Annual Report to Parliament 2005-2006

Transportation Safety Board
Annual Report to Parliament 2005-2006

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

© Minister of Public Works and Government Services
    Cat. No. TU1-2006
    ISBN 0-662-49233-1

TABLE OF CONTENTS

Members of the Board
Chair's Message
Senior Management
Mission of the TSB
Independence
Occurrences, Investigations and Safety Action
Liaison with Canadian Transportation Community
International Cooperation and Knowledge Transfer
Marine Occurrence Statistics and Investigations
Pipeline Occurrence Statistics and Investigations
Rail Occurrence Statistics and Investigations
Air Occurrence Statistics and Investigations
Appendix A - Glossary

LIST OF FIGURES

1. Occurrences Reported to the TSB
2. Investigations in Process/Completed
3. Safety Action by the TSB
4. Board Assessment of Responses to Recommendations Issued in 2005-2006 and those Pending from 2004-2005
5. Marine Occurrences and Fatalities
6. Pipeline Occurrences
7. Rail Occurrences and Fatalities
8. Air Occurrences and Fatalities

MEMBERS OF THE BOARD

Acting Chair Wendy A. Tadros (from 9 December 2005) Transportation and legal experience includes Director of Legal Services for the National Transportation Agency of Canada; Inquiry Coordinator for "The Road to Accessibility: An Inquiry into Canadian Motor Coach Services"; and counsel to the Canadian Transport Commission before the Commission of Inquiry into the Hinton Train Collision.

Acting Chairperson Charles H. Simpson (until 8 December 2005) Transportation executive experience includes Executive Vice-President, Operations, for Air Canada; President of the Canadian Air Line Pilots Association; and Vice-President of the International Federation of Air Line Pilots' Associations.

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

Member James P. Walsh Was the Member of the House of Assembly in Newfoundland and Labrador for the district of Conception Bay East-Bell Island from 1989 to 2003. Most recently, served as Minister of Works, Services and Transportation, and also served as Minister of Tourism and Culture, Parliamentary Secretary to the Minister of Finance and Treasury Board, and Parliamentary Secretary responsible for the Newfoundland and Labrador Housing Corporation. Also served as Caucus Chairman and Vice-Chair of the Public Accounts Committee. In 2003, received the distinction of Honorary Life Member of the Transportation Association of Canada.

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

CHAIR'S MESSAGE

The Transportation Safety Board of Canada (TSB) enjoys a solid reputation, nationally and internationally, as a skilled and professional investigative organization. As one of only a few multi-modal safety investigation agencies in the world, the TSB pursues its mandate within a framework of independence that makes it a global leader in that regard.

The period covered by this annual report spans a year in which the TSB was guided by two Acting Chairpersons - myself and my predecessor and colleague Mr. Charles Simpson. As you will see, it was a period of challenge and reward for this organization.

This annual report provides an update on transportation accidents and incidents reported to the TSB, its investigations, and the recommendations it has issued to address the identified deficiencies. It also presents the responses to these recommendations from the federal departments concerned, as well as the Board's assessments of the responses, which are now posted on the TSB website. We are annually actively reviewing actions taken to address our recommendations and will publish this information on our website. This action is taken in the hope that this public disclosure will act as an incentive to influence greater change and lead to improved safety actions.

The information in this report is divided into the four modes of transportation on which the TSB conducts investigations: marine, pipeline, rail and air. Occurrence statistics and descriptive tables on occurrences are provided, along with an outline of safety action taken during the year. The report also summarizes the Board's activities in areas such as liaison with the transportation community and international cooperation.

The TSB continues to be more efficient: the average time to complete an investigation went from 619 days last year to 464 days this year. This demonstrates steady progress and ensures that the transfer of safety knowledge is expedited, both in Canada and abroad. In addition, we are making significantly more information available online. The latent demand for a broader range of information available from the TSB is reflected in the number of visits to our website, which have more than doubled compared to last year.

In the same vein, the Board has started implementation of its internal information system called the Transportation Investigation Information Management System (TIIMS). This system enables the TSB to meet government information management and technology requirements while also improving operational efficiency in the delivery of our mandate.

The TSB is strongly committed to making a significant contribution to transportation safety in Canada and abroad. Our sustained efforts will ensure that our products and services, as well as our business activities, remain effective and efficient for the delivery of our mandate.

Wendy A. Tadros
Acting Chair

SENIOR MANAGEMENT

MISSION OF THE TSB

We conduct independent safety investigations and communicate risks in the transportation system.

