Annual Report to Parliament 2003-2004

Transportation Safety Board

Annual Report to Parliament 2003-2004

Transportation Safety Board of Canada
Place du Centre
200 Promenade du Portage
4th Floor
Gatineau, Quebec K1A 1K8
(819) 994-3741
1-800-387-3557
www.tsb.gc.ca
communications@tsb.gc.ca

© Minister of Public Works and Government Services
Cat. No. TUI-2004
ISBN 0-662-68101-0

TABLE OF CONTENTS

LIST OF FIGURES

1. Occurrences Reported to the TSB
2. Investigations in Process / Completed
3. Safety Action by the TSB
4. Board Assessment of Responses to Recommendations
5. Marine Occurrences and Fatalities
6. Pipeline Occurrences
7. Rail Occurrences and Fatalities
8. Air Occurrences and Fatalities

MEMBERS OF THE BOARD

Acting Chairperson Charles H. Simpson (from 9 February 2004)
Transportation executive experience includes Executive Vice-President, Operations, for Air Canada; President of the Canadian Air Line Pilots Association; and Vice-President of the International Federation of Air Line Pilots Associations.

Chairperson Camille H. Thériault (until 8 February 2004)
Public management experience includes Premier of New Brunswick, provincial Minister of Economic Development and Tourism, and responsibility for the Information Highway Secretariat. Private enterprise experience includes General Manager of the Kent Industrial Commission and Vice-President of the United Maritime Fishermen.

Member Jonathan Seymour
Transportation policy and marine management experience includes Executive Director of International Maritime Centre-Vancouver; chartering, commercial and general manager for several shipping companies; marine policy advisor to the British Columbia government; and policy and economic consultant.

Member Wendy A. Tadros
Transportation and legal experience includes Director of Legal Services for the National Transportation Agency of Canada; Inquiry Coordinator for "The Road to Accessibility: An Inquiry into Canadian Motor Coach Services"; and counsel to the Canadian Transport Commission before the Commission of Inquiry into the Hinton Train Collision.

Member R. Henry Wright
Management and consulting experience includes auditor for the Ontario Ministry of Community and Social Services; senior management administrator of several non-profit organizations; and consultant in government and public relations.

CHAIRPERSON'S MESSAGE

Canada is a trading nation, and our place in the world is determined in large part by our ability to efficiently transport people, goods and services from coast to coast to coast and beyond our borders. Indicators of our nation's safety culture (for example, the number of reported accidents and related fatalities) show progress in the area of safety across all transportation modes and confirm that the Transportation Safety Board of Canada's (TSB) efforts toward efficiency and improvement are paying off.

In 2003-2004, its efforts were not only successful but also rewarded when, on December 1, 2003, the TSB team that investigated the September 2, 1998 crash of Swissair Flight 111 received the Head of the Public Service Award for Excellence in Service Delivery for its outstanding work.

When the team began its investigation, millions of pieces of wreckage from the aircraft were strewn across the ocean floor approximately 55 metres underwater and there were no recorded voice or technical data to help them reconstruct the final six minutes of the flight. This absence of crucial information forced the team to develop innovative methods to determine what happened.

Working closely with Canadian and foreign government departments and agencies, as well as local authorities, the airline industry, companies and individuals, the members of the team meticulously pieced together the puzzle. The Clerk of the Privy Council and Secretary to the Cabinet considered that their performance was worthy of the Head of the Public Service Award for Excellence in Service Delivery. This award is presented annually to recognize employees who best exemplify the work of public service employees in meeting the challenges outlined in the Clerk of the Privy Council's Annual Report to the Prime Minister on the Public Service of Canada.

The members of the Swissair Flight 111 investigation team demonstrated not only great resourcefulness and professionalism in carrying out their work, but also compassion for the families of the crew and passengers who died. Their dedication and expertise exemplify the best qualities of public service.

It is a momentum of excellence we must continue. Our collective efforts are vital to achieve national prosperity in the new millennium.

In keeping with these efforts, the TSB embarked upon several new initiatives this past year to enhance its overall contributions to domestic and global safety.

