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Transportation Safety Board of Canada Departmental Performance Report For the period ending
Table of Contents Section 1: The Chairperson's Message
Section 3: Departmental Performance
Appendices Appendix A: Transportation Safety Statistics Appendix B: Financial Performance Appendix C: Internet Addresses for Other Organizations List of Figures and Tables Figure 1: Accidents Reported to the TSB Figure 2: Summary Financial Information Figure 3: Occurrences Investigated and Safety Actions-Part I Figure 4: Occurrences Investigated and Safety Actions-Part II Figure 5: Assessment of Responses to TSB Recommendations-Current Year Figure 6: Assessment of Responses to TSB Recommendations (1990-2001) Figure 8: Use of Financial Authorities Figure 9: Detailed Breakdown of 2001-2002 Total Authorities Figure 10: TSB Historical Spending Financial Table 1: Summary of Voted Appropriations Financial Table 2: Comparison of Total Planned Spending to Actual Spending Financial Table 3: Historical Comparison of Total Planned Spending to Actual Spending Section 1: The Chairperson's Message In July 2002, I had the honour of accepting the position of Chairman of the Transportation Safety Board of Canada (TSB). I am very proud to assume leadership of such a professional and credible organization. The raison d'être of the TSB, to advance transportation safety, is a critical and laudable mandate. During the past year, the TSB has been, once again, successful in identifying a broad range of safety deficiencies and in conveying key safety messages to the public, industry and regulators. Stakeholders continue to perceive TSB recommendations in a very positive manner and respond with actions that are clearly focused on improving safety. The various safety actions taken as a result of the TSB's work underscore the important contribution made by this agency in the reduction of risks in the Canadian transportation system and internationally. Indeed, the TSB enjoys an excellent reputation at the national and international levels. The TSB is perceived as an authoritative and independent resource in the field of transportation safety. In September 2001, the TSB was recognized with the Jerome F. Lederer award for its work on the Swissair Flight 111 accident investigation. This prestigious award from the International Society of Air Safety Investigators recognizes the TSB's technical excellence in accident investigation. Despite its successes, the TSB continues to struggle with some perennial issues. Preoccupations with report timeliness and resource management have persisted for many years. During the past year, the senior management team has recognized the need for substantive change, particularly in the area of resource planning and management. A strategic and business planning process was implemented thereby providing the organization with a better sense of overall direction and priorities for all its activities. A strong commitment was made towards incorporating modern comptrollership into the agency's day-to-day management practices, a decision that has elicited positive recognition from the Treasury Board Secretariat. As I undertake my new mandate, I view the future with optimism. Our goal is to build upon well-established strengths while focusing on areas where improvements are required. I fully support the change agenda undertaken by the management team over the past year. The stakeholder needs analysis, one of the priority activities for the current year, will provide us with invaluable information which will help us map a direction for the TSB for years to come, and to review our yardsticks for measuring performance. During my tenure as Chairman, I commit to a philosophy of openness, both personally and organizationally. We will continue to develop links with key stakeholders, while ensuring that our independence is not compromised. Significant challenges lie ahead for the TSB. However, I am confident that the organization is up to meeting these challenges and that we can be counted upon to continue making an effective contribution to a safer transportation system for Canadians and globally. Section 2: Strategic Context 2.1 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, when 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 which in turn may result in recommendations designed to improve safety and reduce or eliminate risks to people, property and the environment.
