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Transportation Safety Board of Canada

Departmental Performance Report

For the period ending
March 31, 2003


Camille H. Thériault
Chairperson
Transportation Safety Board of Canada
Stéphane Dion
President
Queen's Privy Council for Canada

Table of Contents

List of Figures and Tables

Section 1: The Chairperson's Message

Section 2: Strategic Context

2.1 Mandate and Mission

2.2 Key Co-delivery Partners

2.3 Risks and Challenges

2.3.1 Public Interest in Transportation Safety and Evolving Stakeholders Needs

2.3.2 Impact of Technology on Transportation

2.3.3 Level of Activity

2.3.4 Swissair Flight 111 Accident Investigation

2.3.5 Increased Litigation

2.3.6 Human Resources

2.3.7 Information Management

Section 3: Departmental Performance

3.1 Performance Management Framework

3.1.1 Plans and Priorities

3.1.2 Logic Model

3.1.3 Measurement Methodology

3.2 Performance Accomplishments

3.2.1 Swissair Flight 111 Investigation

3.2.2 Public Confidence in the Safety of the Transportation System

3.2.3 Implementation of Appropriate Safety Actions

3.2.4 Awareness of Safety Issues and Strengthened Safety Culture on the Part of Government, Industry and the Public

3.2.5 Increased Level of Safety Through the Reduction of Risk

3.3 Surveying Client Needs and Adjusting Program Delivery

3.3.1 Stakeholder Needs Analysis Project

3.3.2 Government On-Line

3.4 Modern Management

3.4.1 Effective Organizational Performance

3.4.2 Implementing Modern Comptrollership

Section 4: Other Information

Appendices

Appendix A: Transportation Safety Statistics

Appendix B: Financial Performance

Appendix C: Internet Addresses for Other Organizations

Appendix D: Consolidated Reporting

Appendix E: Financial Statements and Auditor's Report

 

List of Figures and Tables

Figure 1: TSB Results-Based Logic Model

Figure 2: Accidents Reported to the TSB

Figure 3: TSB Score Card

Figure 4: SR 111 Costs by Fiscal Year

Figure 5: Tracking the Safety of Modes

Figure 6: TSB Productivity

Figure 7: Safety Outputs by the TSB

Figure 8: Occurrences Investigated and Safety Actions—Part I

Figure 9: Occurrences Investigated and Safety Actions—Part II

Figure 10: Assessment of Responses to TSB Recommendations—Current Year

Figure 11: Assessment of Responses to TSB Recommendations (1990-2003)

Figure 12: Use of Financial Authorities

Figure 13: Detailed Breakdown of 2002-2003 Total Authorities

Figure 14: Net Cost of Program by Operating Activities

Figure 15: TSB Historical Spending

Figure 16: Employment Equity Representation by Designated Group

Figure 17: TSB Contracting Activities


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



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Section 1: The Chairperson's Message

The Transportation Safety Board of Canada (TSB) enjoys a solid reputation as a professional and technically-competent organization that consistently contributes to the advancement of transportation safety in Canada and internationally. The TSB is also recognized as a leader amongst small federal departments and agencies for its efforts on management renewal. Now well into its second decade of existence, the TSB is not content to rest on its past successes. The past year has been extremely busy for our managers, staff and Board members.

March 2003 saw the completion of the investigation into the crash of Swissair Flight 111 and the release of the final Board report. This was the largest and most complex aviation safety investigation the TSB has ever undertaken and required a significant investment of people, resources and time. These efforts culminated in a comprehensive report and 23 safety recommendations that have led to significant changes worldwide.

The TSB also undertook and completed a stakeholder needs analysis. This important consultation, provided us with valuable information that is being used to review and adjust our processes and outputs while maintaining our commitment to investigation quality and report publication timeliness. This will ensure that the TSB can continue to provide a relevant, useful and efficient safety investigation program.

In 2002-2003, the TSB published its first Business Plan bringing together a number of priorities with a strong commitment to action. Modern comptrollership management initiatives were fully integrated into this business plan. Over the course of the year, many excellent results were achieved thereby establishing a solid foundation for further improvements in subsequent years. Our management improvement initiatives, combined with discussions and negotiations with the Treasury Board Secretariat, have led to the approval of additional resources to assist the TSB in dealing with mounting resource pressures.

As we look forward to the future and the challenges that lie ahead, we are confident that the organization will continue to make an effective contribution to advancing transportation safety for Canadians. Given the events of the pasts two years, and concerns with the safety and security of transportation, Canadians expect no less.

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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.

Our Mission: to advance transportation safety.

marine logo/pipeline logo/railwaylogo/airlogo

 

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).

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, Fisheries and Oceans Canada - Canadian Coast Guard or the National Energy Board belong. 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 elsewhere on our Web site.

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2.2 Key Co-delivery Partners

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, whether they contribute as providers of information or of support services.

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.

 

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2.3 Risks and Challenges

The TSB operates within the context of the very large and complex Canadian transportation system (see the Transport Canada Internet site at http://www.tc.gc.ca/pol/en/report/anre2002/1_e.htm and the 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 and Evolving Stakeholders Needs

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 Lady Duck tourist amphibus in Ottawa, 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 closely follow 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. Manufacturers and operators expect more technical information within a shorter time frame to take appropriate safety actions and thereby preserve their competitive interests.

The terrorist attacks in the United States on September 11, 2001 also had a significant impact on transportation activities in Canada and abroad. The public is interested, more than ever before, in transportation security issues and views safety and security as essentially the same thing. The TSB has noted that the "security" concerns of the general population have heightened their preoccupation with "safety" issues.

Fulfilling these evolving needs is proving to be a major challenge with existing resource levels. In 2002-2003, the TSB therefore undertook a stakeholder needs analysis to better understand the current and future needs of its stakeholders. The results of this analysis will be used to adjust the TSB's products and services to optimize results achieved. Section 3.3.1 of this report provides more detailed information on this initiative.

 

2.3.2 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 more complex and specialized. The increased reliance on automation poses particular problems for analysing failures at the human-machine interface.

These rapid technological changes represent dual challenges for the TSB. First, considerable investments must be made in employee training to maintain the required level of technical expertise. Without a solid and current knowledge base, TSB investigators would very rapidly lose their credibility vis-à-vis the industry. Secondly, the TSB must maintain the appropriate capital asset infrastructure required to test and examine the equipment and materials in use by industry. This is a significant challenge, given that the TSB, like most other governmental organizations, had significantly reduced its capital investments over the past 10 years in order to cope with important budget cuts. The cumulative impact of these cuts has led to a significant capital asset rust-out. Rather than simply having to keep up with industry, the TSB must now also face the challenge of catching-up on technology.

TSB senior management recognized the importance of these challenges and the need for immediate action. This led to the identification of employee learning and capital asset replacement as immediate priorities. A number of initiatives were identified in the 2002-2003 Business Plan to address employee learning. Discussions were also held with the Treasury Board Secretariat and the case was made to obtain one-time incremental resources to address the capital asset rust-out problem. Section 3.4.1 of this report provides more detailed information on these initiatives.

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2.3.3 Level of Activity

On average, 3,500 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 which are 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. Approximately 140 investigations are currently in progress. Of that total, approximately 37% 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 expectations arising from the high level of public interest and demand for investigations.

