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Departmental Performance Report

The Chairperson's Message

The past year has been marked by a number of important accomplishments for the Transportation Safety Board of Canada (TSB). We have achieved a significant reduction in the number of investigations in process and in the number of unpublished reports. We have expanded our communications activities. We have also made good progress on the development of a new investigation information management system.

Although we have not yet fully achieved all of our objectives as stated in the Report on Plans and Priorities, we are satisfied that the organization has made good progress on all of its commitments and that potential risks to our program have been reduced. More importantly, I am confident that we will succeed in completing the outstanding work over the next few months.

A substantial portion of this work was made possible by the incremental funding provided by Parliament over the past two years. Now that these temporary resources have expired, the management team is focussing its efforts on ensuring a good balance between the resources available and the uptake of new investigations. This will ensure that the organization does not overextend itself and that the high quality standards that Canadians expect are maintained in all of our work.

Once again this year, various indicators show that Canada maintains a very good transportation safety record. A review of transportation accident rates over the past 10 years reveals a progressive downward trend. We therefore believe that the efforts of the TSB toward advancing transportation safety, in concert with the work of many other organizations, are having a beneficial impact.

Canadians expect and demand a safe and sound transportation system. As we look to the future and the challenges that lie ahead, we are committed to sustaining our efforts and to contributing to a transportation system that is safe and reliable - a system upon which Canadians can rely and of which they are confident.

Section 1: Overview

1.1 Mandate and Mission

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). Under this legislation, the TSB's only objective is the advancement of transportation safety in the marine, rail, pipeline and air transportation systems. This mandate is fulfilled by conducting independent investigations including, if necessary, public inquiries into selected transportation occurrences. The purpose of these investigations and inquiries is to make findings as to the causes and contributing factors of the occurrences and to identify safety deficiencies. As a result, recommendations may be made to improve safety and reduce or eliminate risks to people, property and the environment. The TSB has the exclusive authority to make findings as to causes and contributing factors when it investigates a transportation occurrence.

Our mission: We conduct independent safety investigations and communicate risks in the transportation system

The jurisdiction of the TSB includes all federally regulated transportation occurrences in or over Canada. The TSB may also represent Canadian interests in foreign investigations of transportation accidents involving Canadian registered, licensed or manufactured ships, railway rolling stock, or aircraft. In addition, the TSB carries out some of Canada's obligations related to transportation safety at the International Civil Aviation Organization and the International Maritime Organization.

The TSB reports annually to Parliament on its activities, findings and recommendations through the President of the Queen's Privy Council. As such, the TSB is not part of any portfolio to which Transport Canada, the Canadian Coast Guard or the National Energy Board belong. The creation of the TSB as an independent agency eliminates any potential, real or perceived, for a conflict of interest within government bodies regulating or operating transportation activities who are also investigating failures associated with their own regulations and operations.

1.2 Management Representation Statement

1.3 Operating Environment

The TSB operates within the context of the very large and complex Canadian transportation system (see the Transport Canada website and the National Energy Board site for details).

1.3.1 Key Co-Delivery Parties

Many individuals and groups cooperate with the TSB in the fulfilment of its mandate. During the course of an investigation, the TSB interacts directly with:

• individuals such as survivors, witnesses and next-of-kin;
• operators;
• manufacturers;
• other organizations and agencies, such as coroners, police, 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 as providers of information or of support services. For more details on the investigation process, visit the TSB website.

The TSB is one of many Canadian and foreign organizations involved in improving transportation safety nationally and internationally. While it operates at arm's length from other federal departments involved in the transportation field, it can only succeed in fulfilling its strategic outcome through the actions of others. The TSB presents findings and makes recommendations that call upon others to act, but it has no formal authority to regulate, direct or enforce specific actions. This implies ongoing dialogue, information sharing and strategic coordination with organizations such as Transport Canada, the National Energy Board and the Canadian Coast Guard.

Similarly, the TSB must engage in ongoing dialogue and information sharing with industry and foreign regulatory organizations. 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. The TSB can therefore be deemed successful when others, such as regulators, operators and manufacturers, implement actions to mitigate risks using the TSB outputs.

