ARCHIVED - Transportation Safety Board of Canada

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Section 1: Overview

1.1 The Chair's Message

When a marine, pipeline, rail, or aviation accident befalls in Canada, the Transportation Safety Board of Canada (TSB) stands ready to conduct a full and independent investigation. That is why TSB investigators report again and again to the scenes of accidents, often under the most challenging of conditions, be those scouring ocean floors for wreckage, working with hazardous debris or walking miles of track to recover key pieces to advance transportation safety.

When our work is done, we always tell Canadians what we learned. We report what caused the accident, what underlying safety issues there are and what needs to be done to improve the safety of our transportation system. At the TSB, we believe, in some measure, that our recommendations serve to save lives, preserve the environment and protect the property of Canadians.

To this end, the past year has been another busy year for the TSB as demonstrated in our Annual Report that was tabled last June in Parliament. We completed an increasing number of very complex investigations, some of them having a high profile, while at the same time significantly reducing the number of investigations in progress. No matter the occurrence, we acted quickly to ensure that lessons learned were made public and passed on to those persons and agencies best positioned to take effective action and make changes.

I realize that we did not fully achieve all of the objectives listed in the Report on Plans and Priorities; however, we have taken steps forward in our priority investments to implement new ways of contributing to transportation safety and strengthening the organization's internal management. We have thoroughly assessed our information technology (IT) infrastructure, and we agreed on measures to take to consolidate our acquisitions and ensure the long-time viability of our Investigation and Information Management System. We also reviewed our A-Base budget and our capital assets, and analyzed our historical financial data to ensure that we are using them optimally to achieve the desired results. We should start seeing the results of these exercises next year. I also challenged the management team at the TSB to find ways of ensuring that our recommendations are made public and communicated more rapidly to the change agents as well as improving on the uptake of our recommendations. I am happy to report that work is well underway on this initiative.

I am confident that the TSB has again this year played a strong role to ensure that Canadians will always enjoy one of the safest transportation systems in the world.

1.2 Management Representation Statement

I submit, for tabling in Parliament, the 2007-2008 Departmental Performance Report for the Transportation Safety Board of Canada. This document has been prepared based on the reporting principles contained in the Guide for the Preparation of Part III of the 2007-2008 Estimates: Reports on Plans and Priorities and Departmental Performance Reports: It adheres to the specific reporting requirements outlined in the Treasury Board Secretariat guidance; It is based on the department's Strategic Outcome and Program Activity Architecture that were approved by the Treasury Board; It presents consistent, comprehensive, balanced and reliable information; It provides a basis of accountability for the results achieved with the resources and authorities entrusted to it; and It reports finances based on approved numbers from the Estimates and the Public Accounts of Canada.   The original version was signed by _____________________________________ Wendy A. Tadros Chair

1.3 Summary Information

1.3.1 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 only objective is the advancement of transportation safety. This mandate is fulfilled by conducting independent investigations into transportation occurrences. The purpose is to identify the causes and contributing factors of the occurrences 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 occurrences 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).

A transportation occurrence is any accident or incident associated with the operation of an aircraft, ship, railway rolling stock, or pipeline. It also includes any hazard that could, in the Board's judgement, induce an accident or incident if left unattended.

1.3.2 Operating Framework

The TSB is primarily funded by Parliament through a program expenditures vote and, as a departmental corporation, it has authority to spend revenues received during the year. The TSB operates within the context of Canada's very large, complex, dynamic and ever-changing transportation system. Many individuals and groups cooperate with the TSB in the fulfillment of its mandate. During the course of an investigation, the TSB interacts directly with

• individuals such as survivors, witnesses and next-of-kin;
  
• operators;
  
• other organizations and agencies such as medical examiners, police, manufacturers, owners and insurance companies; and
  
• other federal government departments and agencies.

Their cooperation is essential to the conduct of the TSB's business, whether they contribute information or support services. For more details on the investigation process, visit the TSB site.