As reported in previous Departmental Performance Reports, despite numerous efforts over the past few years, limited success was achieved in reducing the backlog. TSB senior management recognized the need for a totally different approach. A plan was drafted and short term incremental funding was requested for a period of two years to implement the plan. Section 3.2.3 of this report provides more detailed information on this initiative.

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2.3.4 Swissair Flight 111 Accident Investigation

The crash of SR 111, near Peggy's Cove, Nova Scotia, en route to Geneva from New York on the night of September 2, 1998 took the lives of 229 persons. This has been the largest and most complex safety investigation the TSB has ever undertaken. In fact, it is one of the most complex accident investigations ever undertaken by any accident investigation agency worldwide. The extent of destruction of the aircraft, as well as the complexities of wreckage recovery from the bottom of the ocean, made the task of investigating extremely difficult. TSB investigators and support staff worked thousands of hours to get the job done as expeditiously as possible.

The TSB has gone to great lengths to release significant information as it became available. Many of the TSB's recommendations were issued during the course of the investigation and have already been adopted by regulatory authorities, airlines and aircraft manufacturers. However, September 2002 marked the fourth anniversary of the crash, and the final report had not yet been published. There were numerous questions from the next-of-kin, key stakeholders, the local Nova Scotia community and the media with respect to when the investigation would be completed and the final report released. The core TSB investigation team was also becoming exhausted and work on other investigations was being delayed. Everyone sought closure as soon as possible.

Nevertheless, expectations of the final report remained very high. With concentrated effort, the final occurrence investigation report was issued on March 27, 2003. The TSB successfully overcame the risks and challenges by delivering a long awaited report which was universally accepted for its technical excellence and its messages. Feedback was largely positive and a significant number of unsolicited letters of appreciation and commendation were received by the TSB. Section 3.2.1 of this report provides more detailed information on the results of this investigation.

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2.3.5 Increased Litigation

There are significant increases worldwide in litigation surrounding transportation accidents. Civil suits, and in some cases criminal charges, are becoming common practice. Consequently, challenges to information protection provisions of the Canadian Transportation Accident Investigation and Safety Board Act also occur more frequently. This results in a greater pressure and investment by the TSB in legal services and information management activities to preserve the integrity of our investigation process and of our legislation. Given the fundamental and critical tenet that information obtained by the TSB during the course of accident investigations must be used only for the furtherance of transportation safety and not for other purposes, the TSB has little choice but to respond to legal/court proceedings when it is named as a party in a case, when court orders are served to obtain TSB records, or when investigators are summoned as expert witnesses.

 

2.3.6 Human Resources

A key risk for the TSB in delivering on its priorities is related to its workforce. The TSB has already seen a significant turn-over within its management team and investigation staff. More staff departures are foreseen in the next few years as additional employees and managers retire or move on to other career opportunities. This will leave the TSB with a significant loss of corporate memory and of experienced staff in many facets of the operations. Succession planning measures are being considered to ensure that service delivery is not hampered due to gaps created by the departure of these staff members.

In June 2002, the TSB participated in the Public Service Employee Survey. Although the survey results were generally positive, a number of areas of concern were identified. Employees identified concerns with: workload pressures, career development, classification and compensation, as well as internal communications and governance issues. If these issues are left unaddressed, the TSB could be faced with employee retention and morale problems that could detract attention and resources from the corporate priorities. A committee of employees and managers has developed an action plan which addresses these issues of importance. This plan will be implemented in the coming year.

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2.3.7 Information Management

The effectiveness and value of the TSB are derived from its mandate to collect factual information associated with transportation accidents, to analyse that information, and to transfer information and knowledge to agents of change and the Canadian public so that safety improvements may be effected. The TSB's current applications and systems were developed to support only some of the data collection and analysis work of the investigators. Even with numerous attempts to map the core business processes on the systems, they still do not support the full life cycle of the investigation process nor do they support the management of the multimedia case files required for each investigation. As a result, there are now a number of different disconnected systems and databases used to support investigations. Hence, there is no uniform practice by which the information is gathered, created or stored. There is limited knowledge of what we have and where it is. In addition to this, the technology upon which the major data collection systems are based is no longer widely supported in the industry thereby making system maintenance and enhancements difficult and expensive.

The TSB has a well-documented need for an integrated information management solution supporting business requirements and providing for electronic records management. A plan is now being put in place for the development of the next generation of business applications that will replace the current applications. By redesigning the current applications to make better use of new technologies, particularly in supporting unstructured and multimedia information, the TSB can provide more effective and integrated tools for investigators, a more efficient process for producing investigation reports and better long-term sustainability of the information systems at the TSB.

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Section 3: Departmental Performance

 

3.1 Performance Management Framework

In 2002-2003, the TSB undertook the development of an integrated performance management framework. The 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 upon 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.

 

3.1.1 Plans and Priorities

In its 2002-2003 Report on Plans and Priorities, the TSB defined the following desired strategic outcome and related indicators.

Provide Canadians with: To be demonstrated by:
Advancements in safety through independent, objective and timely analysis of safety failures in the federally regulated transportation system.
  • Increased and justified public confidence in the safety of the transportation system.
  • Timely implementation of appropriate safety actions.
  • Increased awareness of safety issues and a strengthened safety culture on the part of government, industry and the public.
  • Increased level of safety through the reduction of risks.
  • Effective organizational performance.

Two major priorities were identified:

    • surveying client needs and adjusting program delivery as a consequence, and
    • implementing modern comptrollership.

The 2002-2003 Report on Plans and Priorities also indicated that during the year, emphasis would be placed on review and analysis activities, as well as the planning and implementation of change in order to better position the organization to fulfill its mandate in a sustainable manner. The Report further noted that this might involve the temporary diminishment or curtailment of certain ongoing activities to free up resources that could be applied to the achievement of corporate priorities. It was therefore anticipated that the more visible outputs of the TSB, such as investigations, reports and publications would not increase and could, in some instances, decrease. TSB management estimated that a minimum of two years would be required to plan and implement changes before any significant benefits are realized. Throughout this period of change, the TSB committed to ensuring that a high level of quality is maintained in its work and that proper attention is placed on other important issues such as occupational health and safety, employment equity and official languages.

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3.1.2 Logic Model

The purpose of the logic model which follows is to identify the linkages between the activities of the TSB and the achievement of its outcomes. The logic model is a roadmap showing the chain of results connecting resources and activities to outputs and to expected intermediate and final outcomes.

Figure 1

Figure 1 - TSB: Results-based logic model

 

3.1.3 Measurement Methodology

As noted earlier, the TSB has been working on the development of a balanced score card which will be the main tool used to measure organizational performance in the future. This score card will track performance along four major perspectives: financial, client / stakeholder, internal business process, and learning and growth. Current plans call for the full implementation of this new tool by the end of fiscal year 2003-2004.

Although definite indicators and the data collection methodology are not yet finalized, some of the indicators are already being used. Various methods are used to identify and capture performance information. Most of the data used in the analysis came from TSB information systems and was supplemented by Transport Canada information where appropriate. Information was also extracted from the stakeholder needs analysis report and the SR 111 post-report release media analysis report. Anecdotal evidence to support the performance assessment was obtained from various sources such as magazine articles, press clippings and individual testimonials. Where sources of information external to the TSB are used, they are identified.