The TSB has established memorandums of understanding with a number of 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 (e.g. assistance for the recovery of wreckage, the documentation of information and the examination or testing of components). The agreements also define operating practices to ensure coordination of activities and to avoid duplication and potential conflicts that could arise from the simultaneous implementation of various organizational mandates. Such agreements are currently in place with Transport Canada, National Defence, the Royal Canadian Mounted Police, the Canadian Coast Guard, Human Resources and Skills Development Canada, the National Energy Board and the National Research Council. Similarly, the TSB has established strategic cooperation alliances with provincial and territorial coroners/chief medical examiners.

Further alliances have been established with the TSB's counterpart agencies in other countries, such as the United States, Australia, the Netherlands, France and the United Kingdom. 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. The TSB is also an active participant in the International Transportation Safety Association (ITSA) and the Nordic Accident Investigation Group. As an internationally respected investigative agency, the TSB regularly shares its investigation techniques, methodologies and tools. For example, the Recorder Analysis and Playback System (RAPS), developed by the TSB for decoding and analysis of flight data recorders and cockpit voice recorders, has now been used for a number of years by 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 and participates in international work groups and studies to advance transportation safety.

1.3.2 Risks and Challenges

The TSB faces a number of risks and challenges that could have a potentially significant impact on the organization's ability to achieve its mandate. TSB managers are aware of these risks and challenges and are expected to take appropriate actions to mitigate the risks while ensuring the delivery of their mandate. The most important challenges are described in the following paragraphs.

1.3.2.1 Managing External Expectations

The TSB has a variety of stakeholders and clients with diverse information needs. Regulators and industry want information in order to fulfill their responsibilities in improving transportation safety. Next-of-kin want information about what happened to their loved ones in order to bring closure. Others want information from a business perspective. Regardless of the motive, all agree that they would like safety information to be made available earlier and more effectively. Furthermore, stakeholders and the public would like the TSB to undertake more safety investigations than what is currently done. The TSB is therefore challenged to find the right balance between the level of activity to be undertaken, potential safety payoffs and the resources available. This implies an ongoing review of products, services and processes to ensure that resources are invested in the best possible way to achieve the optimum results. The TSB must also communicate effectively with its stakeholders and the public in order to convey its priorities and its limited capacity. The TSB must ensure that reasonable expectations are set through appropriate communication.

1.3.2.2 Maintaining Operational Capability

The success of the TSB and its credibility as an organization depend largely on the expertise, professionalism and competence of its employees. Rapid technological changes in the transportation industry, along with the development of new materials, are making the task of investigation and safety analysis increasingly complex and specialized. The TSB must not only maintain an appropriate capital asset infrastructure, but must also keep up its technical expertise and knowledge base in order to maintain credibility within the industry. In recent years, the TSB has mounted a successful effort to "catch up" on essential training for employees and managers to ensure they have the knowledge and skills to meet mandatory job requirements. Nevertheless, the challenge of retaining technical currency requires careful planning backed by adequate financial resources.

1.3.2.3 Increasing Awareness to Influence Positive Changes

To achieve its mandate and to influence stakeholders to take actions that lead to positive changes in transportation safety, the TSB must present compelling arguments for change in its reports and other communication products. This requires a solid understanding amongst stakeholders and the public about who we are, what we do and how we contribute to transportation safety. We believe that improving awareness about the TSB and its work will better position the TSB to influence key change agents. To that end, the TSB has adopted a three-year Corporate Communications Plan, which is essentially a road map of how we want to improve communications. The Plan represents a more active approach to publicizing key safety messages to influence positive changes. However, the challenge lies in finding the right mix of activities within a limited pool of resources.

1.3.2.4 Implementing Government-wide Initiatives

Over the past year the Government has launched a number of government-wide initiatives and reviews that have had, and will continue to have, an impact on the TSB. For example, initiatives such as the proactive disclosure of information regarding travel and hospitality expenses, position reclassifications and contracts have resulted in new work for the TSB with no additional resources being provided. The series of Government Operations Reviews (e.g. shared corporate services, IT services, procurement, institutional governance) has also had a significant impact on workload. These reviews are now completed and decisions will soon be made by the Government. As the TSB proceeds with the implementation of the resulting changes, further impacts are expected. The implementation of Human Resources Management Modernization is an excellent example of centrally directed programs having an immediate and substantial impact on TSB resources. The challenge is to continue to incorporate these cumulative requirements into daily activities within the resource envelope available, while maintaining a suitable balance between the fulfillment of the TSB's mandate and the implementation of the Government's overall agenda.