The TSB is one of many organizations involved in improving transportation safety nationally and internationally. Even if the TSB is operating at arm's length from other federal departments in the transportation field, it cannot achieve its strategic outcome without the cooperation of the other organizations. The TSB presents findings and issues recommendations in such a manner that other organizations feel compelled to act but it has no formal authority to regulate, direct or enforce specific actions. Its success 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 also continuously be in contact with industry and foreign regulatory organizations, and exchange information with them. Through various means, the TSB must present compelling arguments that will convince these "change agents" to take the necessary action in response to identified safety deficiencies.

The TSB has established memoranda of understanding with other federal government departments for the coordination of activities and the provision of support services. These agreements provide the TSB with access to a range of support services that can rapidly supplement internal resources. The agreements also define operating practices to ensure good coordination of activities and to avoid potential conflicts that could arise from the simultaneous implementation of various organizational mandates. Such agreements are currently in place with the Department of National Defence, the Royal Canadian Mounted Police, the Canadian Coast Guard, Human Resources and Social Development Canada, and the National Research Council. Similarly, the TSB has established strategic cooperation alliances with provincial and territorial medical examiners and with certain provincial government departments for rail occurrences that fall under their jurisdiction.

Further alliances have been established with the TSB's counterpart agencies in other countries such as the United States, Australia, the Netherlands, New Zealand, France, the United Kingdom, and the Republic of Korea. The TSB cooperates on a reciprocal basis with foreign safety investigation agencies through the ad hoc exchange of specialized services or the provision of assistance as a means of coping with capacity gaps. As one of the world leaders in its field, the TSB regularly shares its investigation techniques, methodologies and tools with other organizations. For example, the Recorder Analysis and Playback System (RAPS), originally developed by the TSB for decoding and analyzing flight data recorders (FDRs) and cockpit voice recorders (CVRs), is used by several countries. In cooperation with our partners, we are also pursuing our efforts to develop a vessel movement simulation system based on the information contained in voyage data recorders (VDRs). Similarly, the TSB has contributed to the training of 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 gives information and copies of its reports to sister organizations, and participates in international working groups and studies to advance transportation safety.

1.3.3 Risks and Challenges

The TSB faces many risks and challenges that have a potentially significant impact on the organization's ability to achieve its mandate. Managers are aware of these risks and challenges and are expected to take appropriate action to mitigate the risks while ensuring the delivery of their mandate. The most important challenges faced in 2007-2008 are described in the following paragraphs.

Our Capacity to Manage Workload and Priorities Within Available Resources

The TSB continues to receive many investigation requests from the public. It also faces numerous internal and external pressures to sustain existing activities and undertake new initiatives or modify existing practices to meet the central agencies' change requirements. In addition, other factors continue to have an impact on the organization's capacities, including risk mitigation measures that need to be implemented in IT security and business continuity planning.

The challenge we face includes continuing to carry out our mandate with constantly shrinking financial resources, while expectations and requirements grow and some components of our infrastructure age or no longer meet our needs. We must therefore find the right balance between the level of activity and the capacity of available human and financial resources. This means finding even more efficient ways of working, both internally and externally, and continuing to review our processes and practices, products, services and procedures to ensure that our resources are applied in the best possible way to achieve optimum results.

Maintaining a Knowledgeable and Professional Workforce

The TSB's success and credibility depend largely on the expertise, professionalism, and competence of its employees. Although TSB's workforce has traditionally been stable, like many organizations, it faces a specific workforce challenge. Many positions are "one-deep," that is, there is only one person responsible for a specific task or function. In the next few years, the TSB must continue to operate as efficiently as possible while many of its employees and managers retire and the shortage of workers in some operational support areas within the public service will not be remedied. In both the short and long term, a sustained effort is therefore required to implement a more systematic human resources planning process to obtain the skills we need and to develop succession plans and training and mentorship programs that will ensure service delivery and maintain the TSB's knowledge base and its technical expertise.

The results of the 2005 Public Service Employee Survey provided us with an up-to-date assessment of employee satisfaction and concerns. Analysis of the key elements and problems raised showed that efforts are required to respond to employee concerns in some areas including advancement opportunities, job classification, career development, and the opportunity for input into decisions. Here again, the challenge we face is to invest resources and efforts to accommodate employee concerns and the demands of all our obligations.