The jurisdiction of the TSB includes all marine, rail, pipeline and air transportation occurrences in or over Canada. The Board also represents Canadian interests in foreign investigations of transportation accidents involving ships, railway rolling stock, or aircraft registered, licensed, or manufactured in Canada. In addition, the Board carries out some of Canada's transportation safety obligations to the International Civil Aviation Organization (ICAO) and the International Maritime Organization (IMO). 2.2 Key Co-delivery Partners The TSB reports annually to Parliament on its activities, findings, and recommendations through the President of the Queen's Privy Council, and as such is not part of the Transport Canada portfolio. The creation of the TSB as an independent agency eliminated any potential for a conflict of interest within government bodies regulating or operating transportation activities while also investigating the failures associated with their own regulations and operations. The legislation gives the TSB the exclusive authority to investigate for the purposes of making findings as to causes and contributing factors and provides that other departments (such as Transport Canada and the National Energy Board) may investigate for any other purposes. The TSB's investigation process is described on our Web site at http://www.tsb.gc.ca/en/investigation_process/index.asp . 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, next-of-kin, and operators, with other organizations and agencies, such as coroners, police, manufacturers, owners, and insurance companies, and with other federal government departments and agencies. The cooperation of all these individuals and organizations is essential to the conduct of the TSB's business. The TSB has no authority to implement changes; its mandate is limited to the identification of safety deficiencies and the communication of credible safety messages and persuasive arguments to influence change. 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 is one of many Canadian and foreign organizations involved in improving transportation safety nationally and internationally. 2.3 Social and Economic Factors The TSB operates within the context of the very large and complex Canadian transportation system (see Transport Canada's Internet site at http://www.tc.gc.ca/pol/en/t-facts3/Transportation_Annual_Report.htm and National Energy Board site at http://www.neb.gc.ca/energy/index_e.htm for details). This system is very dynamic and in a constant state of change, resulting in particular challenges for the TSB. 2.3.1 Public Interest in Transportation Safety Transportation safety has always been a matter of public concern in Canada. This is largely due to the essential social and economic role that the transportation system plays in this country. New information demands have evolved in the aftermath of such accidents as the crash of Swissair Flight 111 (SR 111) near Peggy's Cove, Nova Scotia, the April 2001 Via Rail train derailment in Stewiacke, Nova Scotia, the sinking of the True North II small passenger vessel near Tobermory, Ontario, and the February 2001 explosion of a gas pipeline compressor station in Quebec's Eastern Townships. News media expect real-time, round-the-clock, on-site coverage. The expectations of the next-of-kin for support from the investigating agencies have also increased. They have an enormous thirst for up-to-date factual information; most wish to follow closely the progress of the investigation. Given the loss they have suffered, great care must be exercised in communicating with them. The TSB also faces increasing demands for occurrence data from regulators, as well as for information through the Access to Information program, especially given the increasing trend toward litigation resulting from transportation accidents. Fulfilling these evolving needs is proving to be a major challenge with existing resource levels. 2.3.2 Government Policy and Industry Environment In recent years, partly as a result of government initiatives and partly in response to commercial imperatives, various changes have occurred that may influence transportation safety. Among the changes are the continued reliance on commercial interests in the transportation system to provide a safe transportation infrastructure without prescriptive regulations, and the increasing consolidation and globalization of companies. The highly competitive environment in all elements of the transportation industry and the demands by the public and shippers for an almost accident-free transportation system are also significant considerations. 2.3.3 Impact of Technology on Transportation Over the last 10 years, the rate of technological change in the transportation industry has been very rapid. This is largely due to significant advances in computer and electronics technology, the development of new materials, and their application to the transportation industry. These advances affect all modes of transportation, and while many of them enable investigators to perform their work more effectively, they also make the job of investigation and safety analysis increasingly complex and specialized. The increased reliance on automation poses particular problems for analysing failures at the human-machine interface. 2.3.4 Level of Activity An average of 3500 transportation occurrences are reported each year in accordance with federal reporting requirements. The TSB bases its decision to investigate on its Occurrence Classification Policy (see the TSB Internet site at http://www.tsb.gc.ca/en/common/policies/occurrences.asp for details) using a comprehensive risk management process aimed at evaluating the consequences of operational decisions. The prime criterion for deciding to investigate is whether an investigation is likely to lead to a reduction in risk to persons, property or the environment. Based upon these considerations, the TSB does not investigate some accidents less likely to result in safety actions, even when they involve fatalities. This has resulted in some adverse public reaction, and the TSB has come under increased public pressure to investigate more occurrences. Approximately160 investigations are currently in progress; approximately 40% of these are more than one year old. For a relatively small organization, the management of this backlog, combined with the sustained uptake of new cases, presents an ongoing challenge to meet the demands. 2.3.5 Aftermath of 11 September 2001 The 11 September 2001 terrorist attacks in the United States have had a significant impact on transportation activities in Canada and abroad. Public confidence in the safety and security of air travel has decreased. These events have fundamentally changed how transportation security is viewed and delivered in all modes in order to ensure the personal safety of Canadians. The TSB was not directly affected by these events as its mandate focuses only on safety. Other federal government departments and agencies, such as Transport Canada and the Royal Canadian Mounted Police, are responsible for all security matters. However, the TSB faced an indirect impact in the weeks and months that followed 11 September 2001 due to the heightened public concern. Increased pressure was placed on the TSB to respond and quickly deploy to investigate accidents and incidents thereby assuaging fears of terrorism. The passage of time has now reduced this pressure to a normal level. Section 3: Departmental Performance 3.1 Strategic Outcomes In its 2001-2002 Report on Plans and Priorities, the TSB defined the following desired strategic outcomes and related indicators.
