived conflicts of interest. The TSB's sole objective is to advance transportation safety. This mandate is fulfilled by conducting independent investigations into selected transportation occurrences. The purpose of these investigations is to identify the causes and contributing factors and the safety deficiencies evidenced by an occurrence. The TSB then makes recommendations to improve safety and reduce or eliminate risks to people, property and the environment.

The jurisdiction of the TSB includes all aviation, marine, rail and pipeline transportation occurrences¹ in or over Canada that fall under federal jurisdiction. The TSB may also represent Canadian interests in foreign investigations of transportation accidents involving Canadian registered, licensed or manufactured aircraft, ships or railway rolling stock. In addition, the TSB carries out some of Canada's obligations related to transportation safety at the International Civil Aviation Organization (ICAO) and the International Maritime Organization (IMO).

1.2  Responsibilities

The TSB exists as an independent investigation body with the sole goal of advancing transportation safety. Since its inception in 1990, the TSB has conducted thousands of investigations across the modes for which it is responsible.

The TSB is one of many Canadian and foreign organizations involved in improving transportation safety nationally and internationally. Because it has no formal authority to regulate, direct or enforce specific actions, the TSB can only succeed in fulfilling its strategic outcome through the actions of others. Operating at arm's length from other federal departments involved in the transportation field, the Board must present its findings and recommendations in such a manner that others feel compelled to act. This implies ongoing dialogue, information sharing and strategic coordination with organizations such as Transport Canada, the National Energy Board and the Canadian Coast Guard. The TSB must engage industry and foreign regulatory organizations in a similar fashion. Through various means, the TSB must present compelling arguments that will convince these "agents of change" to take action in response to identified safety deficiencies.

As one of the world leaders in its field, the TSB regularly shares its investigation techniques, methodologies and tools. For example, the Recorder Analysis and Playback System (RAPS) originally developed by the TSB for decoding, analyzing and creating the animations of flight recorder data, is being used in more than 10 countries to aid in safety investigations. Similarly, the TSB has contributed to the training of safety investigators from numerous countries, either by integrating foreign investigators into its in-house training programs or by sending senior staff to teach abroad. The TSB also shares data and reports with sister organizations, in addition to participating in international working groups and studies to advance transportation safety.

Through its contacts with regulators, manufacturers and other investigative authorities, findings from TSB investigations have led to numerous improvements in operational practices, equipment design and regulations throughout all sectors of the marine, pipeline, rail and aviation industries. These efforts have also established Canada as a leader in transportation safety around the world and contributed to our country's economic and social well-being.

For more details on the TSB investigation process or the links between the TSB and other federal organizations visit the TSB website at http://www.bst-tsb.gc.ca/eng/index.asp.

1.3  Strategic Outcome and Program Activity Architecture

The chart below illustrates the program activities that contribute to the achievement of the TSB strategic outcome.

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1.4  Organizational Priorities

The following table shows the progress achieved against the priorities identified in our 2010-11 Report on Plans and Priorities. Overall, the TSB achieved or exceeded its targeted objectives on certain priorities, while progress on others was less than expected primarily due to the complexity of the issue and/or staff turnover.

Priority Status Legend

Priorities	Type2	Status
Strategic Communication of TSB's mandate, investigative work and safety accomplishments over time	New	Met the expectations. In addition to our regular work, we undertook a number of activities to celebrate our 20th anniversary and to let Canadians know who we are and what we do. These activities included opening the doors of our laboratory to the media and the public, staffing a series of information booths at key locations across the country and, on-line video testimonials. We also undertook a number of targeted media and outreach events to raise greater awareness of the significant transportation risks identified on our new Safety Watchlist. Finally, we continued to leverage technology, improve our website and started to explore social media platforms to communicate more effectively, maximize the reach of all of our safety messages and increase the uptake on our recommendations.
Strategic Human Resources Management	Previously committed	Mostly met the expectations. Significant progress was achieved in the review and update of organizational structures and job descriptions; a recruitment page was created on our website; an alumni program was established; the implementation of the Training and Standards Division was completed. The review of the standby system and the development of an investigator training program are well underway.
Product Improvements	Previously committed	Somewhat met the expectations. The review and improvement of the investigation databases project was divided into smaller and more manageable projects that will be gradually actioned over the next few years. The project was too complex to undertake the improvement of all four modal databases at once. The planned stakeholder consultation on TSB products and services was deferred to 2011-12 due to delays in receiving approval to conduct a public opinion consultation. The streamlining of the report production unit and processes was almost completed by year-end and some improvements were made to the TSB website.
Policy and Procedure Management Framework	New	Somewhat met expectations. Although progress was made under this priority, more work is required. The TSB finalized its formal Governance Structure, which constitutes the foundation of its policy, directive and procedure management framework. Standardized templates were developed for all departmental policies and directives. Some policies and directives were reviewed and updated. Work plans were developed for the review of other policies. The project to implement an electronic document and records management system was re-scoped in 2010-11. The revised plan calls for a gradual implementation of a new system over the next few years. However, priority will first be placed on assessing new Treasury Board policies and directives on information management and updating the department's information management strategy.