Proper care and attention to data quality and limitations were ensured throughout the production of this report. This report presents a most accurate state of the TSB business and affairs on March 31, 2003. The financial statements have been audited by the Auditor General of Canada and her audit report is included in Appendix E. Other performance information is not currently subjected to an independent review or validation process. However, the TSB is in the process of implementing an internal audit function which, in the future, will be able to provide such assurance services.

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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 the ongoing quest to advance transportation safety even further. In 2002, 1,812 accidents and 1,374 incidents were reported in accordance with the TSB's regulations for mandatory reporting. There were also 657 voluntary incident reports. The number of accidents in 2002 decreased by 8% from the 1,959 accidents reported in 2001 and by 13% from the 1997-2001 annual average of 2,071 accidents.

Figure 2 (numbers are by calendar year)

Figure 2 - Accidents reported to the TSB

This year was marked by declines in the number of accidents reported in all the modes. See Appendix A for details. The number of marine accidents was at its lowest since 1975, with a total of 483 reported to the TSB in 2002. This represents a 7% decrease from 2001 and a 14% decrease from the five-year average of 559. Even with increased activity in 2002, rail accidents reported to the TSB reached a ten-year low of 985, representing a 7% decrease from last year's total of 1,060 and a 10% decrease from the 1997-2001 average of 1,089. In the pipeline activities, 20 accidents were reported to the TSB and no serious injuries resulted from these. The last fatal pipeline accident in the portion of the industry under federal jurisdiction occurred in 1988. The accident rate with Canadian-registered aircraft (other than ultralights) is at a 25-year low—with 274 accidents reported in 2002. 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.

It is virtually impossible to accurately measure 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 on that particular undertaking.

Figure 3

TSB Score Card
Performance Indicators
Results
Completion of Swissair Flight 111 Investigation
objectives achieved
Increased and justified public confidence in the safety of the transportation system.
objectives achieved
Timely implementation of appropriate safety actions.
work is underway
Increased awareness of safety issues and a strengthened safety culture on the part of government, industry and the public.
objectives achieved
Increased level of safety through the reduction of risks.
objectives achieved
Effective organizational performance.
work is underway

Note: The symbols used to indicate the results achieved against each performance indicator are as follows:

objectives achieved = objectives achieved work is underway = work is underway

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3.2.1 Swissair Flight 111 Investigation

"It is being called Canada's biggest contribution to aviation safety ever."

The London Free Press (editorial), March 31, 2003.

 

The TSB's investigation into the September 1998 crash of SR 111 off the coast of Peggy's Cove, Nova Scotia was completed after more than four years of effort and an investment of approximately $57.7 million by the Canadian government (see Figure 4 for the annual breakdown). This investigation was the most complex and exhaustive transportation accident investigation ever undertaken in Canada. During the investigation, the TSB led the efforts of thousands of individuals from various countries, companies and regulatory authorities. Complex underwater salvage efforts resulted in the recovery of 98% of the aircraft. Detailed analysis work resulted in a final investigation report which provides the world with one of the most detailed aviation disaster accounts ever compiled. This 338-page report was released on March 27, 2003, along with hundreds of pages of supporting technical information. The complete report is available on the TSB web site at http://www.tsb.gc.ca/en/reports/air/1998/a98h0003/01report/index.asp .

Figure 4

SR 111 Costs by Fiscal Year (in $ millions)
1998-1999
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
(Forecast)
Total
$ 34.0
$ 13.4
$ 3.6
$ 3.0
$ 3.2
$ 0.5
$ 57.7


"The TSB delivered its final report into the crash this week. It was a magnificent document of infinite detail. Investigators didn't pretend to find answers where they couldn't, didn't shirk from making recommendations that will be inconvenient or expensive for the airline industry to follow."

Toronto Star, March 20, 2003.

In its final report, the TSB identified the causes and contributing factors that played a major role in the occurrence. The report reviewed the 14 interim safety recommendations that had already emerged from the TSB investigation, the impact those recommendations have had on aviation safety, as well as introduced nine additional safety recommendations. Throughout the investigation, the TSB worked closely with regulatory authorities, manufacturers, operators, other accident investigation agencies, and a variety of other stakeholders in order to accomplish this very complex investigation.

Action has been taken by various regulatory authorities and others to address the recommendations, advisories and observations made by the TSB during the course of this investigation, significantly improving aviation safety worldwide. Regulatory authorities, including Transport Canada, the Federal Aviation Administration (FAA) and the Joint Aviation Authorities (JAA), have provided beneficial feedback in response to all of the TSB's safety communications. Several recommendations have already been adopted by regulatory authorities, airlines and aircraft manufacturers thereby raising the bar and positively changing the culture of air safety. For example, the FAA issued airworthiness directives that required the removal of the flammable thermal acoustic insulation material known as metallized Mylar® from all affected US-registered aircraft. The FAA has also developed and implemented more stringent flammability standards for thermal acoustic insulation materials used in transport category aeroplanes. Other regulatory authorities will review these actions and apply them in their respective jurisdictions as necessary.

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In addition, ongoing dialogue at the international level has taken place to raise awareness of and help stakeholders better understand and resolve the safety deficiencies. Safety actions initiated to date will result in an estimated cost well in excess of one billion dollars for the worldwide transportation industry. These actions include:

  • the replacement of thermal acoustical insulation blankets in some 1,500 aircraft;
  • the review of flammability test criteria and methods used by regulatory authorities, and the implementation of more stringent certification tests;
  • the preventive inspection and repair of wiring, particularly in MD-11 and similar aircraft;
  • the enhancement of basic aircraft wiring certification standards;
  • the review by both regulatory authorities and aircraft manufacturers of their circuit breaker reset philosophies;
  • the research and development of a more effective circuit breaker known as the Arc Fault Circuit Breaker;
  • the preventive inspection and modification of flight crew reading lights in thousands of aircraft;
  • the review of standby flight instruments to improve the placement, usability, and backup power requirements of such instruments;
  • the provision of additional general training for air traffic controllers when dealing with aircraft emergency situations and special procedures such as fuel dumping;
  • the removal of a specific in-flight entertainment system in Swissair aircraft;
  • the issuance of 18 airworthiness directives requiring changes to a variety of passenger entertainment system design types;
  • the review of specifications for flight recorder recording capacity and power supply;
  • the modification of standard operating procedures for aircraft crews to prepare to land immediately upon detection of smoke from an unknown source in the aircraft;
  • international initiatives to improve in-flight firefighting measures in a comprehensive, integrated way, including fire detection and suppression equipment, access to hidden areas of the aircraft to allow for firefighting, crew checklists, procedures, and training; and
  • the review and revision by regulatory authorities of the conduct of Supplemental Type Certification work.

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Additional safety actions were taken as a result of deficiencies identified during the investigation. More information on the SR 111 investigation report can be found at: http://www.tsb.gc.ca/en/reports/air/1998/a98h0003/01report/04safety/rep4_01_00.asp.