INDEPENDENCE

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

OCCURRENCES, INVESTIGATIONS AND SAFETY ACTION

In 2005, a total of 2037 accidents and 1371 incidents were reported in accordance with the TSB's regulations for mandatory reporting of occurrences.¹ The number of accidents in 2005 increased by 5% from both the 1945 accidents reported in 2004 and the 2000-2004 annual average of 1946 accidents. The number of reportable incidents decreased to 1371 in 2005, down from 1483 in 2004 and the 2000-2004 average of 1414. There were also 615 voluntary incident reports. Fatalities totalled 189 in 2005, up 3 from the 2004 total but equal to the 2000-2004 average.

FIGURE 1 - OCCURRENCES REPORTED TO THE TSB

[D]f1

All reported occurrences were examined in accordance with the Board's Occurrence Classification Policy to identify those with the greatest potential for advancing transportation safety. Information was entered into the TSB database for historical record, trend analysis and safety deficiency validation purposes. Investigations were undertaken for 79 of the approximately 4000 occurrences reported to the TSB in fiscal year 2005-2006. In that same period, 75 investigations were completed, compared to 115 in the previous year.² The number of investigations in process increased to 106 at the end of the fiscal year from 102 at the start. Average time to complete an investigation decreased to 464 days in fiscal year 2005-2006 from 619 days in the previous year.

FIGURE 2 - INVESTIGATIONS IN PROCESS/COMPLETED

[D]f2

FIGURE 3 - SAFETY ACTION BY THE TSB

2005-2006	RECOMMENDATIONS3	SAFETY ADVISORIES	SAFETY INFORMATION LETTERS
Marine	6	5	8
Pipeline	0	0	1
Rail	0	9	8
Air	6	7	5
TOTAL	12	21	22
Note:	A total of 12 Safety Concerns were identified for Marine in 2005-2006. A total of 1 Safety Concern was identified for Rail in 2005-2006. A total of 2 Safety Concerns were identified for Pipeline in 2005-2006.

In accordance with the Canadian Transportation Accident Investigation and Safety Board Act, a federal minister who is notified of a Board recommendation 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 by the proposed or completed action. When a recommendation generates responses from within and outside Canada, the Board's assessment is based primarily on the Canadian response. This year, the TSB began making public its assessments of responses to TSB recommendations from industry and government made after 1 January 2005 by publishing them on this website.

LIAISON WITH THE CANADIAN TRANSPORTATION COMMUNITY

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

Members of the Board made presentations to the International Helicopter Safety Symposium 2005 in Montréal, Quebec, the Canadian Maritime Pilots' Association in Québec, Quebec, the Operation Lifesaver annual conference in Gatineau, Quebec, and the Canadian Board of Marine Underwriters annual general meeting in Toronto, Ontario. They also attended the Air Canada Pilots Association flight safety conference in Toronto, the Air Transport Association of Canada annual symposium in Montréal, the Helicopter Association of Canada annual convention in Vancouver, British Columbia, the Administrative Tribunal Members' Forum in Ottawa, Ontario, and the Council of Canadian Administrative Tribunals annual conference also in Ottawa. Members of the Board also visited Canadian Pacific Railway's new infrastructure in Kamloops, British Columbia.

In addition, the Executive Director was a guest speaker at the Chief Coroners and Chief Medical Examiners annual conference and the Canadian Business Aviation Association annual training seminar. The Executive Director also attended the Canadian Transportation Agency and Railway Association of Canada annual workshop, the Canadian Aviation Executives' Safety Network annual meeting, Transport Canada's annual Canadian Aviation Safety Seminar, the Air Transport Association of Canada annual symposium and the annual executive meeting of the Association québécoise des transporteurs aériens.

The Director General, Investigation Operations, attended meetings with individual Canadian railway companies and an industry association to discuss matters of mutual interest, and participated in consultative sessions of the Canadian Maritime Law Association, the Canadian Marine Advisory Council, the Air Transport Association of Canada and the National Research Council Aerospace and Surface Transportation organizations. He made presentations to the annual Flightscape Users conference, the 2005 SARSCENE conference (search and rescue issues) and the Transportation of Dangerous Goods Advisory Council annual meeting. He also participated in the International Civil Aviation Organization (ICAO) briefings on results of its audit of Canada's conformance to ICAO obligations.

Marine staff in Vancouver, continue to take a leading role in the Marine Action Group activities whereby safety presentations, which include practical displays of vessel stability characteristics, are made to fishing and other interests. Presentations have also been made to Pacific Marine Training Institute students, the BC Seafood Alliance, the Workers' Compensation Board of British Columbia, the Pacific Prawn Fishermen's Association, the Crab Fishermen's Association, the Hupacasath Native Band Fishers and the Pacific Coast Marine Review Panel. In the Central region, staff attended Canadian Marine Advisory Council meetings (both national and regional), gave presentations on fishing vessel safety and participated in important marine discussions. Other presentations have been given to the Canadian Power and Sail Squadrons, the International Shipmasters' Association convention, the Company of Master Mariners of Canada and the Golden Horseshoe Advisory Group. Quebec staff in the Laurentian region conducted presentations to the biannual meeting on Naval Applications of Materials Technology and attended a monthly meeting of the Constructeurs et navigateurs amateurs (CONAM). In the Maritimes region, a presentation was made to the Marine Medical Seminar for the Medical Examiners of Seafarers.