1.3.2.5 Balancing Resources and Results

The TSB, like all other government departments and agencies, must operate with a fixed resource base. Over time this base is eroded by numerous external factors such as inflation, new service fees and general price increases. The TSB must therefore contend with diminishing resources as time passes. Furthermore, the Government has directed that new requirements be funded through reallocation rather than through the provision of incremental funding. The resultant challenge is to maintain an appropriate balance in the level of operational activity in a context of increasing demand for services and diminishing resources.

For some time now, the TSB has been struggling with the issue of performance measurement. Progress has been made on the development of meaningful performance indicators. However, more work is required in this regard, particularly with respect to linking resources to results. Given that no two investigations are identical, and that some investigations lead to safety changes whereas others do not, it is very difficult to establish the return on investment in safety investigations. The direct and positive impact of TSB investigation activities can be readily demonstrated; conveying the value for money using traditional financial measures is, however, much more challenging.

1.4 Resources

The following tables summarize the total financial and human resources allocated to the TSB in 2004-2005, as well as the actual resources utilized for the delivery of the mandate. Section 3.2 of this report provides detailed information on the overall financial performance of the TSB.

1.5 Summary of Departmental Performance

In its 2004-2005 Report on Plans and Priorities, the TSB identified four priorities. All were described as strategic investments aimed at finding ways to enhance the TSB's relevance, its contribution to advancing transportation safety in Canada and internationally, and its strength from within. The first two priorities - Improving Service Delivery and Improving Communications - were directly linked to external products, while the other two - Sustainable Human Resources, and Information and Technology Management - were more internally focussed.

Overall, substantial progress was achieved against all priorities. However, not all objectives were fully achieved, primarily due to our limited human resources capacity. On many occasions throughout the year, managers were faced with the difficult choice of reallocating people from one project or investigation to another. Despite the challenges, positive results have been achieved and lessons have been learned with respect to project planning and resource allocation. Table 2 provides a quick overview of the results achieved this year.

1.5.1 Improving Service Delivery

The TSB sought and obtained special incremental funding in 2003-2004 and 2004-2005 to address its perennial problem of a backlog of investigations in progress. Specific commitments were made to reduce the number of investigations in progress and to improve the average time in process. Excellent results have been achieved on both commitments. For example, the number of investigations in progress decreased from 142 at the start of the fiscal year to a year-end total of 99. The average time to complete an investigation, from the time of the accident to publication of the official report, decreased to 619 days in 2004-2005 from 684 days in the previous year. A further decrease in the average time is expected in future, now that the backlog of old reports has been significantly reduced. Investments were made in investigator training workshops in order to improve their efficiency and effectiveness. TSB Manuals of Investigation were reviewed and updated. Section 2.9 provides more details on the results achieved against this priority.

1.5.2 Improving Communications

In 2004-2005, the TSB implemented its new corporate communications plan. A proactive public outreach program was also successfully implemented, providing opportunities for the Members of the Board, the Executive Director and other senior personnel to meet with various groups and discuss key safety messages. Progress was also made on publishing more reports and safety information on the TSB website. From an internal perspective, improvements were made to vertical and horizontal communications through the involvement of employees and managers in various working groups, as well as the publication of internal newsletters and communiqués. Sections 2.4 and 2.9 provide more details on the results achieved against this priority.

1.5.3 Sustainable Human Resources

Work continues to ensure that human resources are managed in a strategic and sustainable manner. Work has progressed on the review and modernization of our human resources management frameworks, and a number of new policies have been implemented. New tools to assist managers are being developed but have yet to be fully implemented. Although some training has been provided to employees and managers, more efforts are required in this regard. However, to date, the TSB has met all its obligations with respect to the implementation of the Public Service Modernization Act; all mandatory activities have been completed on time. Section 3.4 provides more details on the results achieved against this priority.

1.5.4 Information and Technology Management

New information management policies and guidelines were developed and implemented. Training sessions were provided to all staff across the country. New function-based corporate file plans were developed. Significant progress has been made on the development of the Transportation Investigation Information Management System (TIIMS) despite difficulties encountered along the way that led to delays in piloting and implementation of system modules. Section 2.9 provides more details on the results achieved against this priority.