However, in mid-year, after completing its 2000-2001 Departmental Performance Report (which showed mixed results for another year), the TSB senior management determined that a different approach was required. The TSB then undertook a comprehensive strategic planning process with participation of a broad cross-section of departmental employees. An examination of the internal and external environment provided support to this planning process by identifying issues that must be resolved to maximize the potential for achieving the strategic outcomes. These issues were used to elaborate revised strategies that provide a basic sense of direction for the activities of the TSB for the 2002-2005 planning period. This led to the publication of a strategic plan followed by the development of the 2002-2003 Report on Plans and Priorities and a detailed business plan for 2002-2003 (see the TSB Web site for the complete strategic plan at http://www.tsb.gc.ca/en/publications/rpp/2002/rpp2002.asp ). This was therefore a transition year for the TSB as the organization started moving towards a renewed agenda. Much effort and resources were placed on this transition process for the second half of the year. The performance results reported in this report are therefore not substantially different from those of previous reports. However, the TSB senior management is confident that significant change can be effected over the next two to three years. 3.2 Performance Accomplishments Canada's transportation system is considered one of the safest in the world. Again this year, progress has been achieved in our ongoing quest to advance transportation safety even further. In 2001, a total of 1959 accidents and 1448 incidents were reported in accordance with the TSB's regulations for mandatory reporting. There were also 643 voluntary incident reports. The number of accidents in 2001 decreased by 2% from 2000 and by 9% from the 1996-2000 annual average of 2156 accidents. However, the number of reported incidents increased, particularly in the aviation sector. This year was marked by declines in the number of accidents reported in the aviation and marine sectors, whereas the rail sector's record remained relatively the same (see Appendix A for details). In fact, the number of reported accidents involving Canadian-registered aircraft represents the lowest number of accidents reported in the last 25 years. This reduction 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.
It is virtually impossible to measure accurately the impact of the TSB on transportation safety. No two investigations are identical. Some lead to significant safety improvements, and others do not. There is also no good way to link costs incurred by the TSB directly to specific improvements in transportation safety. However, the TSB has certainly been successful in achieving its strategic outcomes over the past year as evidenced by the numerous safety actions taken by its co-delivery partners using the TSB's findings and outputs. The next few pages of this report summarize the results and outcomes of the TSB's work over the past year as measured against the stated performance indicators. Given the magnitude of the SR 111 accident investigation, a separate section is dedicated to reporting the results achieved to date on that particular undertaking. 3.2.1 Summary Financial Information Figure 2 below summarizes the financial performance of the TSB and separates resources utilized for the SR 111 investigation and for other departmental activities. Detailed information about the TSB's financial performance is included in Appendix B.
3.2.2 Results Achieved Against Performance Indicators The following symbols are used to indicate the results achieved against each performance indicator:
Our Accomplishments: Overall, the TSB has been successful in identifying safety failures and in reducing risks in the transportation systems. TSB investigations result in widely distributed 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 a careful application of the TSB's occurrence classification policy in deciding whether to investigate or not, and on 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 2001-2002, the TSB issued a total of 80 safety outputs (16 recommendations, 37 safety advisories and 27 safety information letters). 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 alert 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 operational practices and procedures, preventive modifications to equipment, replacement of parts, and the modification of training programs. Figure 3 provides a few specific examples of such safety actions that were taken during 2001-2002.