The TSB released the final investigation report at a news conference in Halifax in the presence of journalists as well as families of the crash victims. The news conference also aired live on a web cast which allowed anyone from around the world with Internet access to watch the news conference. Media from Switzerland, the United States, Germany, France and the United Kingdom provided substantial coverage of the report, although major international events such as the war in Iraq and SARS had an impact on both the quantity and positioning. During the month of March, the TSB website was visited 44,551 times, and 70% of these were international visits. There was a significant spike in the number of visits on March 27 and 28 surrounding the release of the SR 111 report, representing approximately 22% of the total number of visits in March.

"My family and I extend to you and your staff our sincere thanks for their hard work and dedication. It is our sincere belief that your work will lead to safer air travel and save the intense pain of these types of tragedies. "

Quote from a SR 111 next-of-kin, March 2003.

After more than four years, stakeholders were happy to see the completion and publication of the final investigation report, allowing closure to be achieved. Media coverage notes that the SR 111 report layed to rest any speculation about the pilots' actions and whether an emergency landing should have been immediately undertaken—this provided a measure of closure to the next-of-kin about the last moments of their loved ones. The open communications with the next-of-kin throughout the investigation and the special briefings provided to them after the release of the final report were really appreciated. Canada, through the TSB, was truly perceived as a caring nation that could handle the human aspect of such a tragedy in a compassionate manner. An event was also held in Halifax for more than 100 local community and emergency services representatives, allowing them to connect, have discussions around the outcome of this most tragic event, thank them for their valuable contribution and providing them with a sense of closure around the accident.

This investigation has also permitted the advancement of safety investigation techniques and tools. The complexity of this investigation, and the lack of similar precedents, led the investigation team to exercise creativity in finding solutions to the problems at hand, from the recovery of wreckage from the ocean floor through to the use of special forensic techniques to help differentiate between electrical wire arcs, as well as the management and interpretation of an enormous amount of information. New automated tools, such as the computer fire modelling system, were developed and will remain with the TSB for use in future investigations. New techniques currently used primarily in a research environment were used in practical applications again resulting in a legacy that can be applied in future investigations. The TSB's work in this regard was recognized by the International Society of Air Safety Investigators in September 2001 with the presentation of its Jerome F. Lederer award.

The investigation has generated significant interest from many other organizations in Canada and around the world. Many are interested in learning from the TSB experience in order to improve their readiness to handle large disasters which could occur within their own jurisdictions. For example, foreign safety investigation agencies have contacted the TSB to enquire about sea recovery operations and techniques. Others have expressed interest in the TSB's database system to track wreckage components and in the three-dimensional computer modelling work. An association of chief information officers has even expressed interest in finding out how the TSB successfully managed the huge amount of information collected and created during the investigation. The TSB is willingly sharing this knowledge with others in the spirit of collaboration and in order to further contribute to the advancement of transportation safety through the work of others around the world.

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 among the Canadian public of the complexity of certain types of investigations, nor why they can take several years to complete. This investigation, which generated a significant level of public interest, presented an excellent opportunity for the TSB to get better known by Canadians. On many occasions, the TSB has attempted to explain its role in meeting its responsibilities, as well as the complexities of the tasks. For example, the general public's understanding of the effort that went into this investigation was greatly reinforced by a 90-minute documentary on the CBC program "The Nature of Things" which was aired a few days after the public release of the report.

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3.2.2 Public Confidence in the Safety of the Transportation System

Canada has one of the safest and most secure transportation systems in the world. A threat to the safety and security of the transportation system could affect Canada's economic prosperity and its ability as a nation to trade effectively, as well as affecting Canadians' ability to travel.

The safety and security of the transportation system are a shared responsibility. The TSB works with governments, transportation industries, agencies, associations and international organizations in order to further improve the system. It also collaborates with other government departments and agencies whose programs and services may be affected by transportation activities.

Reported accidents and incidents provide indicators of the transportation system's safety performance as well as help focus efforts on those initiatives and activities that have high safety benefits. As demonstrated in the tables of Appendix A, Canada continued to maintain a good safety record in 2002. The 2002 accident rates, per activity level for all modes, reflect a downward trend from the 2001 statistics while the 2002 accident rates for aviation, rail and marine are lower than the five-year average. Another indicator of the safety performance of the transportation system is the number of fatalities. In 2002, the aviation, marine and rail modes showed a decrease in fatalities from the five-year average. While the TSB cannot claim that the reduction in transportation occurrences is solely related to its work, a reduction in accidents and fatalities will positively influence the public's confidence in the safety of the transportation system.

In August 2002, Transport Canada commissioned EKOS Research to conduct a survey on Canadians' confidence in transportation safety and security. This survey found that, overall, the majority of Canadians had a high level of confidence in the safety and security of the transportation modes (as illustrated in Figure 5). This is, in part, due to a high level of awareness of the many safety and security initiatives undertaken by government and industry.

Figure 5

Figure 5 - Tracking the safety of modes, 2002


"The safety and security of Canada's transportation system continued to improve in 2002, demonstrated by decreases in the number of accidents in all modes and by security enhancements implemented since the September 11, 2001, terrorist attacks. Public confidence in the safety and security of the transportation system returned to near pre-September 11, 2001, high-confidence levels."

Transport Canada website

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3.2.3 Implementation of Appropriate Safety Actions

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. It is not uncommon for the TSB to provide, on an informal basis, critical safety-related information throughout the investigative process when it becomes apparent that important information should be shared with others. From time to time, the TSB also produces 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.

For the second consecutive 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. This year, 109 investigations were completed, compared to 111 in the previous year. The number of investigations in process decreased to 140 at the end of the fiscal year, from 160 at the start, a reduction of 12.5%. This reduction in the number of investigations in process is primarily due to a reduction in the number of new investigations undertaken during the year. Only 89 new investigations were started in 2002-2003 compared to the average of 100+ new cases in previous years. The average time to complete an investigation also dropped slightly to 580 days in fiscal year 2002-2003, from 586 days in the previous year.

Figure 6

TSB Productivity
 
Marine
Rail / Pipeline
Air
Total
2001-2002 2002-2003 2001-2002 2002-2003 2001-2002 2002-2003 2001-2002 2002-2003
Investigations started 16 13 13 20 65 56 94 89
Investigations completed 18 15 19 24 74 70 111 109
Average duration of completed investigations (number of days) 817 703 680 757 505 494 586 580
Note: Results shown in this table can fluctuate significantly from year-to-year due to a number of factors such as staff turnover, complexity of investigations and the investigation of major occurrences.

Treasury Board ministers have recently approved the inclusion of short term funding requests in the Supplementary Estimates of the next two fiscal years to help the TSB reduce its backlog of investigations in process, without further reducing the intake of new investigations. This investment will enable the TSB to reduce the backlog from 160 investigations (on January 1, 2003) to less than 100 and improve the mean time in process by 10% (approximately 60 days) by the end of fiscal year 2004-2005. As part of a broader human resources strategy, staff hired with these incremental resources will be viewed as potential replacements for staff expected to depart over the next two to three years. These resources will also permit current, more-experienced staff to contribute to a full range of longer-term initiatives to improve performance in the future, including training, quality assurance and development of modern tools and procedures to aid investigative staff.

