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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

To achieve this outcome, the TSB counts on its four key program activities, which are the conduct of safety investigations into the following four transportation sectors:

• Air
• Marine
• Rail
• Pipeline

As described in the 2010-11 Main Estimates, within each of the four program activities, personnel conduct independent investigations into occurrences in the federally regulated elements of the transportation system to identify causes and contributing factors, publish investigation reports, formulate recommendations to improve safety, communicate safety information to stakeholders, undertake outreach activities with key change agents, as well as assess and follow-up on responses to recommendations. This includes the execution of specialized work in the fields of: engineering, macro analysis, human performance, legal services, communications, quality assurance, as well as publishing and linguistic services.

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: human resources management; financial management; information management; information technology; real property; materiel; procurement; and other administrative services.

2.3  Air Investigations

2010-11 Financial Resources ($ thousands)

Planned Spending	Total Authorities	Actual Spending
12,780	14,923	14,311

2010-11 Human Resources (FTEs)

Planned	Actual	Difference
100	94	6

Expected Results	Performance Indicators	Targets	Performance Status and Summary
Increased productivity while conducting investigations	Number of investigation reports published	50 reports	Somewhat met. The TSB published 38 investigation reports.
	Average time for completing investigation reports	457 days	Mostly met. The average time for completing the investigation reports was 503 days.
	Number of safety communications issued	Not applicable7	Met all. The TSB issued: 6 safety recommendations 6 safety advisories 3 information letters
Increased effectiveness of safety communications	Results of Board assessment of responses to recommendations	Not determined	Somewhat met. From 1990 to 2011, 59 per cent of responses to recommendations were assigned a fully satisfactory rating.

2.3.1  Performance Summary and Analysis of Program Activity

In 2010-11, the Air Program Activity expended the majority of its available financial resources, lapsing $612 thousand. The lapse is primarily explained by employee turnover and a decrease in the number of deployments to occurrence sites, which reduced travel and overtime costs.

The Air Program Activity's actual staff level was below planned by six full-time equivalents. This gap was due to two vacancies in investigator positions, with the remainder attributed to vacancies in the various supporting functions such as: Communications, Operational Services and the Corporate Secretariat, which are allocated to the Air Program Activity.

In 2010-11, the TSB published 38 Air investigation reports, 12 reports below the target objective (50). The TSB also communicated safety deficiencies it identified through 6 safety advisories and 3 information letters. The 38 reports were completed within an average time of 503 days, or 46 days more than the target objective (457) and 53 days more than the previous five-year average (450).

There are a number of reasons why the established targets were not reached. A number of complex investigations required more work than normal. Some investigations required more time due to the involvement of international stakeholders. Additionally, over the past year, a significant number of new Air investigations were undertaken in the Quebec Region, which significantly impacted the workload of the investigators in that region. Finally, the investigation into the 2009 Sikorsky S-92A helicopter crash off Newfoundland also involved a large portion of the Air Investigations Branch, Communications Branch and Board resources during the last three months of the fiscal year thereby delaying work on other investigations and reports.

A comparison with last year shows an increase in the number of investigations undertaken, 37 compared with 33, and a decrease in the number of investigations completed, 38 compared with 50. Among the 38 investigations completed, 8 per cent (3) were started in this fiscal year, 55 per cent (21) in 2009-10, 29 per cent (11) in 2008–09 and 8 percent (3) in a previous year.

From 1990 to 2011, the 247 responses to air safety recommendations assessed by the Board have resulted in some positive changes. The change agents took fully satisfactory measures to address the deficiencies described in the recommendations in 59 per cent of cases (145 of 247) and plan to take such action in 8 per cent of cases (20 of 247). The TSB is not satisfied with the results achieved on the Air safety recommendations and plans to increase its efforts to encourage the regulators and industry stakeholders to undertake more safety actions.

2.3.2  Lessons Learned

It is difficult to predict from year to year where the investigation efforts will be required across the country. Better planning and management of investigation resources is required at the national level in order to shift resources according to these fluctuations. In future, efforts will be made to shift resources to areas of greater need in a timely manner.