Pipeline staff gave presentations on the TSB investigation process to industry representatives both in the Atlantic Provinces and in Alberta. Additionally, they participated in a mock pipeline rupture exercise that involved the National Energy Board, industry, local fire and police departments and other governmental organizations.

Rail staff gave presentations on the TSB and its work at conferences in Moncton, New Brunswick, at Transport Canada's Annual Workshop on Highway-Railway Grade Crossing Research, to coroners' offices, to police organizations and to railway companies. Staff also participated in a mock rail accident in Ottawa, along with municipal representatives, emergency response personnel and industry representatives.

Air staff participated in annual meetings with departments and associations within the aviation community. It also provided formal briefings to Canadian airport fire chiefs attending the Canadian Airport Fire Protection Association meeting in Richmond, British Columbia; to the International Helicopter Symposium in Montréal, on lessons learned from TSB investigations into helicopter accidents; to the Canadian Aerospace Institute on basic helicopter aerodynamics and lessons learned from TSB investigations into helicopter accidents (1994-2003); to Air Canada on the interaction between the TSB and the Air Canada emergency response team after an accident; and to the International Confidential Aviation Safety Systems (ICASS) on SECURITAS (the TSB Confidential Safety Reporting System). The Air Branch improved partnerships and working procedures with other departments and agencies (Transport Canada, NAV CANADA, Foreign Affairs Canada, Canada Border Services Agency, Canadian Air Transport Security Authority, Department of National Defence, National Research Council and ICAO). The Air Branch contributed support to seminars conducted by the Air Canada Pilots Association, the Air Line Pilots Association, the Air Transportation Association of Canada, the American Helicopter Society International, the Canadian Aeronautics and Space Institute, the Canadian Aviation Maintenance Council, the Helicopter Association of Canada, the Northwest Territories Government Airports Group and the International Society of Air Safety Investigators.

The TSB Engineering facilities continued to support occurrence investigations with their core business of timely and quality engineering investigation reports, and provided briefings and support for visits of particular interest to industry groups. This year, the Engineering Branch provided support and was instrumental in the following:

• a briefing to the Department of National Defence Icing Operations Standing Committee;



• worked with Canadian Pacific Railway, DaimlerChrysler Canada and the County of Renfrew following a rail crossing accident;



• during the underwater search and recovery of the Messerschmitt-Bolkow-Blohm BO 105 Canadian Coast Guard helicopter, assisted Canadian Coast Guard ships and helicopters, a Royal Canadian Mounted Police patrol boat, an Irving Oil dive ship and remotely operated vehicles, and the Bedford Institute of Oceanography;



• cooperated with Environment Canada and Canadian National to ensure that the TSB could continue its investigation while Environment Canada and Canadian National were conducting their own independent parallel investigations and is currently negotiating with the National Research Council Chalk River laboratories to use the neutron diffraction method for measuring residual stresses in the rails;



• continued support to the Transport Canada Dangerous Goods Branch, which is looking into tank car failures not being investigated by the TSB.

The Human Performance Division delivered the Human Factors in Investigations course to external participants, including provincial and federal investigative bodies (Canadian Coast Guard, Department of National Defence, Transport Canada and National Energy Board), industry (NAV CANADA, Serco, and WestJet Airlines) and academia (Laurentian University). Human Performance staff also made educational presentations at academic institutions such as the University of Toronto.

The Macro-analysis Division provided support to Transport Canada's multi-disciplinary research project on grade-crossing accidents.

INTERNATIONAL COOPERATION AND KNOWLEDGE TRANSFER

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

Over the past year, Board members attended the International Aviation Security Conference in Washington, D.C. and visited the U.S. National Transportation Safety Board in Washington, D.C. The Executive Director also participated in that visit and attended the annual meeting of the International Transportation Safety Association (of which Canada is a founding member). Finally, an investigation information management system development memorandum of understanding was signed with the Australian Transport Safety Bureau.