1.5.5 Ongoing Activities

In 2004-2005, the TSB succeeded in delivering the expected results from its ongoing activities. The number of new investigations started was maintained compared with previous years, and process improvements were implemented to ensure a timely completion of investigation reports. The ongoing dialogue was maintained with industry and key stakeholders. Strategic investments continued to be made in order to maintain the competencies of staff and the required technical infrastructure. Additional management improvement initiatives were also implemented, including the introduction of a new internal governance structure.

Obviously, the TSB cannot claim that the general reduction in transportation occurrences is solely related to its work. The safety and the security of the transportation system are a shared responsibility. The TSB works with governments, transportation industries, agencies, associations and international organizations to improve the system. It also collaborates with other government departments and agencies whose programs and services may be affected by transportation activities. It is virtually impossible to accurately measure the impact of the TSB on transportation safety. However, the TSB has certainly been successful in achieving its strategic outcome over the past year, as evidenced by the numerous safety actions taken by change agents within the transportation sector using the TSB's findings and outputs. These results are described in detail in section 2. Therefore, it can be asserted that the TSB is fulfilling its obligations within the Canadian transportation safety mosaic in a highly competent and professional manner.

Section 2: Detailed Analysis of Performance

2.1 Performance Management Framework

The TSB has developed and implemented an integrated performance management framework. This framework consists of five key documents. The five-year TSB Strategic Plan is used to set the strategic directions. The annual Business Plan is then used to set the short-term priorities and to guide the activities and resource allocation decisions for the coming year. The Report on Plans and Priorities, based on the Business Plan, defines the commitments to Parliament and Canadians. The Balanced Score Card defines specific performance indicators and is used by management to measure and monitor progress. Finally, the Departmental Performance Report closes the accountability loop by reporting to Parliament on the results achieved.

This has been a transition year for the TSB in terms of performance management, as we undertook to adapt our performance management framework in order to align it with the new Program Activity Architecture. This Departmental Performance Report is therefore based in part upon the new accountability structure. Detailed performance information is presented for each key service area of our main program activity.

2.1.1 Plans and Priorities Commitments

In its 2004-2005 Report on Plans and Priorities, the TSB defined one strategic outcome and a number of performance indicators. The following logic model identifies the linkages between the activities of the TSB and the achievement of its strategic outcome. The logic model is a road map showing the chain of results connecting resources and activities to outputs and to expected intermediate and final outcomes.

2.1.2 Measurement Methodology

The TSB has introduced a balanced score card, which will now be the main tool used to measure organizational performance. This score card tracks performance along four major perspectives: financial, client/stakeholder, internal business process, and learning and growth. Fiscal year 2004-2005 is the first year in which the TSB has used this tool. It is therefore expected that refinements will be required in future years to ensure that the balanced score card is fully tailored to the TSB's needs and that it provides a comprehensive performance picture. Adjustments may also be required to ensure proper alignment with the Treasury Board's new Management, Resources and Results Structure Policy.

Various methods are used to identify and capture performance information. Most of the data used in the analysis came from TSB information systems, supplemented by Transport Canada information where appropriate. Anecdotal evidence that illustrates the performance assessment was obtained from various sources, such as stakeholder feedback, magazine articles, press clippings and individual testimonials. Where sources of information external to the TSB are used, they are identified.

As noted, some of the performance indicators are being used for the first time. Only very limited analysis of these measures can therefore be done at this time, given that only baseline data are currently available.

Proper care and attention to data quality and limitations were ensured throughout the production of this report. This report presents an accurate picture of the state of TSB business and affairs on March 31, 2005. The financial statements have been audited by the Auditor General of Canada, and her audit report is included in Appendix C. Other performance information is not currently subjected to an independent review or validation process.

2.2 Transportation Occurrences

In 2004, a total of 1,935 accidents and 1,476 incidents were reported in accordance with the TSB's regulations for mandatory reporting of occurrences.¹ The number of accidents in 2004 decreased by 2% from both the 1,973 accidents reported in 2003 and the 1999-2003 annual average of 1,978 accidents. The 1,476 reportable incidents in 2004 was up from the 1,390 reported in 2003 and the 1999-2003 average of 1,361. There were also 679 voluntary incident reports. Fatalities totalled 185 in 2004, up from 172 in 2003 but down from the 1999-2003 average of 202.