More robust analysis is also required when defining performance targets to ensure that they are realistic and achievable. The target of publishing 50 Air reports a year may be too high given the decreasing trend in the number of occurrences that merit investigation under the TSB's Occurrence Classification Policy.

2.4  Marine Investigations

2010-11 Financial Resources ($ thousands)

2010-11 Financial Resources ($ thousands)

Planned Spending	Total Authorities	Actual Spending
5,310	4,665	4,474

2010-11 Human Resources (FTEs)

Planned	Actual	Difference
41	37	4

Expected Results	Performance Indicators	Targets	Performance Status and Summary
Increased productivity while conducting investigations	Number of investigation reports published	10 reports	Target mostly met. The TSB published 8 investigation reports.
	Average time for completing investigation reports	426 days	Target somewhat met. The average time for completing the investigation reports was 529 days.
Increased effectiveness of safety communications	Number of safety communications issued	Not applicable8	Met all. The TSB issued: 5 safety advisories 6 information letters.
	Results of Board assessment of responses to recommendations	Not determined	Mostly met. From 1990 to 2011, 77 per cent of responses to recommendations were assigned a fully satisfactory rating.

2.4.1  Performance Summary and Analysis of Program Activity

In 2010-11, the Marine Program Activity expended the majority of its available financial resources. The lapse of $191 thousand is primarily explained by vacancies in investigator positions. Additionally, the number of deployments to occurrence sites decreased, which reduced travel and overtime costs.

The TSB published 8 Marine investigation reports, 2 reports below the target objective (10). The TSB also communicated safety deficiencies it identified through 5 safety advisories and 6 information letters. The 8 investigation reports were completed within an average time of 529 days, or 103 days more than the target objective (426) and 215 days below the previous five-year average (744).

A comparison of the results from this year and last year shows a decrease of 55 per cent in the number of investigations undertaken, 5 compared with 11 and a decrease of 11 per cent in the number of investigations completed, 8 compared with 9. Among the 8 investigations completed, 88 per cent (7) were started in 2009-10 and 13 per cent (1) in a previous fiscal year.

Throughout the fiscal year, the Marine Investigations Branch faced challenges due to significant fluctuations in human resources. Several investigator positions in Head Office and in the regions were vacant. In addition, some key management positions were also vacant for part of the year requiring employees to carry out both investigative and managerial duties. As a consequence, the overall performance suffered with a noticeable impact on the planned targets. Difficulties were also encountered with a few investigations resulting in delays in the completion of quality reports.

From 1990 to 2011, most of the marine safety recommendations assessed by the Board have resulted in positive changes. The change agents took fully satisfactory measures to address the deficiencies described in the recommendations in 77 per cent of cases (113 of 146) and plan to take such action in 17 per cent of cases (25 of 146).

2.4.2  Lessons Learned

More robust human resources management and succession planning are required to minimize the number of vacant positions and to reduce the length of time during which positions are vacant. In 2011-12, the TSB will undertake a more strategic approach to staffing investigator positions, including the creation of pre-qualified pools of candidates for investigator positions.

Opportunities for improvement were also identified in the Marine Investigations Branch business processes. In 2011-12, efforts will be made to optimize these processes. Closer attention will also be placed on the establishment of realistic timeliness performance targets that more closely align with the available resources.

2.5.  Rail Investigations

2010-11 Financial Resources ($ thousands)

Planned Spending	Total Authorities	Actual Spending
4,678	4,796	4,598

2010-11 Human Resources (FTEs)

Planned	Actual	Difference
34	34	-

Expected Results	Performance Indicators	Targets	Performance Status and Summary
Increased productivity while conducting investigations	Number of investigation reports published	13 reports	Target exceeded. The TSB issued 16 investigation reports.
	Average time for completing investigation reports	498 days	Target exceeded. The average time for completing the investigation reports was 442 days.
Increased effectiveness of safety communications	Number of safety communications issued	Not applicable9	Met all. The TSB issued: 1 safety recommendation 9 safety advisories 8 information letters.
	Results of Board assessment of responses to recommendations	Not determined	Mostly met. From 1990 to 2011, 82 per cent of responses to recommendations were assigned a fully satisfactory rating.