In 2002-2003, in addition to investigation reports, the TSB issued a total of 86 safety outputs—27 safety recommendations, 26 safety advisories and 33 safety information letters (see Figure 7 for breakdown by mode).

Figure 7

Safety Outputs by the TSB in 2002-2003
 
Recommendations
Safety Advisories
Safety Information Letters
Marine
5
7
17
Pipeline
0
0
1
Rail
5
6
9
Air
17
13
6
Total
27
26
33

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 operating practices and procedures, preventive modifications to equipment, replacement of parts, and the modification of training programs. Figure 8 provides a few specific examples of such safety actions that were taken during 2002-2003.

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Figure 8

Occurrences Investigated
Safety Actions

Sinking of the Fishing Vessel Nadine

(The investigation revealed the lack of training hindered the abandonment of the ship and contributed to the loss of life.)

In July 2002, Transport Canada put into force an implementation policy to ensure that all fish harvesters have completed the required basic safety training by July 30, 2007.

Canadian Pacific Railway Collision

(The investigation revealed that an unattended train had been left and although the reverser handle (commonly considered being the key to the locomotive) was removed, an unauthorized person had gained access to the locomotive cab and had been able to remove the brakes, causing a train collision and injury to the conductor.)

CP mechanical inspectors have repaired all door and window locks on locomotives and instructions have been distributed to all crew members pertaining to the securement of unattended locomotives. In addition, CP has distributed reverser handles to all locomotive engineers in order that no reversers are left unattended.

VIA Rail has reviewed its internal procedures and has reinforced their importance among locomotive engineers, with particular emphasis on the locking of windows and doors when the equipment is left unattended in an unprotected area.

Beech 1900D Controlled Flight Into Terrain

(The investigation revealed that there is a pressing need for additional restrictions related to instrument approaches in poor weather. In its final report, the TSB recommended that the Department of Transport expedite the approach ban regulations prohibiting pilots from conducting approaches in visibility conditions that are not adequate for the approach to be conducted safely.)

As of May 26, 2002, Transport Canada indicated it had prepared Notices of Proposed Amendments to Regulations to address the TSB's recommendation concerning approach ban regulations related to visibility. Transport Canada advises that these Notices are currently under review at the Department of Justice prior to their publication in the Canada Gazette and implementation.

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 actions being taken by industry and government during the course of TSB investigations. For example, during the SR 111 investigation, the TSB released a series of recommendations relating to recording capacity and power source requirements for cockpit voice recorders and flight data recorders, thermal acoustic insulation, in-flight firefighting, and material flammability standards for materials used in commercial aircraft. The industry took action on these recommendations, even before the final report was produced.

Such safety actions 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. In such situations, rather than issuing recommendations, the TSB can then report on the corrective actions already taken by industry and government agencies. The following table highlights a few specific examples of safety actions that were taken before the TSB investigations were completed.

Figure 9

Occurrences Investigated
Safety Actions

Near sinking of the Catamaran Passenger Vessel Wasca II

(The investigation revealed the combined weight of the operator, three wheelchairs, 16 passengers and their effects resulted in both pontoons being nearly submerged, leaving insufficient freeboard and reserve buoyancy for safe navigation.)

The void spaces of the small catamaran passenger vessel were filled with marine styrofoam for positive buoyancy to the satisfaction of a Transport Canada inspector.

MD-11 In-Flight Fire Leading to Collision with Water

(The investigation identified a recessed map light installation in the MD-11 cockpit ceiling which was subject to arcing and heat damage. This discovery prompted an inspection of 12 additional MD-11 aircraft, which revealed various discrepancies, including cracked protective covers, repairs not in accordance with the component maintenance manual, heat deformation, evidence of arcing, and heat discolouration.)

The Boeing Company issued an Alert Service Bulletin prompting the United States Federal Aviation Administration to issue an Airworthiness Directive. The Airworthiness Directive mandated a recurring inspection for the affected lights in the MD-11. Subsequently, the Federal Aviation Administration approved the flight crew reading light manufacturer's Service Bulletin which highlighted several design changes. Goodrich Hella Aerospace and Boeing Engineering conducted a successful design review in August 2002. Production of the new flight crew reading light series, based on these product improvements, began in November 2002.

Bulk Carrier Windoc striking Bridge 11 of the St. Lawrence Seaway

(The investigation revealed the bridge operator represented the sole line of defence for ensuring the area below the bridge is clear of vessel traffic before the bridge is lowered.)

St. Lawrence Seaway Management Corporation introduced new communication procedures for vessels transiting all free-standing bridges between Montreal and Port Colborne.

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3.2.4 Awareness of Safety Issues and Strengthened Safety Culture on the Part of Government, Industry and the Public

The TSB continues to promote the awareness of safety issues and of a safety culture amongst the various transportation stakeholders. Overall, TSB investigators have observed a greater awareness of safety issues and the early signs of development of a safety culture amongst people with whom they interact in the course of their work. Furthermore, significant events such as the crash of SR 111 and the September 11, 2001 terrorist attacks in the United States have also increased the level of public awareness about transportation safety. Although it is very difficult to measure the TSB's results in this area, the level of TSB activity demonstrates sustained efforts to achieve the desired outcome.

The TSB utilizes every opportunity to reiterate its key messages and create awareness of safety issues. In 2002-2003, the TSB published 109 investigation reports, as well as monthly and annual statistical reports. The TSB continues to publish the Reflexions safety digest. Four issues of Reflexions were published during fiscal year 2002-2003, however only three were distributed before March 31, 2003. 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 has taken a proactive 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 is 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 thirst for up-to-date factual information, the TSB responded to 1,158 information requests received through its web site and 697 media calls, not including those inquiries handled at the scene of an accident or at a report release news conference. The TSB held five news conferences and issued eight news releases. The TSB's Macro Analysis Division also responded to 618 requests for complex transportation occurrence database information.

The TSB has also been using its Internet site to increase awareness of safety issues and other transportation safety information. More than 22,000 visitors consult the TSB Web site every month—and that number reached a record high of 44,500 in March 2003 due to the release of the SR 111 investigation report. 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.

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. Such cooperation between the TSB and foreign organizations contributes to greater public access to safety information worldwide.

The TSB's expertise and its investigation methods are recognized internationally. For the second consecutive year, the TSB has been invited to teach investigative methodologies to air investigators in Singapore. 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. Staff from the TSB has 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. By participating in such events and sharing methodologies, the TSB not only provides industry with its best practices for their own internal use, but also paves the way for a better understanding by industry of the rigour applied to those investigations undertaken by the TSB.

The Integrated Safety Investigation Methodology (ISIM) training program developed by the TSB continues to draw significant interest from the transportation industry, including air carriers and railway companies, as well as other safety organizations within and outside of Canada (i.e. the United States, the Netherlands, New Zealand and the United Kingdom). 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, private or para-public organizations. The provision of such training has proven beneficial as external participants are gaining a better understanding of how the TSB works and are acquiring methodology and safety approaches enabling them to apply such methodology toward achieving similar objectives of advancing transportation safety. Furthermore, the Canadian Coast Guard is looking at developing an investigation training package for their field agents based on the TSB methodology.

