Investigation Process

Our Resources

The TSB has approximately 230 employees in offices nationwide. Its head office is located in Gatineau, Quebec, and its engineering laboratory is in Ottawa. Investigative staff are located in regional offices across Canada and can respond quickly to transportation accidents and incidents anywhere in the country.

Our Methodology

There are three main phases of a TSB investigation: the Field Phase, the Post-Field Phase and the Report Production Phase.

Field Phase

Once the decision has been made to investigate an occurrence, an Investigator-in-Charge (IIC) is appointed and an investigation team is assembled. The makeup of the team is based on the circumstances of the occurrence and investigation needs, and may consist of operations, equipment, maintenance, engineering, scientific and human performance specialists. The number of investigators sent to an occurrence site varies from one or two, for a relatively straightforward investigation, to 10 or more for a major investigation.

The field phase can last from one day to several months. During the field phase, team members generally:

• secure and examine the occurrence site;
• examine the equipment, vehicle or wreckage;
• interview witnesses and company and government personnel;
• collect pertinent information;
• select and remove specific wreckage items for further examination;
• review documentation; and
• identify potential unsafe acts and unsafe conditions.

Post-Field Phase

Significant investigation activity takes place after the TSB team departs the occurrence site. The post-field phase can take many months, depending on the investigation's size and complexity. During the post-field phase, the TSB may:

• examine all pertinent company, vehicle, government and other records;
• examine selected wreckage in the laboratory and test selected components and systems;
• read and analyze recorders and other data;
• create simulations and reconstruct events;
• review autopsy and toxicology reports;
• conduct further interviews;
• determine the sequence of events; and
• identify safety deficiencies.

When safety deficiencies are suspected or confirmed, the TSB will advise the appropriate person or authority as quickly as possible, without waiting until publication of the final report, so that the problem can be corrected. The Board may make formal recommendations to draw immediate attention to particular safety deficiencies. The TSB practice is not to wait for a final report, or until an investigation is complete, to make important safety information public.

At the end of the post-field phase, the IIC produces an initial draft investigation report.

Report Production Phase

The Board reviews the initial draft investigation report, which may be approved, amended or returned for further staff work. Once the draft report is approved, a confidential draft report is sent to persons and corporations whose interests may be affected by the report and who are most qualified to comment on its accuracy. They then have the opportunity to dispute, correct or contradict information that they believe is incorrect or unfairly prejudicial to their interests.

This process is intended to ensure procedural fairness and the accuracy of the Board's final report. The Board considers all representations (comments) and will amend the report if required. Once the Board approves the final report, it is prepared for release to the public.

The TSB aims to publish investigation reports as quickly as possible. However, the agency takes the time necessary to do a thorough investigation and to produce a report that advances safety and meets the expectations of the Canadian public and the transportation industry.

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