Safety information is also provided to key stakeholders throughout the investigation process permitting them to take immediate safety actions where appropriate. It is common practice to observe safety action being taken by industry and government during the course of TSB investigations. In such situations, rather than issuing recommendations, the TSB can then report on the corrective actions already taken by industry and government agencies. Such safety action can range widely in scope and importance. Operators will often take immediate remedial action after discussion with TSB investigators (for example, 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. Figure 4 provides a few specific examples of safety actions that were taken before the TSB investigations were completed.
Our Accomplishments: The TSB continues to be successful in providing access to safety information and recommendations. In 2001-2002, the TSB published 110 investigation reports, as well as monthly and annual statistical reports. The TSB continues to publish the Reflexions safety digest. 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. During the year, the TSB surveyed readers of the Reflexions safety digest to assess their views about this publication. Results of this study were extremely positive. Reflexions is viewed as an effective vehicle to reach frontline workers and operators in the transportation industry and to expose them to the TSB's safety messages. Readers find the publication interesting, informative, and useful. The study concluded that the TSB should expand the contents and increase the frequency of publication. After careful consideration of the study results, TSB senior management has deferred implementing any changes to Reflexions pending the results of a broader stakeholder needs analysis currently underway. The TSB has taken a pro-active approach to 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 dialogue with key stakeholders, including the early communication of safety issues that arise during the investigation. The Communications Division took over the responsibility of filling client requests for publications and encourages clients to access information through informal requests, thereby providing Canadians with information without the need to use the formal Access to Information process. This has resulted in a significant decrease in the number of requests processed by the Access to Information staff.
The TSB is making use of its Internet site to make its reports and other transportation safety information available to Canadians. An average of 288 000 pages of information are downloaded from the TSB Web site every month - an increase of 21% over last year. Visitors to the site are Canadians and people from all around the world. The increased traffic on the Web site can be attributed to the ease and timing of access, and to the increased volume of information made available. The use of the Web site has proven to be a cost-effective and more timely way of disseminating information. Building upon this success, the TSB is currently further improving the Web site to meet government on-line objectives and to provide faster, more user-friendly access to safety information. The TSB contributes to the dissemination of safety information at the international level. Many TSB information products are distributed not only in Canada but also in the United States, in Europe, and in various other countries around the world. The TSB also assists in the distribution of information originating from foreign countries. Over the past year, the TSB distributed to Canadian media copies of the news releases published as part of the Portuguese investigation of the Air Transat flight that landed in the Azores due to fuel starvation. Such cooperation between the TSB and foreign organizations contributes to greater public access to safety information worldwide. This year, the TSB has started including its news releases on the Publiservice What's New site, thereby broadening the dissemination and increasing the visibility of TSB safety information. The TSB is consolidating its role as the official Canadian repository of transportation accident/incident data by ensuring that these data can be made available to others when and as required. During this year, the TSB has undertaken a joint project with Transport Canada to create a common data warehouse permitting greater access to transportation safety data. The TSB has also contributed to the review and enhancement of national and international transportation safety regulations through the provision of safety information. For example, the Marine Branch presented safety information relating to occurrence statistics and investigation reports to the fishing vessel working groups of the Canadian Marine Advisory Council and to committees at the International Maritime Organization. This information was used by participants to determine the appropriateness and scope of changes to regulations.
Our Accomplishments: One important measure to gauge the quality of TSB findings and recommendations is by assessing the TSB's effectiveness in convincing others of the need for change to improve safety. The TSB therefore assesses the responses to its recommendations to establish the extent to which the underlying safety deficiency has been or is being redressed. Logically, the extent of the planned implementation of safety actions will be predicated upon the degree to which the addressee has accepted the existence of a particular unsafe condition and the magnitude of the associated risks. In 2001-2002, the TSB received responses to 17 safety recommendations. Sixteen were assessed as either Fully Satisfactory or having a Satisfactory Intent to address safety deficiencies identified in the recommendations. No response was assessed as Unsatisfactory. The results of this assessment are shown in figure 5.
Over a longer time frame, the response to TSB recommendations is also very positive. Figure 6 illustrates the assessment of responses to TSB recommendations issued since 1990.