1.5  Risk Analysis

The TSB operates within the context of Canada's very large, complex, dynamic and ever changing transportation system. The most important external and internal challenges faced in 2010-11 are described in the following paragraphs.

From an External Point of View

Government in a Deficit Economy

In Budget 2010, the Government announced the requirement for departments to fund within their existing budgets any wage and salary increases resulting from collective agreements for fiscal years 2010-11 to 2012-13 and confirmed that expenditures in the areas of travel, conferences and hospitality were still capped at the 2008-09 level. In response, the TSB undertook a closer scrutiny of its expenditures and made some adjustments in order to continue delivering on its mandate within available resources.

From an Internal Point of View

Development and Maintenance of a Knowledgeable and Professional Workforce

The success of the TSB and its credibility depend largely on the expertise, the professionalism and the competence of its employees. However, the TSB is faced with workforce challenges. Many of the positions are "one deep," that is, there is only one person responsible for a specific task or function. Over the last few years, the TSB has faced a high level of attrition which is expected to continue for the next couple of years. During 2010-11, there were 25 employee departures from the TSB (14 retirements, 11 transfers to other departments), which represents more than 10% of its planned full-time equivalent positions. Although the TSB's hiring has increased, it is a constant challenge for the organization to backfill the departures particularly in the areas where there are shortages, opportunities for career progression elsewhere and where the knowledge and the skills are highly transferable from one department to another.

Product Improvements and Timeliness

The fulfillment of our mandate primarily depends on our ability to deliver, in a timely manner, quality safety products and services that contribute to the achievement of our strategic outcome. The TSB must therefore continue to improve the speed at which it publishes safety information while maintaining a high level of quality. It must also seek the opinion of stakeholders regarding the quality of its products and services to ensure their efficiency and relevance.

Improvement of Policies, Procedures and Processes

The TSB's work is fundamentally reliant on its information. The TSB must ensure that its information and knowledge are not only current but appropriately stored and readily accessible to employees who need it when they need it. To this end, the TSB must manage effectively and efficiently its policies, directives and procedures in all activity sectors. It must also continue to enhance the processes and tools in support of the management of paper and electronic records and data. These tasks are especially difficult because of the constantly evolving working environment and the on-going staff turnover.

1.6  Summary of Performance

2010-11 Financial Resources ($ thousands)³

Planned Spending	Total Authorities	Actual Spending
29,786	32,017	30,698

2010-11 Human Resources (FTEs)

Planned	Actual	Difference
235	219	16

Strategic Outcome: The mitigation of risks to the safety of the transportation system through independent accident investigations

Alignment of Program Activities to the Government of Canada Outcome: Safe and secure Canada

Program Activities	2009-10 Actual Spending ($ thousands)	2010-11 ($ thousands)
		Main Estimates	Planned Spending4	Total Authorities4	Actual Spending
Air Investigations	13,589	12,780	12,780	14,923	14,311
Marine Investigations	5,502	5,310	5,310	4,665	4,474
Rail Investigations	5,091	4,678	4,678	4,796	4,598
Pipeline Investigations	449	376	376	509	489
Total	24,631	23,144	23,144	24,893	23,872

The following table shows the actual spending for the Internal Services program activity, which supports the needs of the four program activities outlined in the previous table.