Maintaining an Information Technology and Physical Asset Infrastructure to Meet the Business Needs

As mentioned earlier, the TSB must balance its priorities to carry out its mandate consistently and economically while assuring stakeholder confidence in the integrity of its operations. Maintaining a reliable, sustainable infrastructure that meets our needs regarding IT or other asset categories is essential if we wish to reach this objective. The TSB currently has close to 14 million dollars in capital assets. However, a little over one million dollars has been expended this year to replace or acquire new assets, which is not nearly enough. Thus, we are making ourselves vulnerable to major risks that could compromise our capacity to meet our needs in the longer term if we do not rapidly take steps to optimize the management of our assets and the resources allocated to them.

Transitioning the TSB Investigation and Information Management System from the Project Stage to a Work Tool

We have invested substantial time, resources, and money to develop the TSB Investigation and Information Management System to better manage our business while meeting government information management and technology requirements. To ensure the system's ongoing viability, we must use it and follow the systematic change management approach that is integrated into it. The sustained participation of investigators in managing change as we move forward is essential to guarantee compliance with the fundamental principles that are the basis of the system. We must encourage finding ways to meet our needs for investigation information using the TSB Investigation and Information Management System, and managers at all levels must discourage the introduction of independent alternatives.

We must make all the TSB Investigation and Information Management System components fully functional. This remaining work has to be done in parallel with the ongoing maintenance and change management required to ensure that the investigation management module is stable. This increases the workload of the system design team and IT staff.

Investigators and support staff also experience increased workloads because they need to participate in designing and testing other system features. Therefore, ongoing expenditures are necessary to operate and maintain the TSB Investigation and Information Management System components both from an IT perspective as well as from an operational and organizational perspective. To not meet these challenges would have a significant impact on the delivery of products and services given that we have decided to not revert to old tools and systems. Partial adoption and use of the TSB Investigation and Information Management System would result in loss of productivity and create inefficiencies in work processes.

Managing Commitments and External Expectations

Over the past few years, a number of TSB communications initiatives have raised public and stakeholder awareness of the TSB and its program. While these initiatives enabled the TSB to influence key change agents for the improvement of transportation safety, they also increased related stakeholder demands (for example, the media request live broadcasts and constantly updated information). Given our operating methods and increasingly limited resources, we must continue to ensure that our external communication products and services are available, up-to-date and of the highest quality to retain the integrity and credibility required to fulfill our mandate. We must also expend more effort to focus our awareness activities on those safety issues for which it is necessary to obtain results.

1.3.4 Resources

The following table summarizes the total financial and human resources allocated to the TSB in 2007-2008, as well as the actual resources utilized for the delivery of the mandate. Financial tables 1 and 2 in Section 3 of this report provide detailed information on the overall financial results of the TSB and Appendix C presents the audited financial statements.

Financial Resources (in thousands of dollars)

2007-2008
Planned Spending	Total Authorities	Actual Spending
29,350	31,546	30,440

Human Resources (full-time equivalents)

2007-2008
Planned	Actual	Difference
235	216	19

1.3.5 Program Activity Architecture

The following table shows the TSB's Program Activity Architecture (PAA). Based on the comments provided by the Treasury Board Secretariat during its assessment of the TSB against the Management Accountability Framework, the Department revised its PAA in 2007-2008. The revised architecture was approved by the Treasury Board and will come into effect in 2008-2009. It will allow to better distinguish the TSB's strategic outcome from the one of the other organizations playing a role in the transportation field and to bring the sub-activities showed in the following table to the program activity level.

Program Activity and Sub-activity by Strategic Outcome
Strategic Outcome	To advance transportation safety, thereby reducing risks to people, property and the environment.
Expected Result	Increased awareness of safety issues and a strengthened safety culture on the part of governments, industry and public.
Program Activity	To conduct safety investigations.
Expected Result	The timely implementation of safety actions by stakeholders to improve transportation safety for Canadians.
Sub-activities	Air Investigations Marine Investigations Rail/Pipeline Investigations
Expected Result	Identification and communication of safety deficiencies in the transportation system to stakeholders and the public.

1.3.6 TSB Priorities

In its 2007-2008 Report on Plans and Priorities, the TSB had identified five priorities. All were strategic investments aimed at enhancing the TSB's contribution to transportation safety in Canada and internationally and strengthening the organization from within.