Although clients are satisfied with the quality of TSB findings, the TSB regularly undertakes continuous improvement initiatives. During the year, a working group reviewed the effectiveness of investigation reports and subsequently introduced a new presentation format for conclusions and findings. Depending on the depth of the investigation, findings are reported under one or more of the following categories: Findings as to Causes and Contributing Factors, Findings as to Risks, and Other Findings. In this format, safety deficiencies are more focused and are more clearly communicated to stakeholders so that appropriate remedial actions can be taken. Since its inception, the TSB has been acutely aware of the obligation to provide key safety information in a timely fashion to those who are in a position to implement changes. As discussed in previous pages, critical safety related information is provided informally throughout the investigative process. It is also provided through such mechanisms as safety advisories or information letters, once again during the investigation when it becomes apparent that important information should be shared with others. The TSB also produces, from time to time, recommendations when enough information is available to recommend safety changes even before the conclusion of an investigation or the publication of the report. That notwithstanding, a final investigation report, particularly one that contains safety recommendations, is one of the most anticipated of the TSB's safety products. In recognition of that, the TSB's objective for many years has been to publish final reports within a year of the occurrence. Despite the emphasis placed on report timeliness and efforts to accelerate the investigation / report production process, adherence to the one-year standard has yet to be consistently achieved.
This year a conscious decision was made to reduce the number of new investigations started so that resources could be focussed on in-progress investigations and the renewal agenda. The 92 investigations started this year constitute a 20% decrease from 2000-2001. A total of 110 reports were completed during this period, an increase from the 90 reports completed the previous year. The average time in progress was approximately 20 months, results comparable to 2000-2001, as shown in figure 7. Overall, this effort contributed to the decrease in the number of investigations in progress at year-end (159 ongoing investigations versus 177 last year) and to the decrease in the number of investigations that had passed the one-year objective (67 compared to 102 last year). The reduced uptake of cases and the reduction in the number of old cases in progress demonstrate modest progress in improving our performance on report timeliness.
A fundamental review of performance measures for success in the timely provision of important safety information is the first priority articulated in the 2002-2003 Business Plan. This priority has been outlined in the 2002-2003 Report on Plans and Priorities and will be reported on in next year's performance report.
Our Accomplishments: Overall, recognition of the TSB's name by the media and the public continues to increase. The TSB is very well recognized within the transportation industry and the specialized media. More and more Canadians now recognize the TSB name and can make a distinction between the TSB and Transport Canada. This recognition continues to develop in the context of high profile accident investigations such as the sinking of the Lady Duck amphibus, the Stewiacke train derailment, and the crash of SR 111. However, there remains a certain confusion within the mainstream media and the general public. TSB investigators are often mistaken as Transport Canada employees. Therefore, improving Canadians' recognition of the TSB is a continuing effort. One of the products used by the TSB to promote its role and its activities is the Annual Report. In 2001-2002, the TSB contacted a sample group of people included in the distribution list of its Annual Report to seek their views on the usefulness of that report. This study revealed that the Annual Report did not serve as a primary source of information about the TSB and its activities, and that other means (that is, Reflexions, investigation reports, brochures and Web site) could be as effective in disseminating information and reaching target audiences. The study concluded that the TSB should reduce its investment in this product and make greater use of other means of disseminating information. After consideration of the study results, the TSB decided to produce a shorter and less-detailed Annual Report for 2001-2002. The TSB is also currently exploring the feasibility of combining the Annual Report with future Departmental Performance Reports, starting in 2002-2003. This measure would fulfill the TSB's legislated obligations and free-up resources that could then be reinvested in other more effective communication products. A new brochure on the TSB investigation process was developed and distributed for use as a tool to provide accurate, succinct and straightforward information on the role of the TSB. This brochure is distributed to next-of-kin, media, police officers, local government officials and other Canadians by TSB investigators during the course of their activities in order to increase the awareness and understanding of the TSB's role and its processes. It is also distributed to members of the general public to provide information on the TSB's mandate and activities. Feedback on this new brochure has been extremely positive. In the past year, the TSB worked closely with the National Aviation Museum in Ottawa to develop a major exhibit at the museum called "Seeking Safer Skies." The exhibit showcases different elements of the TSB's work thereby increasing the awareness by Canadians of the TSB's role in advancing transportation safety. The exhibit is planned as a permanent exhibit for the museum, but designed to be portable so that it can be displayed at different venues across Canada in the future. The exhibit opened to the public in May 2002 and has since become a very popular attraction for visitors to the museum.