The TSB is also involved in an initiative to enhance and promote a positive safety culture in the west coast marine community, particularly amongst operators of small vessels and fishing vessels. The Inter-Agency Marine Action Group brings together agencies from both the federal and provincial governments and provides an opportunity to work together to promote safety awareness, provide safety education and foster safe operating practices within the marine community. The objective is to effect behavioural change within the marine community and thereby reduce the incidence of marine-related accidents and fatalities.

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3.2.5 Increased Level of Safety Through the Reduction of Risk

Overall, 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 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.

A total of 3,848 occurrences were reported to the TSB in fiscal year 2002-2003, of which the TSB decided to investigate 89 occurrences. 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 on all reported occurrences was entered in the TSB database for historical record, trend analysis, and safety deficiency validation purposes.

"Transport Canada has made considerable changes to its regulations, inspection and certification of small passenger vessels following the sinking of the True North II. The department has addressed the TSB's concerns and recommendations, and has nearly completed related regulatory changes and initiatives."

David Collenette, Minister of Transport

One way to measure 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 2002-2003, the TSB received responses to fifteen safety recommendations—seven assessed as having a "satisfactory intent" to address safety deficiencies identified in the recommendations and three assessed as "satisfactory in part". No response was assessed as Unsatisfactory.
The results of this assessment are shown in Figure 10.

Figure 10

Assessment of Responses to TSB Recommendations - Current Year
2002-2003
(Year response received)
Fully satisfactory attention to safety deficiency
Satisfactory intent to address safety deficiency
Attention to safety deficiency satisfactory in part
Unsatisfactory attention to safety deficiency
To be assessed
Total
Marine
0
0
2
0
0
2
Pipeline
0
0
0
0
0
0
Rail
0
4
1
0
1
6
Air
0
3
0
0
4
7
Total
0
7
3
0
5
15

 

Over the longer term, the response to TSB recommendations is also very positive. Figure 11 illustrates the assessment of responses to TSB recommendations issued since 1990.

Figure 11

Figure 11 - Assessment of respnses to TSB recommendations (1990-2003)

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3.3 Surveying Client Needs and Adjusting Program Delivery

One of the priorities identified in the 2002-2003 Report on Plans and Priorities was to survey key stakeholders as to their needs and then to adjust the TSB's program delivery in order to better respond to those needs. During the year, work was done on two parallel paths. First, a stakeholder needs analysis project was undertaken. Secondly, work was undertaken under the broader government-wide initiative of Government On-Line. Results achieved on both initiatives are described in the following sections.

 

3.3.1 Stakeholder Needs Analysis Project

During the 2002-2003 fiscal year, the TSB initiated a consultative process designed to seek the input of a wide range of TSB stakeholders. A selection of primary transportation safety change agents representing national and international interests was interviewed, and provided a good appreciation of these stakeholders' views and needs with respect to TSB products and services. To supplement the results of this research, and to provide for a high level, strategic commentary on the TSB and its products and services, a group of senior transportation executives from across the transportation industry, key associations and unions were also consulted in an expert panel setting.

These consultations have provided the TSB with a broad assessment of stakeholders' needs and expectations, an appreciation of how successfully the TSB is achieving its mandate and how it is viewed from the outside.

Regulators and safety agencies / associations regard the TSB as a very important potential source of information and the TSB's ability to deliver on its mandate (i.e. the monopoly to investigate for cause) is seen to be key in advancing safety in the transportation sector. However, many believe that the TSB is not realizing its full potential as an important source of information.

Among other stakeholder groups, particularly small carriers / operators / owners, the TSB is not viewed as a main source for safety-related information. A number of them have either no experience or direct contact with the TSB or have not been exposed to the TSB's products and services. Many view the TSB as an investigative body only, a reactive organization, and not one that is proactively involved in either the prevention of accidents / incidents or in the promotion of safety issues per se.

There is agreement that the TSB's main strengths are the technical competence and professionalism of its staff, and the TSB's ability and expertise in identifying the causes and contributing factors of occurrences. The TSB's independence and impartiality in its processes, both during investigations and in its reporting, are seen, by stakeholders, to give the TSB a great deal of credibility with all players concerned with transportation safety and with the general public.

Amongst all the information collected, the following major issues were identified for further consideration:

  • the timely and effective dissemination of safety information;
  • the demand for broader stakeholder consultation in investigation reports and the development of safety recommendations;
  • the lack of awareness of TSB products and services;
  • the small proportion of occurrences that are investigated;
  • the perception that the TSB focuses too much on reactive occurrence investigations and not enough on proactive safety studies and analysis; and
  • the demand to expand the TSB's mandate to include truck, bus and marine pleasure craft occurrence investigations.

Over the coming year, the results of the consultation process will be used, along with other information, in the review of departmental operational processes and outputs to ensure that they continue to meet the needs of stakeholders and that optimal results can be achieved with the resources provided by Parliament. Once the review process is completed during the first part of 2003-2004, an operational action plan including organizational impact, costs, change management considerations and internal and external communications strategies will be developed and implemented.

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3.3.2 Government On-Line

Work was undertaken in partnership with Transport Canada (TC) to improve the quality of TSB data, improve the mechanism by which we share the data with TC, and contribute to the construction of the TC safety data warehouse project. In addition, a pilot system was developed to make occurrence data available via an online query on the TSB's public web site. Work will continue on this project as resources permit in fiscal year 2003-2004.

Work was also done to completely redesign the TSB web site. The site is now fully compliant with the Government On-Line requirements and much more user-friendly. Significant additions were also made to the content of the site.

 

3.4 Modern Management

The TSB senior management team has recognized the importance of modernizing and strengthening the organization's management frameworks. A number of efforts have been undertaken to integrate various departmental and governmental management initiatives. Our focus is on building a solid foundation—leaders who are committed to results; motivated people who are contributing to results and working in a learning, challenging and rewarding environment; and a clear set of shared values that governs the way in which we work.

The tabling in Parliament of legislative changes to modernize the management of human resources in the Public Service will have a significant impact on the TSB. Although it is too early to articulate specific departmental plans on the modernization of human resources, the TSB is currently reviewing the potential implications in order to prepare for the development of an action plan soon after the new legislation is approved by Parliament.

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3.4.1 Effective Organizational Performance

In 2001-2002, the TSB embarked on a path of change essential to its future success. The renewal agenda was motivated by three main factors: the requirement to function under a more structured planning and resource management framework; the resolve to strengthen internal management practices consistent with the government's Modern Comptrollership initiative; and the imperative to define the appropriate balance between activity levels and the resource base within which the TSB must operate. This ambitious change agenda has required and will continue to require persistence, patience, understanding and involves a certain level of risk.

Fiscal year 2002-2003 saw the publication of the organization's first-ever business plan based upon seven corporate priorities. A summary of this plan is accessible on the TSB website at http://www.tsb.gc.ca/en/publications/index.asp. The business plan clearly layed out specific initiatives with deliverables and accountabilities. Identifying the areas requiring priority attention was not difficult, however, determining the source of financial and human resources to address them was. Tradeoffs had to be made—resources from the operations were freed-up and applied to the achievement of corporate priorities. It was also anticipated that the more visible outputs of the TSB, such as investigations, reports and publications would likely decrease. Nevertheless, throughout this period of change, the TSB ensured that a high level of quality was maintained in its work and that proper attention was placed on other important issues such as occupational health and safety, employment equity and official languages. A total of $1.1 million was dedicated to the achievement of the Business Plan activities.