For example, the TSB began efforts to improve its response to stakeholder needs. The results of extensive TSB research showed that stakeholders expect the organization to take on a more formal and active role in the safety mosaic, including vigorous and continuous communications.

To this end, the TSB initiated a public awareness program designed to foster dialogue and share information with the industry, operators and regulators. It is our firm belief this program will forge more meaningful relations and, in turn, strengthen our mutual objective to advance safety.

Another TSB priority was to reduce the overall number of open investigations so that our recommendations remain timely and relevant upon their publication in TSB final reports. In 2003-2004, the Treasury Board allocated short-term funding to the TSB to reduce, by the end of 2004-2005, its backlog of investigations in process from 158 to 100 and improve the average time to complete investigations.

During the reporting period, significant progress was made to provide clarity and stability to the way we operate. The adoption of a new business and resources planning framework has enabled the TSB to carry out its mandate more effectively. Throughout the organization, we will continue to refine our business processes in an effort to enhance our relevance and contribution to transportation safety in Canada and around the world.

As in previous years, TSB's practices and methodologies have been sought out by other countries and we have freely shared information and investigative skills with them. Our presence on the international scene contributes to the advancement of transportation safety worldwide and allows our staff to stay abreast of rapid technological changes.

The goal of improving transportation safety is one that provides us with constant challenge. It is important that we take time to review our work, note the strides that we take towards our goal and to celebrate those important milestones. We must rededicate ourselves to this important endeavour and strive to ensure that Canadians can rely on a safe transportation system.

Charles H. Simpson
Acting Chairperson

SENIOR MANAGEMENT

MISSION OF THE TSB

The Canadian Transportation Accident Investigation and Safety Board Act is the legal framework governing the TSB's activities.

The mission of the TSB is to advance transportation safety by:

• conducting independent investigations, including public inquiries, into selected transportation occurrences to make findings as to their causes and their contributing factors;
  
  
• identifying safety deficiencies;
  
  
• making recommendations designed to eliminate or reduce safety deficiencies; and
  
  
• reporting publicly on its investigations and findings.

It is not the function of the Board to assign fault or to determine civil or criminal liability.

INDEPENDENCE

To encourage public confidence in transportation accident investigation, the investigating agency must be, and be seen to be, objective, independent, and free from any conflicts of interest. The key feature of the TSB is its independence. It reports to Parliament through the President of the Queen's Privy Council for Canada and is separate from other government agencies and departments. Its independence enables it to be objective in arriving at its conclusions and recommendations. The TSB's continuing independence and credibility rest on its competence, openness, and integrity and the fairness of its processes.

OCCURRENCES, INVESTIGATIONS AND SAFETY ACTION

In 2003, a total of 1968 accidents and 1388 incidents were reported in accordance with the TSB's regulations for mandatory reporting of occurrences.¹ The number of accidents in 2003 increased by 9% from the 1812 accidents reported in 2002, but decreased by 2% from the 1998-2002 annual average of 1999 accidents. There were also 670 voluntary incident reports. Fatalities totalled 172 in 2003, down from 188 in 2002 and the 1998-2002 average of 263.

Figure 1 - Occurences Reported to the TSB

[D]f1

All reported occurrences were examined in accordance with the Board's Occurrence Classification Policy to identify those with the greatest potential for advancing transportation safety. Investigations were undertaken for 72² of the approximately 4000 occurrences reported to the TSB in fiscal year 2003-2004. In that same period, 73 investigations were completed,³ compared to 109 in the previous year. The number of investigations in process decreased to 137, at the end of the fiscal year, from 139 at the start. Average time to complete an investigation increased to 684 days in fiscal year 2003-2004, from 580 days in the previous year. Several complex multi-year investigations were finalized during the reporting period, which increased the average completion time. We anticipate that the average time will be significantly lower in the coming years. Information on all reported occurrences was entered in the TSB database for historical record, trend analysis, and safety deficiency validation purposes.