Our Accomplishments:
The TSB is very well recognized at both the national and international levels. A number of memoranda of understanding have been negotiated to facilitate cooperation with other Canadian organizations. These organizations recognize the professionalism and expertise of the TSB in its field of competence and have come to rely on the TSB's findings. This recognition transcends the federal and provincial jurisdictions. For example, at the request of the provincial government, the TSB has successfully conducted an investigation into a short-line railway accident in Alberta. The Canadian transportation industry has also developed a high level of confidence in the work of the TSB. This is demonstrated by numerous invitations to present papers and to participate in various conferences and technical meetings related to transportation safety.
The TSB is also recognized for its contribution to safety by people and organizations outside the transportation industry. OHS Canada, a reputable magazine devoted to occupational health and safety issues, published a feature article on the TSB outlining the TSB's expertise, timely release of findings, investigative techniques and independence. This magazine also regularly uses TSB statistics and information in its articles. The Integrated Safety Investigation Methodology training program developed by the TSB continues to draw significant interest amongst other safety organizations within and outside of Canada. Numerous requests have been received for participation in these training sessions. Although the TSB is not in the business of providing training to others, vacant seats in the investigator training sessions have been offered to other persons involved in transportation safety either in public or para-public organizations. The provision of such training has proven beneficial as participants are gaining a better understanding of how the TSB works and how they can work with us more effectively in the future. Similarly, the TSB included participants from safety agencies in the United States and Jamaica, as well as the International Transportation Safety Association (ITSA), in its "Investigating for Human Factors" course. The TSB was also invited to attend national and international conferences and workshops to present the TSB methodology for investigating for human factors in transportation occurrences. By participating in such events and sharing methodologies, the TSB not only provided industry with its best practices for their own internal use, but also paved the way for a better understanding by industry of the rigour applied to those investigations undertaken by the TSB. The International Society of Air Safety Investigators (ISASI) honoured the TSB with the Jerome F. Lederer award in September 2001. This award, which recognizes outstanding contributions to technical excellence in accident investigation, is much coveted by those in the aviation accident investigation fraternity. The award was presented to the TSB for the conduct of its investigation of the SR 111 accident and for its use of non-conventional methodologies that advanced the field of aviation accident investigations. The TSB contributed with other member states in the International Civil Aviation Organization's Flight Safety and Human Factors Study Group and in the Human Element Forum of the International Maritime Organization, resulting in the development of guideline documents for use around the world. Staff from the TSB have also been requested to lecture annually at the International Maritime Academy in Trieste, Italy where students are taught methodologies and legislation used by marine investigation organizations worldwide. 3.2.3 Swissair Flight 111 (SR 111) Investigation The crash of SR 111 has resulted in the most complex transportation accident investigation ever undertaken in Canada. Since the accident, TSB staff have worked tirelessly on this investigation. To date, the incremental cost of the investigation to the Canadian government has been approximately $53.7 million.