The focussed efforts on the plan's priorities produced many excellent results throughout the year. As much of the work was developmental, it established a solid foundation for further improvements in subsequent years. The development of a priorities and resource planning cycle adapted to TSB needs, the execution of a formalized stakeholder needs analysis, the development of a performance management framework, focussed training for investigative staff to improve the quality and timeliness of TSB safety products, and the integration of workplace and human resource issues into day-to-day management deliberations are some of the indicators of progress achieved.

A particular focus of the business plan was targeted to employee learning. In 2002-2003, the TSB identified urgent training requirements and provided appropriate training and learning in order to ensure that all employees had the basic skills and knowledge required to perform their work efficiently. In parallel, the TSB also undertook to develop competency profiles and learning standards for all its occupational groups. Once these profiles and standards are completed they will be used to establish individual learning plans for each employee. In 2002-2003, the TSB invested approximately $1.5 million or 4.6% of its total operating costs in employee training and education activities. For the same year, other federal government departments invested an average of 2.6% of their total expenditures on training.

Work was also undertaken to develop a multi-year capital asset replacement plan and to find solutions to an important asset rust-out problem. A business case was developed and submitted to the Treasury Board seeking additional funding to implement solutions to this problem. Funding in the amount of $1 million was received over a two-year period to assist the TSB in this regard.

The TSB conducted a detailed analysis of its information management practices and systems. Business needs were documented and an approach was developed to start work on the next-generation business applications. A major upgrade of the TSB's information technology infrastructure was also completed.

Overall, the TSB has made significant progress toward improving its internal management frameworks and optimizing the use of its resources. During the year, the TSB was often cited by Treasury Board Secretariat officials as a model of effective organizational performance for others to follow. TSB senior managers have also been invited on a number of occasions to share their experience with their colleagues in other organizations.

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3.4.2 Implementing Modern Comptrollership

The multi-year modern comptrollership initiative aims to modernize management activities within the Public Service thereby providing for better performance information, sound risk management and appropriate control systems, as well as reinforcing values and ethics and improving the Government's accountability to Parliament and to Canadians.

In late 2001, the TSB conducted a self-assessment of its current management practices against thirty-three criteria of sound organizational management. The Capacity Assessment report, issued in March 2002, identified a number of areas of the management framework where important changes were needed in order to achieve a state of modern comptrollership. This report is available on the TSB website at
http://www.tsb.gc.ca/en/publications/Mod_Comp/2002/Mod_Comp_2002.asp.

Understanding the importance and the value of modernizing management practices, as well as the risks to the organization if strong comptrollership capabilities are not entrenched in daily operations, the TSB identified modern comptrollership as a management priority and integrated modern comptrollership activities and projects in the departmental 2002-2003 Business Plan (available on the TSB website at http://www.tsb.gc.ca/en/publications/BusPlan/2002/biz_plan02_03.asp).

During the 2002-2003 fiscal year, much of the work done in the context of modern comptrollership has been developmental. The TSB has developed a business planning framework that integrates all TSB planning activities in a coherent manner and that coincides with the government-wide planning cycle. This framework has already improved and facilitated resource allocation decisions for the 2003-2004 fiscal year as well as ensuring resources are linked to corporate plans and priorities. Work was also done on the development of two new management tools: a performance measurement tool and a risk-based internal audit plan. It is expected that these new tools will be fully implemented in fiscal year 2003-2004 and that adjustments will be required as the framework matures. The TSB has also defined specific knowledge and skills required by managers and functional specialists in the context of modern management. Competency profiles and learning standards have been developed. These will be used to assess current management competencies and to develop learning plans to support the implementation of modern management and human resources modernization.

In line with our modern comptrollership priorities and with corporate preoccupations, the TSB is also actively involved in working with other departments and agencies on modern comptrollership projects; sharing best practices and working at finding solutions to minimize costs and efforts. For example, the TSB has led three interdepartmental innovation projects touching upon: cultural change within organizations, the integration of performance information, and values and ethics as they apply to partnerships between organizations. TSB staff has been recognized by the Treasury Board Secretariat and the small agencies community for their leadership in this regard.

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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 and a periodic safety magazine titled Reflexions, all available in printed form upon request.

Previous year Reports on Plans and Priorities and Departmental Performance Reports are available on the TSB Internet site. 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
Transportation Safety Board of Canada
Place du Centre
200 Promenade du Portage
4th Floor
Gatineau, Quebec
K1A 1K8

e-mail: communications@tsb.gc.ca
Telephone: (819) 994-3741
Fax: (819) 997-2239

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Appendices

A - Transportation Safety Statistics

B - Financial Performance

C - Links to Other Organizations Involved in Transportation Safety

D - Consolidated Reporting

E - Financial Statements and Auditor's Report

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Appendix A
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 2002 continue to exhibit a general downward trend.

Transportation Occurrences by Mode - 2002 versus Previous Five-Year Average (1997-2001)
  Marine Pipeline Rail Air
Accidents

2002

485 20 985 324

Five-Year Average

559 13 1088 403
Fatalities

2002

28 0 96 63

Five-Year Average

33 0 100 138
Incidents

2002

173 34 303 865

Five-Year Average

197 27 373 747

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 2002: Annual Report published by Transport Canada. More comprehensive information is available in that publication at http://www.tc.gc.ca/pol/en/report/anre2002/1_e.htm.

Accident Rates in Transportation - 2002 versus Previous Five-Year Average (1997-2001)
  Air1 Marine2 Rail3
Accidents

2002

7.8 3 25

Five-Year Average

8.7 2.9 31

1 Per 100,000 hours flown (Canadian-registered aircraft only)
2 Per 1,000 commercial non-fishing vessel trips
3 Per million main-track train-miles

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Appendix B
Financial Performance

Financial Performance Overview

The TSB started the year with authorities of $24.8 million. Supplementary Estimates in the amount of $5.3 million were then approved for the carry-forward of the previous year's lapse, resource pressure adjustments and for the extraordinary costs of the SR 111 investigation. Transfers in the amount of $1.9 million were also made from Treasury Board votes for collective bargaining adjustments and the implementation of Modern Comptrollership, thereby increasing total authorities to $32 million. In 2002-2003, the TSB spent $31.3 million of its $32 million total authorities. The TSB lapsed $1 million from its operating budget. However, costs of the SR 111 investigation exceeded the special funding provided by Parliament by $0.3 million thereby reducing the lapse to $0.7 million. This lapse is primarily due to lower spending than anticipated on salaries and training for new employees, as well as the deferral of some projects to 2003-2004. The complete audited financial statements of the TSB are enclosed in Appendix E.

The total expenditures of the TSB, minus SR 111, represent an approximative cost of $0.89 per Canadian citizen. With SR 111 investigation costs included, the number rises to $1.00 per Canadian citizen. For this amount, Canada maintains the capability to investigate major failures in four different modes of the national transportation system.

Figure 12

Figure 12 - Use of financial authorities (millions of dollars)

Financial Table 1: Summary of Voted Appropriations

This table explains the way Parliament voted resources to the TSB.