Program Activities	2009-10 Actual Spending ($ thousands)	2010-11 ($ thousands)
		Main Estimates	Planned Spending4	Total Authorities4	Actual Spending
Internal Services	6,818	6,642	6,642	7,124	6,826

Occurrences Reported to the TSB

In 2010, a total of 1727 accidents and 1349 incidents were reported in accordance with the TSB's regulations for mandatory reporting of occurrences.⁵ The number of accidents in 2010 decreased by 1% from the 1748 accidents reported in 2009 and by 15% from the 2005–09 annual average of 2038 accidents. The number of reported incidents decreased to 1349 in 2010 from 1360 in 2009, and was below the 2005–09 average of 1397. In 2010, the TSB also received 765 voluntary reports. Fatalities totalled 168 in 2010, up 13 from the 2009 total, but the same as the 2005–09 average.

Figure 1: Occurrences Reported to the TSB

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Investigations Started, in Process and Completed

In fiscal year 2010-11, investigations were undertaken for 57 of the occurrences reported to the TSB, compared to 65 in 2009-10. In that same period, 65 investigations were completed, compared to 73 in the previous year.⁶ The number of investigations in process decreased to 71 at the end of the fiscal year from 79 at the start. The TSB continues to rigorously apply its Occurrence Classification Policy to determine which occurrences to investigate. The decrease in the number of investigations undertaken is primarily explained by a decrease in the overall number of occurrences and by the fact that many occurrences do not involve significant safety issues that warrant detailed analysis.

The average time to complete an investigation was 488 days in fiscal year 2010-11, which represents an increase from the 2009-10 result of 454 days in 2009-10 but a decrease compared to the previous five-year average (531). The time required to complete investigations depends on many factors such as the complexity of the investigation work, the involvement of external/international stakeholders and the availability of TSB investigation resources.

Figure 2: Investigations Started, in Process and Completed

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Overall, the TSB has been successful in identifying safety deficiencies and in reducing risks in the transportation system. TSB investigations result in reports identifying safety deficiencies and, where appropriate, containing recommendations to reduce risks. Over this past year, in all cases where the TSB undertook an investigation, safety deficiencies and contributing factors were identified and communicated. These results reflect careful application of the TSB's Occurrence Classification Policy in deciding whether to investigate, and a thorough implementation of the investigation methodology. This systematic approach ensures that TSB investigation resources are invested in areas with the greatest potential safety payoffs.

Safety Communications Issued

In 2010-11, in addition to investigation reports, the TSB issued a total of 46 safety outputs: 7 recommendations, 22 safety advisories and 17 safety information letters. Safety information is also provided informally to key stakeholders throughout the investigation process, permitting them to take immediate safety actions. It is common practice for industry and government to take safety actions during the course of TSB investigations. Such safety actions range widely in scope and importance. Operators will often take immediate remedial action after discussion with TSB investigators (for example, to clear the sight-lines at a railway crossing by trimming bushes and vegetation). Regulators such as Transport Canada (TC) and the Federal Aviation Administration in the United States regularly issue mandatory directives requiring inspections and/or component replacement based on the TSB's preliminary findings. In such situations, rather than issuing recommendations, the TSB can then report on the corrective actions already taken by industry and government agencies.

Board Assessment of Responses to Safety Recommendations

In accordance with the Canadian Transportation Accident Investigation and Safety Board Act, a federal minister who is notified of a TSB recommendation must, within 90 days, advise the Board in writing of any action taken or proposed to be taken in response to the recommendation, or the reasons for not taking action. The Board considers each response, assessing the extent to which the related safety deficiency was addressed. When a recommendation generates responses from within and outside Canada, the Board's assessment is based primarily on the Canadian response. The TSB publishes on its website (www.bst-tsb.gc.ca) its assessment of the responses to its recommendations.

During the period between March 1990 and March 2011, a total of 537 recommendations were assessed by the Board. In addition, 7 recommendations are awaiting Board assessment, bringing the total number to 544.

In the 21-year period from 1990 to 2011, a majority of Board recommendations have effected positive change. As shown in Figure 3, in 71% of cases fully satisfactory responses were obtained from change agents and safety deficiencies were adequately addressed. In 11% of cases (satisfactory intent), change agents plan to take action that will substantially address the deficiency noted in the recommendation. In 13% of cases (satisfactory in part), change agents have taken or plan to take action that will only partially address the deficiency noted in the recommendation. Finally, in 4% of cases (unsatisfactory), change agents have neither taken nor plan to take action that will address the deficiency noted in the recommendation.

Over the next four years, the Board is aiming to have the status of 80% of all its recommendations as "Fully Satisfactory". Renewed outreach efforts will be made to engage key change agents in discussions on a number of long standing issues that remain unresolved in order to generate further safety actions.