Our Accomplishments: This single investigation has already led to significant advancements in transportation safety worldwide. Numerous safety deficiencies have been identified by the TSB and communicated publicly. Although the final investigation report has yet to be published, the TSB has, in the interim, communicated important factual information and released safety recommendations. Fourteen safety recommendations, five safety advisories, and three safety information letters have been issued to Canadian, United States, and European authorities, resulting in a number of safety actions to reduce risks (see the TSB Web site at http://www.tsb.gc.ca/en/investigations/swissair/index.asp for details). In addition, ongoing dialogue has taken place to raise the awareness of and help stakeholders better identify and resolve the related potential safety deficiencies. Safety actions initiated to date will result in an estimated cost of well over one billion dollars for the worldwide transportation industry. They include:
Clients are generally very satisfied with the work of the TSB on this investigation. Many TSB recommendations were quickly accepted by the regulatory agencies in Canada, the United States and Europe, due to the compelling case submitted to them. Specialists in the industry have also commended the TSB on its thorough work in identifying the safety deficiencies. News coverage of this investigation has been very positive towards the TSB and its work. Feedback from next-of-kin of the victims has also been very positive. However, questions about the publication of the final investigation report are now being raised. After more than three years, some stakeholders would like to see the completion and publication of the final investigation report so that closure can be achieved. However, considerable work remains before the TSB can consider SR111 activity complete. Although the technical investigation and analysis work is now concluded and a draft report has been written, the TSB must now complete the report review and production phases before the final report can be released publicly. International agreements require that the draft investigation report be provided to the representatives of the State of manufacture of the aircraft (USA) and the State of Operation (Switzerland) to allow them an opportunity to review and comment on the report. Canadian legislation also requires that those individuals or organizations whose product or reputation is commented upon in the investigation report and who may be adversely affected be given an opportunity to make representations concerning the Confidential Draft Report. That confidential draft review process is now underway, thereby marking a significant milestone towards completion of the final investigation report. Many Canadians are not fully aware of the international agreements that oblige the Canadian government to conduct thorough investigations into aircraft accidents that occur within its territory. Neither is there a full understanding of the complexity of certain types of investigations, or why they can take several years to complete. On many occasions, the TSB has attempted to explain its role in meeting its responsibilities under the international agreements signed by Canada. However, more work is required in this area before Canadians fully understand Canada's obligations and reciprocal arrangements under which other countries would be obliged to investigate accidents involving Canadian aircraft if they were to occur within their territory. 3.3 Other Performance Issues to Note
Our Accomplishments: In 2001-2002, the TSB set out on the ambitious renewal agenda described in the Report on Plans and Priorities. Renewal activities were defined under three major headings: operational readiness, report timeliness and resourcing strategies. Work was undertaken on these activities but, after a few months, the TSB senior management determined that a different approach was required if the organization was to succeed. The work plan was revised and the course of action was adjusted for the remaining portion of the year. Significant progress was made on the achievement of the revised objectives; however, more work is required to improve the organizational performance. First, the TSB undertook and completed a comprehensive strategic planning process which now provides a basic sense of direction for TSB activities over a five year period. This new orientation was integrated in the 2002-2003 Report on Plans and Priorities (accessible at http://www.tsb.gc.ca/en/publications/index.asp) and then further elaborated in a detailed Business Plan for the 2002-2003 fiscal year. This business plan clearly lays out specific deliverables and accountabilities. Many elements of the initial renewal agenda have been brought forward in these new planning documents. Progress was also made on a number of other fronts. A departmental assessment was initiated in collaboration with Treasury Board Secretariat officials and resulted in a one- time infusion of $1 million to address some of the resource pressures faced by the TSB. This new funding allowed the TSB to make a major investment in capital assets (motor vehicles and informatics infrastructure) to alleviate a growing rust-out problem, as well as to catch up on in a few other operational areas. This assessment process is ongoing and now focuses on the ongoing resource pressures faced by the TSB. The TSB took steps to rationalize spending on information technology by implementing a strategy for the centralized management and upgrading of equipment and software. Workforce rejuvenation has started due to the retirement of a number of employees; staffing actions are currently underway to replace these recent retirees. A national recruitment campaign for investigators was undertaken, attracting significant interest. However, the TSB was not able to take full advantage of the campaign in 2001-2002 due to internal resource allocation issues and conflicting management priorities. Significant improvements were made on the timeliness of internal resource allocations for 2002-2003. A number of management improvements initiatives were undertaken and are now starting to yield results. For example, the Financial Information Strategy was fully implemented, staffing delegations were reviewed and updated, an employee recognition program was implemented, and a Modern Comptrollership capacity assessment was completed. A particular emphasis was placed on employee learning. Approximately 4% ($1.2 million) of the TSB resources were invested in employee training and development activities in 2001-2002. Although significant, this investment is not sufficient for employees to keep up with the accelerated pace of change in technology used within the transportation industry. Learning was therefore identified as one of the top priorities for 2002-2003. A competencies-based approach to learning is now an integral part of the TSB business plan for 2002-2003.