Figure 2 - Investigations in Process / Completed

[D]f2

Figure 3 - Safety Action by the TSB

2003-2004	Recommendations4	Safety Advisories	Safety Information Letters
Marine	7	6	11
Pipeline	0	0	0
Rail	4	7	11
Air	0	9	8
TOTAL	11	22	30
Note: A total of six Safety Concerns were issued for Marine in 2003-2004. A total of two Safety Concerns were issued for Rail in 2003-2004.

Figure 4 - Board Assessment of Responses to Recommendations⁵

2003-2004	Fully Satisfactory Attention to Safety Deficiency	Satisfactory Intent to Address Safety Deficiency	Attention to Safety Deficiency Satisfactory in Part	Unsatisfactory Attention to Safety Deficiency
Marine	2	0	2	1
Pipeline	0	0	0	0
Rail	0	0	2	1
Air	0	8	0	3
TOTAL	2	8	4	5

In accordance with the Canadian Transportation Accident Investigation and Safety Board Act, a federal minister who is notified of Board recommendations must, within 90 days, advise the Board in writing of any action taken or proposed to be taken in response or reasons for not taking action. The Board considers each response, assessing the extent to which the related safety deficiency was addressed.

LIAISON WITH CANADIAN TRANSPORTATION COMMUNITY

As part of the TSB's effort to keep abreast of technological change and to maintain contact with the transportation industry in Canada, TSB staff and Board members attend and participate in various conferences and technical meetings pertinent to transportation safety.

Through the Industry Visits Program, members of the Board travelled to Pratt & Whitney and the Canadian National (CN) Taschereau Yard in Montréal; the Port Authority, NAV CANADA, container shipping companies, BC Ferries and the Delta Container Port in Vancouver; and the Harbour Authority, Transport Canada Regional and Coast Guard in Victoria. In the same period, briefings were presented to the Board by the Aerospace Industries Association of Canada (AIAC), the Railway Association of Canada (RAC) and Transport Canada. Members of the Board also made presentations to the Empire Club of Canada, the Canadian Railway Club, and the International Aircraft Cabin Safety Symposium of Canada.

In addition, the Executive Director attended numerous safety and association meetings, including the Canadian Business Aircraft Association's Annual Stakeholders Meeting; the Air Transport Association of Canada's Annual General Meeting; the Canadian Owners and Pilots Association Annual General Meeting; the Canadian Aviation Executives' Safety Network Annual Meeting; and the Transport Canada-sponsored Canadian Aviation Safety Seminar.

Marine staff participated in meetings with the Society of Naval Architects and Marine Engineers, the Canadian Maritime Law Association, the Canadian Marine Pilots Association and the Canadian Marine Advisory Council (at the regional and national level), and made presentations to several organizations. They are also closely involved in the recently formed Inter-Agency Marine Action Group in Vancouver, which promotes marine safety, particularly in the fishing industry.

Pipeline staff made presentations about TSB's mandate and investigative process to the pipeline industry, including TransCanada PipeLines Limited, Enbridge Inc. and Duke Energy, and the National Energy Board, the pipeline safety regulator.

Rail staff made presentations to the rail industry, international rail industry experts, Transport Canada, the Railway Association of Canada, the Rotary Club and the Canadian Fertilizer Institute.

Air staff provided formal briefings on the TSB's mandate, organization and operations to Transport Canada, the Canadian Business Aircraft Association, the Air Line Pilots Association, the Air Canada Pilots Association, the Air Transportation Association of Canada, and to a number of other associations, clubs and organizations. In addition, they worked with the Department of National Defence (DND) to establish a Working Arrangement between the TSB Air Investigations Branch and the DND Directorate of Flight Safety.

Members of the Swissair 111 investigation team provided briefings on the Swissair investigation, as well as other investigation-related topics, to the Conference Board of Canada, the North American Aerospace Congress and Exhibitions (Flight Safety Foundation), the Canadian Association of Fire Investigators, the Air Canada Pilots Association investigators refresher training, the Canadian Association of Fire Chiefs, Transport Canada's Engineering and Flight Test Delegates Conference, an Air Canada engineering managers briefing, a DND Advanced Flight Safety Course, and the Workplace Safety and Health Conference. Team members also participated in the production and airing of two documentaries on the TSB's Swissair 111 investigation.