Figure 3: Ratings of Assessments of Responses, 1990–2011

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Board Assessment of Responses to Watchlist Recommendations

In March 2010, we released our safety Watchlist, which highlights nine critical issues posing the greatest risk to Canadians, issues that must be tackled to make Canada's transportation system safer. Prior to this, our experts had found troubling patterns in their work. In fact, far too frequently, they arrived at the scene of an accident only to see the same set of persistent safety issues. In some cases these outstanding issues were up to 15 years old, and yet still not sufficiently addressed.

The Watchlist, then, became a "blueprint for change"—a way to restate the TSB's safety messages, stimulate discussion, and generate further action on the part of the regulators and industry.

Underpinning the nine issues in the Watchlist are 41 safety recommendations—action items aimed at both industry and regulators. Prior to March 2010, only a handful of the responses to these recommendations had received our highest rating of Fully Satisfactory. Since the Watchlist's release, however, we have added the Fully Satisfactory rating to seven more. This means that, in the first year, we are a little under a third of the way in addressing these critical issues. Detailed information about the actions taken in response to the Watchlist recommendations is available in the TSB's 2010-11 Annual Report at http://www.bst-tsb.gc.ca/eng/publications/index.asp .

While some progress has been made, much more remains to be done. We have set a goal of 100% implementation. Over the next four years, we want the status of every single Watchlist recommendation—all 41 of them—to become Fully Satisfactory.

To this end, we will monitor all actions taken and provide regulators with periodic scorecards. We will also continue our outreach activities to raise greater awareness of the Watchlist issues. Next spring, we will conduct a more fulsome assessment and report publicly on actions taken and the results that have been achieved. We will also review and update our Watchlist. Issues that have been addressed in a Fully Satisfactory manner will be removed, and new issues may be added.

Figure 4: Watchlist Recommendations Ratings of Assessments of Responses, 1990–2011

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Communicating Transportation Safety to Canadians and the Transportation Community

At the TSB, investigating accidents is only part of our job. When something goes wrong—on our waterways, along our railroads or pipelines, or in our skies—we do our best to find out what happened, why, and what can be done to prevent something similar in the future. But just as important is communicating that information to the people who need it most: government and industry stakeholders, media outlets, first responders, national and local authorities, manufacturers—and the Canadian public.

To do that, we use a variety of forums and formats: safety advisories and information letters, investigation reports, regular updates on the TSB website, monthly statistical reports, and media events organized across the country. In 2010-11, we released 65 investigation reports, and held 7 media events from coast to coast. We also responded to thousands of media inquiries through our central media line, at a regional level and face-to-face at accident sites.

In addition, the TSB has built a vibrant outreach program, informing various groups and associations about who we are, how we can work together, and generally making sure our message gets "out there." To this end, Board members regularly give speeches and presentations, connecting with decision makers, raising awareness of transportation risks and encouraging further action on TSB recommendations. This fiscal year, they spoke to 23 audiences representing all four modes. TSB investigators also play an important role in promoting the TSB's work and sharing information learned from investigations by attending and giving presentations at numerous events and conferences in Canada and abroad.

1.7  Expenditure Profile

The TSB is primarily funded by Parliament through an operating expenditures vote, and as a departmental corporation it has authority to spend revenues received during the year. As shown in the table below, expenditures for 2010-11 are below previous years' expenditures. Program expenditures in 2010-11 decreased from 2009-10 by $0.8 million or 2.4 per cent. This decrease is explained by several factors:

• staff turnover which reduced spending on salaries and training;
• a decrease in the number of deployments to occurrences which reduced travel and overtime costs;
• delays in the project to update the modal investigation databases which reduced informatics spending; and
• a planned decrease in discretionary spending in response to restraint measures in Budget 2010.

The following chart shows the TSB spending trend over a three-year period. Reference levels provided through the Main Estimates have remained stable over the past three years. However, additional authorities have been provided through Supplementary Estimates and Treasury Board vote transfers. These authorities were essentially intended to cover incremental costs to offset collective bargaining increases and the carry-forward of previous years' lapses.

Figure 5: Spending Trend between 2008–09 and 2010-11

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1.8  Estimates by Vote

For information on TSB organizational votes and/or statutory expenditures, please see the
2010-11 Public Accounts of Canada (Volume II) publication. An electronic version of the Public Accounts is available at http://www.tpsgc-pwgsc.gc.ca/recgen/txt/72-eng.html .

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