2.5.1  Performance Summary and Analysis of Program Activity

In 2010-11, the Rail Program Activity expended the majority of its available financial resources and all of its human resources. The lapse of $198 thousand is primarily explained by a decrease in the number of deployments to occurrence sites, which reduced travel and overtime costs.

Fiscal year 2010-11 was a very successful year for the Rail Program Activity. All of its performance targets were met and some were exceeded. The TSB published 16 Rail investigation reports, exceeding its target of 13 reports. These reports were completed within an average period of 442 days, or 56 days less than the target objective. The TSB also communicated safety deficiencies it identified through 9 safety advisories and 8 information letters.

A comparison of the results from this year and last year shows a decrease of 22 per cent in the number of investigations undertaken, 14 compared with 18, and an increase of 23 per cent in the number of investigations completed, 16 compared with 13. Among the 16 investigations completed, 63 per cent (10) were started in 2009-10, 38 per cent (6) in 2008-09.

The average time to complete an investigation report fell from 498 days in 2009-10 to 442 days in 2010-11, a drop of 11 per cent. The 2010-11 average time also decreased compared to the previous five-year average (570). This improvement in timeliness is primarily attributed to the reduced number of investigations and to some adjustments made to the internal business processes, which permitted resources to be better focused on fewer investigations.

From 1990 to 2011, most of the 131 rail safety recommendations assessed by the Board have resulted in positive changes. The change agents took fully satisfactory measures to address the deficiencies described in the recommendations in 82 per cent of cases (108 of 131) and plan to take action in 8 per cent of cases (11 of 131).

2.5.2  Lessons Learned

Over the past year, the Rail Investigations Branch has focused its efforts on managing the investigation process in a more rigorous manner. Through effective coordination within the investigation team, early development of the sequence of events and early identification of safety deficiencies, concise, focused reports were completed in a shorter timeframe. Better focused reports ensures that change agents are made aware of the safety deficiencies in a timely manner, which often translates to direct safety action and reduction of risk.

2.6  Pipeline Investigations

2010-11 Financial Resources ($ thousands)

Planned Spending	Total Authorities	Actual Spending
376	509	489

2010-11 Human Resources (FTEs)

Planned	Actual	Difference
3	3	-

Expected Results	Performance Indicators	Targets	Performance Status and Summary
Increased productivity while conducting investigations	Number of investigation reports published	3 reports	Met all. The TSB published 3 investigation reports.
	Average time for completing investigation reports	490 days	Target exceeded. The average time for completing the investigation reports was 431days.
Increased effectiveness of safety communications	Number of safety communications issued	Not applicable10	Met all. The TSB issued 2 safety advisories.
	Results of Board assessment of responses to recommendations (since 1990)	Not determined	Met all. From 1990 to 2011, 100 per cent of responses to recommendations were assigned a fully satisfactory rating.

2.6.1  Performance Summary and Analysis of Program Activity

In 2010-11, the Pipeline Program Activity expended the majority of its available financial resources (lapse of $20 thousand) and all of its human resources.

Fiscal year 2010-11 was a very successful year for the Pipeline Program Activity. All of its performance targets were met or exceeded. The TSB published 3 pipeline investigation reports in 2010-11. These reports were completed within an average time of 431 days, or 59 days less than the target objective. The 2010-11 average time to complete a pipeline investigation report also remains 107 days below the previous five-year average (538). The TSB also communicated safety deficiencies it identified through 2 safety advisories.

From 1990 to 2011, all of the 20 pipeline safety recommendations assessed by the Board have resulted in positive changes.

2.6.2  Lessons Learned

The TSB has been able to meet its targets through careful and effective management of resources. Adherence to the investigation process and coordination within the Branch and with other TSB team members resulted in the early identification of metallurgical testing requirements and in the preparation of concise, focussed reports over a shorter timeframe.