The TSB's Engineering facilities continued to be of particular interest to industry groups through briefings and visits, resulting in an enhanced awareness and understanding of how scientific methods and technology are used during TSB investigations.

INTERNATIONAL COOPERATION AND KNOWLEDGE TRANSFER

The TSB's mission is to advance transportation safety, not only in Canada but worldwide. This cooperation comes in many forms: participation in safety symposiums, international safety organizations and international investigations.

Over the past year, Board members visited the U.S. National Transportation Safety Board to observe their recommendations follow-up process and the public tabling of an accident report and attended the Air Line Pilots Association Annual General Meeting. The Board was also visited by the Chairman of the Australian Transport Safety Bureau.

The Executive Director attended the Chairman's visit to the U.S. National Transportation Safety Board, met with International Transportation Safety Association executives, and attended the Air Line Pilots Association Annual General Meeting and the Flight Safety Foundation Annual Safety Conference.

Marine staff attended international transportation meetings, including International Maritime Organization (IMO) meetings in London, the Marine Accident Investigators' International Forum in Chile, the International Fishing Industry Safety and Health Conference in Alaska and a Society of Naval Architects and Marine Engineers meeting in San Francisco. They provided a TSB representative to an accident investigation conducted by the IMO on behalf of the government of Senegal and assisted with the presentation of a marine accident investigation course, sponsored by IMO and held in Trieste, Italy.

Air staff participated in foreign investigations in support of the Portuguese authorities in the Air Transat accident investigation, the United Kingdom's Air Accidents Investigation Branch, France's Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile (formerly Bureau Enquêtes-Accidents) and the National Transportation Safety Board of the United States. Formal briefings were provided to Cubana Airlines personnel, the United States Federal Aviation Administration Transport Safety Directorate, the General Aviation Manufacturers Association and the International Aircraft Wiring Issues Conference.

Air staff also participated in consultations and conferences on international standards, bilateral agreements and protocols with the investigation authorities of France, Iceland, Norway, Sweden, Finland, Denmark, Portugal, Italy, Czech Republic, South Africa, China and the United States. Further, participants attended the International Society of Air Safety Investigators Conference, the Flight Safety Foundation Conference, the Human Factors in Aviation Seminar organized by the Australian Aviation Psychology Association and lectured at the Singapore Aviation Academy Aircraft Accident Investigation Course.

TSB's Flight Data Recorder Analysis software has now become widely recognized as a leading Canadian technology. In 2003, users included major aircraft manufacturers and airlines, as well as accident investigation authorities in 11 other countries worldwide. This has led to improved information exchange and international cooperation of benefit to all users and will assist in future TSB investigation efforts.

Also of note, a 90-minute documentary by CBC on the Swissair 111 accident investigation was aired in several European countries in the French and German languages.

Rail staff had formal and informal discussions with regulatory, industry and investigative bodies at two separate international conferences with counterparts from Australasia, China, India, the Middle East, Western and Eastern Europe, and North America. A presentation on vandalism was made at one of these conferences. Rail managers met with the Chairman and the Director of New Zealand's Land Transport Safety Authority who were on a fact finding mission to discuss rail-related safety issues in Canada.

Human Performance staff made a presentation on the application of human factor techniques to accident investigation at the 12^th International Aviation Psychology Symposium. They also delivered the Human Factors in Investigations course to external participants including international investigative agencies (New Zealand, Holland and Turkey), provincial and federal investigative and regulatory bodies (Workers' Compensation Board of BC, Government of Manitoba, Saskatchewan Government Insurance, DND, Transport Canada and the National Energy Board), and industry (Air Canada, NAV CANADA, PROAV International Aviation Services Corporation, Pakistan International Airlines and Nexen Chemicals).

Macro Analysis staff presented the research report "An Accident-Based Examination of Factors Associated with Train-in-Crossing Collisions" to the 34^th Annual Conference of the Association of Canadian Ergonomists. A representative also gave a presentation on applicability of safety investigations to industry as the invited International Luncheon Speaker for the 21^st International System Safety Society Annual Conference.

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