The Marine Branch continued its important work with International Maritime Organization (IMO) committees and sub-committees, particularly the Human Element and Casualty Analysis working group and correspondence group. Marine staff reviewed several international investigation reports, and lessons learned have been submitted to the IMO for global publication. The IMO Code for the Investigation of Marine Casualties and Incidents is under review, and Canada is taking a lead role in the recommendation to have the Code become part of the prestigious International Convention for the Safety of Life at Sea (SOLAS). This will improve international cooperation and standardize procedures. Marine staff made two presentations to the Marine Accident Investigators' International Forum at its annual meeting in Port Vila, Vanuatu, where the Code was also addressed in detail by 45 nations. Partnering is being actively sought with other countries concerning the requirements to download and play back voyage data recorder (VDR) information following marine accidents. Marine staff are taking an active role in assuring technical competence by attending and participating in International Electrotechnical Commission meetings in the United Kingdom.

Rail staff attended the Wheel/Rail Interface Seminar in Chicago, Illinois, in May 2005, and the Advanced Hazmat Technician training at the Transportation Technology Center in Pueblo, Colorado, in October 2005. The Rail Branch sent a full set of investigation procedures and standards to the Republic of South Africa, which has just started a new regulatory regime. Informal discussions ensued on the application of the standards. In November 2005, Rail staff attended the International Rail Safety Conference in Cape Town, South Africa, and presented a paper describing lessons learned from three accident investigations to delegates from five countries.

The Air Branch improved communications and cooperation with the investigation agencies of Australia, China, Denmark, Finland, France, Germany, Iceland, the Netherlands, Norway, Portugal, the Republic of Korea, Sweden, the United Kingdom and the United States, and with industry manufacturers Bombardier, Pratt & Whitney Canada, Bell Helicopter, Airbus and Boeing. The Air Branch hosted the annual Nordic Accident Investigation Group meeting, which was attended by accident investigation authorities from Denmark, Finland, Iceland, Norway and Sweden. The Air Branch also participated in the European Aviation Safety Conference and the annual Flight Safety Foundation International Air Safety Seminar.

The Engineering Branch has an excellent working relationship with worldwide investigative agencies and assists, when requested, to complement the capabilities of those agencies with:

• flight data recorder (FDR) analysis and animation to assist in the investigation of the China Eastern CRJ aircraft accident;



• FDR and cockpit voice recorder (CVR) download, analysis and animation in support of the Sky Services B767 accident in Punta Cana, Dominican Republic;



• recorder download and technical support in the landing gear analysis for the Dash 8 accident in Trinidad and Tobago;



• FDR data analysis, flight animation and photogrammetric analysis of aircraft height above terrain and metallurgical work in Toulouse, France, following a CL-415 aircraft accident;



• CVR download for a DHC-6 aircraft accident in Costa Rica;



• as a member of the Accident Investigation Recorders (AIR) Working Group, took part in the international meeting in September 2005;



• as a member of the ICAO Flight Recorder Panel, participated in the international meeting at ICAO;



• for the Air France Airbus accident, worked with the U.S. National Transportation Safety Board (NTSB), France's Bureau d'Enquêtes et d'Analyse pour la Sécurité de l'Aviation Civile (BEA), the United Kingdom Air Accidents Investigation Branch, the U.S. Federal Aviation Administration (FAA) Technical Center, Messier Bugatti and Goodrich (brake systems), Michelin (tires), Zodiac (aircraft oxygen systems), Airbus, Team (solid state CVR) and Air France;



• technical non-disclosure arrangements were implemented to allow the access to Garmin International's schematics and layout diagrams to examine and retrieve stored data in global positioning system receivers recovered from accident vehicles;



• worked in cooperation with Dukane Seacom in the analysis of underwater acoustic locator beacons and established a working relationship to obtain schematics for future investigation purposes;



• carried out digital flight data recorder (DFDR) and CVR download, analysis and flight animation work, as well as direct access recorder (DAR) analysis and synchronization with DFDR data;



• worked with the aircraft manufacturer (Airbus), as well as with the BEA, the Federal Bureau of Aircraft Accidents Investigation (BFU) of Germany and the NTSB;



• developed the scope of the testing program undertaken by Airbus and partnered with the National Research Council for the composites aspect of the testing and analyses, and made a significant contribution in the publication of the safety advisories that affected the Airbus fleet worldwide;



• following a CL-415 accident in Europe, ensured continued support as the accredited representative from the state of manufacture; and



• ensured continued investigation support into a Pratt & Whitney PT6-20 engine failure on take-off in Australia on a King Air, which then crashed and was consumed by fire.

Human Performance staff participated in human factors working groups at international meetings, including the meeting of the International Maritime Organization in London, England, and chaired a panel session on human factors in helicopter safety and presented a research paper at the International Helicopter Safety Symposium in Montréal.

Macro-analysis staff participated in the International Civil Aviation Organization Safety Indicators Study Group. The Macro-analysis Division also provided several statistical reports to international agencies and industries.

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