2.7  Internal Services

2010-11 Financial Resources ($ thousands)

Planned Spending	Total Authorities	Actual Spending
6,642	7,124	6,826

2010-11 Human Resources (FTEs)

Planned	Actual	Difference
57	51	6

Expected Results	Performance Indicators	Targets	Performance Status and Summary
Strengthening Management Practices	Continuous improvement in ratings for the individual areas of management of the Treasury Board Secretariat's Management Accountability Framework (MAF) assessment	Address any issues from MAF round VII	Mostly met the expectations. Progress has been made however sustained efforts will be required in 2011-12 to address the remaining items in the action plan.

2.7.1  Performance Summary and Analysis of Program Activity

The financial resources planned for Internal Services were not fully expended in 2010-11.  The lapse in funds is primarily explained by the turnover in staff and the delay in implementing two projects: the implementation of an electronic records management system and the improvement of the modal databases, which reduced informatics spending.

The human resources staffing level in Internal Services was below planned in 2010-11.  This gap was attributable to unplanned employee departures and to the time required to complete the related staffing processes to find suitable replacements. Over the course of the year, the TSB had to work hard to maintain adequate human resources capacity within its Corporate Services Branch. Nevertheless, all external corporate obligations were met and temporary help services were utilized to fill the short-term gaps to ensure the continuity of internal operations.

In 2009-10 the TSB was assessed as part of the Treasury Board Secretariat's Round VII of the Management Accountability Framework (MAF) assessments. The observations by the Treasury Board Secretariat related to the TSB management capacity were very positive. However, opportunities for improvement were identified with respect to departmental performance reporting. In response, the TSB has refined the wording of its Strategic Outcome and its Program Activities, which will be reflected in its 2012-13 Report on Plans and Priorities. Additionally, a review of performance indicators was completed and some changes were introduced in time for the 2011-12 Report on Plans and Priorities. Further work is required in order to finalize the TSB's performance management framework.

During 2010-11, the TSB undertook a number of major corporate planning activities. A new integrated human resources and business planning process was implemented. The departmental Corporate Risk Profile was updated and a new five year Strategic Plan was developed.

Due to conflicting priorities and vacancies in some key positions, limited progress was achieved in the development and update of policies, the review and streamlining of internal procedures and the documentation of internal service standards. The update of the policies and directives for the Corporate Services functional areas remains a priority going forward into 2011-12.

During 2010-11, the TSB faced a significant increase in workload arising from the new government-wide financial reporting requirements. In response to new Treasury Board policies, the TSB prepared future-oriented financial statements and revised the format of its audited year-end financial statements. Additionally, the TSB participated in an inter-departmental working group for the development of templates to meet the new reporting requirement to produce quarterly financial reports. This initiative resulted in the TSB's Quarterly Financial Report being distributed government-wide as a model for use by other small departments and agencies. Finally, the Treasury Board Policy on Internal Control applied to the TSB for the first time for fiscal year 2010-11. This required a detailed assessment of the department's internal controls over financial reporting and the preparation of a management disclosure which is published as an annex to the TSB's financial statements in this Departmental Performance Report. 

2.7.2  Lessons Learned

The TSB's success in achieving its Internal Services priorities is dependent upon having experienced staff in place that are knowledgeable about the TSB's operations. In order to minimize the impact of unplanned employee departures, the TSB has increased its usage of temporary help and casual employees to fill vacancies on an urgent basis. Additionally, the staff complement of financial officer positions has been increased by one in response to the increase in financial reporting requirements and to reduce the risk to internal controls of employee turnover among financial staff. Finally, the human resources strategies to staff Internal Services positions will be reviewed and improved in order to develop more permanent solutions.

In reviewing the project delays, it was identified that better planning was required in order for the full scope of projects and their timelines to be better understood at the time of their initial approval. For 2011-12, projects have been divided into smaller components in order for the deliverables to be better understood and gated.

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