Table 4 presents data on accident rates by mode for the current year, as well as the five-year average. Keeping in mind that each has its own inherent limitations, these aggregate measures of activity provide a general point of reference on transportation safety. Overall, Canada continued to maintain a good safety record in 2004. The 2004 accident rates, per activity level for all modes, reflect a downward trend from the five-year average.

Reported accidents and incidents also provide indicators of the transportation system's safety performance and help focus efforts on those initiatives and activities that have high safety benefits. Table 5 presents the statistics on transportation occurrences by mode, including comparisons with the five-year average. Taking into account the level of activity in each mode, the accident rates for 2004 continue to exhibit a general downward trend. Another indicator of the safety performance of the transportation system is the number of fatalities. In 2004, the air, marine and rail modes showed a decrease in fatalities from the five-year average. A reduction in accidents and fatalities would be expected to positively influence the public's confidence in the safety of the transportation system.

Despite fluctuations in the number of accidents and incidents reported on an annual basis, the trend over the past 10 years shows a progressive decline in accident rates in all modes (see the graphs in subsections 2.5 to 2.8). These reductions cannot be directly attributed to the efforts of any specific organization. Improvements in transportation safety are the result of the combined efforts of many participants including manufacturers, carriers, crews and regulators, as well as the TSB.

More comprehensive information is available on the TSB website or in Chapter 4 of the Transportation in Canada 2004: Annual Report published by Transport Canada.

2.3 Investigations and Safety Action

All reported occurrences were assessed in accordance with the Board's Occurrence Classification Policy to identify those with the greatest potential for advancing transportation safety. Information on all reported occurrences was entered into the TSB database for historical record, trend analysis and safety deficiency validation purposes. In-depth investigations were undertaken for 74 of the approximately 4,000 occurrences reported to the TSB in fiscal year 2004-2005. In that same period, 115 investigations were completed, compared with 73 in the previous year.² The number of investigations in progress decreased to 99 at the end of the fiscal year from 142 at the start. The average time to complete an investigation decreased to 619 days in fiscal year 2004-2005 from 684 days in the previous year (see Table 6 for details).

Significant progress was made on reducing the backlog of very old investigation cases. Of the 99 investigations in progress at year-end, only 6 were more than two years old, representing a significant improvement over previous years. These results are directly attributable to the allocation of incremental investigation resources in order to focus efforts on the completion of complex investigations that were more than two years old and on a number of other initiatives aimed at improving performance over the longer term. These efforts should translate into measurable productivity gains in future years. More details on the improvement results achieved to March 31, 2005 are available in section 2.9.1 of this report.

In general, the TSB has been successful in identifying safety failures and in reducing risks in the transportation systems. TSB investigations result in reports identifying safety failures and, where appropriate, containing recommendations to reduce risks. Over this past year, in all cases where the TSB undertook an investigation, safety failures or factors contributing to the occurrence 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.

In 2004-2005, in addition to investigation reports, the TSB issued a total of 59 safety outputs: 11 safety recommendations, 24 safety advisories and 24 safety information letters (see Table 7 for a breakdown by mode).

These outputs led to concrete actions by other organizations that directly improved safety and/or reduced risks. For example, Transport Canada has targeted safety inspections, issued bulletins to inform industry about specific safety concerns, and introduced changes to safety regulations and procedures. Similarly, industry has reacted to the TSB's work by undertaking numerous safety actions, such as changes in operating practices and procedures, preventive modifications to equipment, replacement of parts, and the modification of training programs. Sections 2.5 to 2.8 provide specific examples of such safety actions that were taken for each mode during 2004-2005.

Safety information is also provided informally to key stakeholders throughout the investigation process, permitting them to take immediate safety actions where appropriate. 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 (e.g. to clear the line of sight at a railway crossing by trimming bushes and vegetation). Regulators, such as Transport Canada 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.

In accordance with the Canadian Transportation Accident Investigation and Safety Board Act, a federal minister who is notified of TSB recommendations must, within 90 days, advise the Board in writing of any action taken or proposed to be taken in response, 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.