Our Accomplishments: The TSB has made significant progress on the implementation of government-wide initiatives. This was the first year of operation under the Financial Information Strategy (FIS) environment for the TSB. Residual activities to achieve full compliance with FIS requirements were completed. The implementation of the accrual accounting system and related new procedures was successful. Comprehensive financial statements were produced and subsequently audited by the Auditor General of Canada (accessible on the TSB Web site at http://www.tsb.gc.ca/en/publications/index.asp). Efforts led to the achievement of full compliance with the employment equity provisions of the Canadian Human Rights Act. Input was also provided to the Task Force on the Modernization of Human Resources. The TSB demonstrated leadership and commitment towards modern comptrollership by quickly undertaking to review and complete a capacity assessment initiated during the previous year. The results of this assessment were discussed between the TSB senior management team and senior Treasury Board Secretariat representatives. Priorities for action were identified and specific action items were subsequently integrated into the annual TSB business plan (available on the TSB Web site at http://www.tsb.gc.ca/en/publications/strategic_planning/strat_plan.pdf). Work is now underway to improve organizational management performance as described under the previous performance indicator. The TSB also played an active role within the federal government small agencies community. TSB officials participated in a number of work groups in order to share best practices and to collaborate on certain projects in order to minimize costs and efforts. TSB staff were recognized by the Treasury Board Secretariat and the small agencies community for their leadership in this regard. Section 4: Other Information The TSB reports publicly on all its investigations. Most TSB investigation reports published since 1995 are available on the TSB Internet site. The TSB also publishes periodic statistical reports for each of the four transportation modes. These reports are also available on the TSB Internet site. Finally, the TSB publishes an annual report to Parliament, detailed audited financial statements, and a periodic safety magazine titled Reflexions, all available in printed form upon request. Miscellaneous additional information is also available on the TSB departmental Internet site at http://www.tsb.gc.ca. For further information, you may also contact us at: Communications Division e-mail: communications@tsb.gc.ca Appendices A - Transportation Safety Statistics C - Internet Addresses for Other Organizations Involved in Transportation Safety Transportation Safety Statistics The following table presents the statistics on transportation occurrences by mode, including comparisons with the five-year averages. Taking into account the level of activity in each mode, the accident rates for 2001 continue to exhibit a general downward trend.
The following table 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. The statistics provided in this table are
extracted from Chapter 4 of the Transportation in Canada 2001: Annual Report
published by Transport Canada. More comprehensive information is available in
that publication at
Financial Performance Financial Performance Overview The TSB started the year with authorities of $24.1 million. Supplementary Estimates in the amount of $6.3 million were then approved for the carry-forward of the previous year's lapse, collective bargaining adjustments, program integrity adjustments and for the extraordinary costs of the SR 111 investigation. Transfers in the amount of $0.5 million were also made from Treasury Board votes, thereby increasing total authorities to $30.9 million. In 2001-2002, the TSB spent $30.1 million of its $30.9 million total authorities. The lapse of $0.8 million is primarily due to lower spending than anticipated on salaries and training for new employees, as well as lower spending on operational activities. The complete audited financial statements of the TSB are available on the Web site at http://www.tsb.gc.ca/en/publications/index.asp . The total expenditures of the TSB, minus SR 111, represent an approximative cost of $0.87 per Canadian citizen. With SR 111 investigation costs included, the number rises to $0.97 per Canadian citizen. For this amount, Canada maintains the capability to investigate major failures in four different modes of the national transportation system.
Financial Table 1: Summary of Voted Appropriations This table explains the way Parliament voted resources to the TSB.
Financial Table 2 : Comparison of Total Planned Spending to Actual Spending This table explains, in a government-wide standardized fashion, the way resources are used by the TSB.
Financial Table 3: Historical Comparison of Total Planned Spending to Actual Spending This table provides an historical perspective on how resources are used by the TSB.
In 1998-1999 and 1999-2000, spending is much higher due to SR 111 investigation costs of $34.0 million and $13.4 million, respectively. Internet Addresses for Other
Organizations More information on transportation safety in Canada is available from other federal government agencies who also play a role in this area. The Internet addresses for the main organizations are as follows:
More information on transportation safety in selected countries is available on the following Internet sites:
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: work is underway
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achieved. 