Overall, progress was achieved against all priorities. However, not all objectives were fully achieved, due to our limited human resources capacity and events outside of our control. On many occasions throughout the year, managers were faced with the difficult choice of reallocating people from one project or investigation to another. The following table provides a quick overview of the results achieved this year against our priorities.

TSB Priorities
TSB Priorities	Type	Performance Status	Planned Spending (in thousands of dollars)	Actual Spending (in thousands of dollars)
Continuous Improvement of Information Management	Previously committed to	Meets expectations in part	480(*)	467
Management of Workload and Priorities Within Available Resources	New	Meets expectations in part	75	59
Increased Human Resources Planning to Ensure the Retention of a Professional Workforce	Previously committed to	Meets expectations in part	100	0
Review of the Sustainability of the Infrastructure	New	Meets expectations in part	50(*)	41
Continuation of Residual 2006-2007 Priority Projects	Previously committed to	Meets entirely	95	110

^(*) A supplementary amount of $33,500 was allocated to these two priority projects at mid-year

1.4 Performance against Priorities

Continuous Improvement of Information Management

In 2006-2007, we have deployed a large part of the Investigation and Information Management System, which follows central documentation principles and allows us to collaborate and share information and employ consistent procedures and processes across all sectors.

This year, in addition to providing ongoing support services to users, we evaluated the performance of our IT infrastructure in order to ensure its long-term viability. This exercise revealed that we have to dedicate additional effort to developing our applications and our core IT processes, supporting IT operations, and developing IT personnel's skills. This is why we decided to delay most of the activities set out in this year's plan, so that we could first implement measures to lay the foundation for consolidating our acquisitions and improve the performance of the Investigation and Information Management System. We have also nearly completed the implementation of our new Enterprise File Plan for our records.

Management of Workload and Priorities within Available Resources

To offset the impact of our shrinking resources over the years and to ensure that we are able to respond to growing public expectations as regards to investigations in light of our workload and our priorities, we have nearly completed our A-Base budget review. Once this exercise is complete, we will have a model for establishing the costs per activity of occurrence investigations and will thus be better equipped to reallocate our human and financial resources to better meet our immediate and future needs. In parallel with this work, we also reviewed the structure and processes for the management of our financial resources to ensure that we are making optimal use of them to achieve the desired results.

Increased Human Resources Planning to Ensure the Retention of a Professional Workforce

TSB's credibility and success are based largely on its capacity to build and maintain a professional workforce to ensure continuity in its operations. This fiscal year, management made enhanced human resources planning a priority in order to be able to more strategically recruit the employees it needs to fulfill its mandate and train and develop employees already in place.

No project to facilitate the transfer of knowledge from experienced to new employees has been undertaken this year. However, senior managers have decided to continue to set aside a portion of the TSB budget for this purpose against next fiscal year in anticipation of the retirement of employees in key positions.

Senior management has also continued this year to address and monitor some TSB-specific issues detailed in the 2005 Public Service Employee Survey.

Review of the Sustainability of the Infrastructure

Because of the ongoing erosion of our resources and in order to maintain our capacity to fulfill our mandate and meet future challenges, we have expanded the capital asset review launched last year. This year, we reviewed our Engineering Laboratory and associated equipment as well as the complete informatics and office equipment infrastructure. This work should be completed by the beginning of the next fiscal year, and should result in a strategic asset management framework as well as an investment plan based on the life cycle of our assets.

Continuation of Residual 2006-2007 Priority Projects

We also continued the initiatives started in 2006-2007 to improve business continuity planning. The development of our business contingency and business resumption plans is now completed. They will be implemented next fiscal year. These plans are essential to ensure the continued availability of TSB services and associated assets that are critical to the delivery of our mandate. These plans will be complemented by an ongoing governance and review process.

We have also completed the implementation of information technology security measures to achieve compliance with Treasury Board's Management of Information Technology Security standards. We have delivered security awareness training to all employees and have updated our IT Network Acceptable Use Policy. We have also completed the detailed threat and risk assessments of our network infrastructure, major IT systems and physical accommodation.

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