In 2004-2005, the TSB received responses to 18 safety recommendations. The Board assessed 3 responses as "fully satisfactory," 7 as having a "satisfactory intent" to address safety deficiencies identified in the recommendations, and 4 as "satisfactory in part." Further, 4 responses were assessed as "unsatisfactory." The results of this assessment process are shown in Table 8.

The Board has recently approved the posting on the TSB website of its initial assessment of the responses to all new safety recommendations. This new measure will be implemented during the 2005-2006 fiscal year and will provide the public with an indication of the safety actions taken in response to the TSB's recommendations.

In 2004-2005, the TSB undertook a comprehensive reassessment of responses to all recommendations issued since its creation in 1990. All safety recommendations were reviewed. A number of them were categorized as inactive by the Board, requiring no further follow-up either because the safety deficiency has been rectified or because the residual risk is relatively low. The detailed reassessment of all active recommendations was completed by TSB staff, and the results were presented to the Board for further consideration. The Board has also approved the re-establishment of an annual reassessment process to ensure that structured follow-up is done on all outstanding recommendations in future. This process will provide a longer-term view of the results achieved from the TSB's safety recommendations.

2.4 Liaison, Cooperation and Knowledge Transfer

The TSB continues to promote awareness of safety issues and of a safety culture among transportation stakeholders. Every opportunity is taken to reiterate key messages and create awareness of safety issues. In 2004-2005, the TSB published 115 investigation reports, as well as monthly and annual statistical reports. Two issues of the Reflexions safety digest were published during fiscal year 2004-2005. These digests contribute to the advancement of transportation safety by reflecting on the safety lessons learned from accident and incident investigations. They also provide an effective tool to disseminate the results of safety investigations to a broad audience.

The TSB maintains a proactive approach to the dissemination of information. Information is made readily available to industry, next-of-kin, the media and the public throughout the investigation process. Investigative staff are encouraged to maintain a dialogue with key stakeholders, including the early communication of safety issues that arise during the investigation. In an effort to satisfy both the public and the media's expectation for up-to-date, factual information, the TSB responded to 1,289 information requests received through its website and 528 media calls during the year, not including those inquiries handled at the scene of an accident or at a report release news conference. The TSB held six news conferences and issued 38 news releases. The TSB's Macro-analysis Division responded to 602 requests for complex transportation occurrence database information.

The TSB uses its website to increase awareness of safety issues and other transportation safety information. The site (www.tsb.gc.ca) received an average of more than 51,000 daily hits and 2,300 daily visits, a 24% increase in daily visits over the previous year. The visitors are Canadians and people from all around the world. The increased traffic on the site can be attributed to the ease of access and the expanded volume of information made available. The site has proven to be a cost-effective and timely way of disseminating information.

TSB library staff participated in the formation of the Canadian Transportation Research Gateway, a collection of Internet resources on transportation research in Canada. The Gateway was formed through a collaboration of the libraries of the Canadian Transportation Agency, Transport Canada, the Transportation Development Centre, the Transportation Association of Canada and the TSB.

Marine staff continued to participate on various International Maritime Organization (IMO) committees and subcommittees, and particularly in the Human Element and Casualty Analysis working groups and correspondence groups. The TSB has contributed to the identification and validation of marine safety issues for IMO committees and assisted in the development and subsequent amendments of the IMO Code for the investigation of marine casualties and incidents. The TSB is a founding member of the Marine Accident Investigators' International Forum and this year made presentations at the meeting in South Africa. Marine staff were again requested to present a marine accident investigation course, sponsored by the IMO and held at the International Maritime Academy in Trieste, Italy. A monthly column about noteworthy Canadian marine investigations is prepared for the Marine Engineers Review, a noted United Kingdom publication. Informatics hosted a site for the Marine Accident Investigators' International Forum, where they posted the results of a survey on the implementation of the IMO Code for the investigation of marine casualties and incidents.

Given the high number of fishing accidents reported to the TSB (approximately half of the shipping accidents reported involve fishing vessels), the TSB is also involved in an initiative to promote a safety culture in the west coast marine community, particularly among operators of small vessels and fishing vessels. The Inter-Agency Marine Action Group brings together agencies from both the federal and provincial governments and industry, and provides an opportunity to collaborate to promote safety awareness, provide safety education and foster safe operating practices. The objective is to effect behavioural change within the marine community and thereby reduce the incidence of marine-related accidents and fatalities. During 2004-2005, a dozen presentations were made to the regional fishing community and various safety promotional materials were distributed. Particular efforts were made to translate, publish and distribute safety information cards in Vietnamese to more effectively communicate with a large segment of the regional marine community in their mother tongue.

Air staff completed its support to the Gabinete de Prevenção e Investigação de Acidentes com Aeronaves, the accident investigation authority of Portugal, in its release of the final investigation report on the 2001 Air Transat accident in the Azores. Air staff also attended the 2004 International Society of Air Safety Investigators Conference and presented a discussion paper on the theme "Investigate, Communicate, Educate: Are We Doing Things Right?" The TSB participated as part of the Canadian delegation at the International Civil Aviation Organization (ICAO) 35th Assembly. It consulted with the Director General of the Swedish Board of Accident Investigation on the fundamentals of national legislation for accident investigation authorities. The TSB briefed the Republic of Congo Civil Aviation Administration delegation on Canada's approach to accident safety investigation. It participated in the Flight Safety Foundation International Safety Symposium and held meetings with France's Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile on international investigations and inter-agency procedures. The TSB also participated in the 21st meeting of the Group of Experts on Accident Investigation of the European Civil Aviation Conference. Air Branch investigators continued to represent the TSB as accredited representatives in numerous foreign accident investigations involving Canadian-manufactured, designed or certified products, or when Canadian passengers had been exposed to risk.

Engineering staff participated in the Accident Investigation Recorders Working Group held in Washington in June 2004, the Recorders Analysis and Playback System Users Conference in Ottawa in June 2004, and the Flight Data Recorder Parameter Working Group. A TSB staff member has been designated the Canadian representative for the ICAO Flight Recorder Panel. Engineering staff examined aircraft instruments for investigations carried out by Zimbabwe and Japan. Staff also attended engine tear-down at Pratt & Whitney as an accredited representative for Italy and helped the U.S. National Transportation Safety Board in failure analysis.

Rail staff made a presentation on organizational and cultural impacts on safety at the International Rail Safety Conference in Perth, Australia. Staff also attended the International Pipeline Conference in Calgary. At both the Perth and Calgary events, attendees came from a wide range of countries. Formal meetings were held with the South African rail regulator in Ottawa and with the new British Rail Accident Investigation Branch of the Department of Transport, the British rail regulator, and the Health and Safety Executive. These discussions were wide-ranging, covering regulatory and investigative philosophies and processes, as well as issues related to operational approaches to investigation. Finally, the TSB established a link to a new Internet domain for the International Rail Safety Conference. This will make the majority of papers that have been presented at the conference over the years available to a wider audience.

Pipeline staff held formal and informal discussions with regulatory, industry and investigative bodies at an international conference with their counterparts from South America, Asia and North America. The Manager of Pipeline has been corresponding with his counterpart in Brazil, providing details on the regulatory and investigative regime in Canada.

Human Performance staff participated in human factors working groups at international transportation meetings, including IMO meetings in London and ICAO meetings in Montréal. They attended the ICAO Threat and Error Management Symposium in Seattle and the Associated Professional Sleep Societies Conference in Philadelphia. Human Performance staff also delivered the Human Factors in Investigations course to external participants, including provincial and federal investigative and regulatory bodies (Department of National Defence, National Energy Board, Transport Canada - Rail, and Workers' Compensation Board of British Columbia), industry (Air Line Pilots Association, Canadian Pacific Railway, Quebec North Shore and Labrador Railway Company) and academia (University of British Columbia).

Macro-analysis staff participated in the ICAO's Safety Indicators Study Group. The Macro-analysis Division also provided statistical reports to international agencies and industries.

Although it is difficult to measure the results of TSB activity in this area, tangible signs point toward a certain degree of effectiveness in achieving the desired outcome. For instance, the demand for TSB safety information continues to increase year after year. Stakeholders and the media make use of TSB safety messages in their activities. There is a sustained level of interest, both in Canada and around the world, in TSB techniques and methodologies.

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