Financial Requirements by Authority ($ millions)
Vote  
Planned Spending
2002-2003 Total
Authorities
Actual Spending
  Canadian Transportation Accident Investigation and Safety Board
25 Operating expenditures 21.5 28.9 28.2
(S) Contributions to Employee Benefit Plans 3.3 3.1 3.1
  Total Department 24.8 32.0 31.3
Total Authorities are Main Estimates plus Supplementary Estimates plus other authorities (see Figure 13 for details).

Figure 13

Detailed Breakdown of 2002-2003 Total Authorities ($ millions)
Authorisations
Amount
Main Estimates
24.8
Supplementary Estimates - Carry-Forward of Previous Year Lapse
1.1
Supplementary Estimates - SR 111 Investigation
2.9
Supplementary Estimates - Resource Pressures
1.2
Supplementary Estimates - Lady Duck Investigation
0.1
Transfers from Treasury Board - Collective Bargaining
1.5
Transfers from Treasury Board Vote 10 - Modern Comptrollership
0.4
Total Authorities
32.0

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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.

Departmental Planned versus Actual Spending ($ millions)
 
2002-2003
Business Line Planned
Planned
Spending
Total
Authorities
Actual
Spending
Staff in Full-Time Equivalents 235 235 214
Operating 24.8 32.0 31.3
Total Gross Expenditures 24.8 32.0 31.3
Less:
Re-spendable Revenues - - -
Total Net Expenditures 24.8 32.0 31.3
Other Revenues and Expenditures
Non Re-spendable Revenues - - -
Cost of Services Provided by
Other Departments
2.8 2.8 3.0
Net Cost of the Program 27.6 34.8 34.3
Note: Total Authorities and Actual expenditures are significantly higher than Planned Spending due to the SR 111 accident investigation, compensation for new collective agreements, the carry-forward of the previous year's lapse and special funding to address resource pressures.

Figure 14 below shows the breakdown of the net cost of the TSB program by operational activities. All overhead costs have been allocated to the operational activities directly supporting the program delivery. The largest portion of resources (67.2%) was expended on the conduct of investigations (identification of safety failures and investigation support). A significant portion of resources (23.7%) was also expended on communicating safety information.

Figure 14: Net Costs of Program by Operating Activities

Operating Activities
Expenditures ($ millions)
% of Total Expenditures
Identification of safety failures
$17.69
51.6%
Investigation support
$5.35
15.6%
Public access to safety information
$ 8.11
23.7%
Satisfaction with quality and timeliness
$ 0.87
2.5%
Awareness by Canadians of TSB role
$ 0.61
1.8%
International recognition of the TSB
$ 0.04
0.1%
Training and education
$ 1.59
4.6%
Total
$ 34.26
100.0%

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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.

Historical Comparison of Departmental Planned versus Actual Spending ($ millions)
   
2002-2003
Actual
2000-
2001
Actual 2001-
2002
Planned Spending

Total
Authorities
Actual
Canadian Transportation Accident Investigation and Safety Board
30.1
30.1
24.8
32.0
31.3
Total
30.1
30.1
24.8
32.0
31.3

Total Authorities are Main Estimates plus Supplementary Estimates plus other authorities.

Note: Total Authorities and Actual expenditures are significantly higher than Planned Spending due to the SR 111 accident investigation, compensation for new collective agreements, the carry-forward of the previous year's lapse and special funding to address resource pressures.

Figure 15

Figure 15 - TSB Historical Spending

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. In 2000-2001, 2001-2002 and 2002-2003 SR111 investigation costs have averaged approximately $3.3 million per year. From 1999-2000 onward, TSB spending has also increased progressively each year due to increases in employee salaries and general operating costs.

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Appendix C
Internet Addresses for Other Organizations
Involved in Transportation Safety

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:

United States:

Australia:

France:

United Kingdom:

International:

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Appendix D
Consolidated Reporting

Introduction

Government departments and agencies are required by legislation to report to Parliament on a number of specific topics. They are also required to report to central agencies such as the Treasury Board Secretariat on a broader range of topics. Under the auspices of modern comptrollership, the Transportation Safety Board of Canada (TSB) has partnered with four other small agencies to undertake a review of all these reporting requirements with the objective of streamlining these reports and simplifying the reporting process. The Treasury Board Secretariat provided funding through the modern comptrollership innovation funds, as well as support for this initiative.

The first phase of this initiative consisted in research work to better define the issues and to identify best practices already in use. A research report was published and is available upon request from the TSB. A summary of the report is also available on the small agencies web site at http://www.cso-cpo.gc.ca.

The second phase of the initiative consists in the piloting of various options. The TSB has accepted to lead one of these pilots which is centred around the Departmental Performance Report. This appendix has been added to the TSB's Departmental Performance Report in order to demonstrate what the consolidation and streamlining of various reports would look like. This mock-up will be used over the coming year to engage in a dialogue with various stakeholders in order to determine if this is a good approach to reporting that serves the information needs of everyone while reducing the burden of the reporting organization. Recommendations will then be formulated for the consideration of Treasury Board Secretariat.

It is important to note that all reports consolidated in this appendix have been included only for demonstration purposes. Each individual report for 2002-2003 has been produced by the TSB and has been tabled in Parliament or submitted to the Treasury Board Secretariat in the normal manner. The information contained in this appendix is therefore a duplication. However, subject to the results of this pilot project, in future years the intent would be to provide this information only in the Departmental Performance Report.

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1 - Statutory Reporting

The TSB is required by legislation to formally report to Parliament on five topics:

  • its own activities, findings and recommendations;
  • its financial accounts along with the Auditor General's audit report;
  • its administration of Access to Information activities;
  • its administration of Privacy activities; and
  • its administration of employment equity programs.

The following pages provide a consolidation of the key information on each one of these topics. More detailed information is available on the TSB web site at http://www.tsb.gc.ca

 

1.1 TSB Activities
(Pursuant to section 13(3) of the Canadian Transportation Accident Investigation and Safety Board Act)

The TSB activities and results achieved are described in section 3 of this report. Detailed findings and recommendations made by the TSB during 2002-2003 are included in the TSB Annual Report and are also available on the TSB web site at http://www.tsb.gc.ca. The TSB also reports publicly on all of its investigations and individual investigation reports are available on its web site.

 

1.2 Financial Accounts and Auditor General's Report
(Pursuant to section 13(2) of the Canadian Transportation Accident Investigation and Safety Board Act)

The TSB has produced a complete set of financial statements in accordance with the Treasury Board accounting standards. These statements are based upon the accrual basis of accounting and the Canadian generally accepted accounting principles. Appendix E contains these financial statements. The Auditor General of Canada has audited these financial statements and provided her independent report which is also enclosed.

The financial information provided in Appendix B of this report has been compiled on a cash accounting basis in order to coincide with the resources approved by Parliament in the Appropriation Acts. The numbers provided in the financial statements will therefore not match completely with those provided in Appendix B. However, Note 3 of the financial statements provides a reconciliation of the two sets of numbers.

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1.3 Access to Information
(Pursuant to section 72(1) of the Access to Information Act)

The TSB's administration of its access to information activities is in accordance with the government's legislation and policies. An appropriate delegation of authority is in place. A total of 82 requests were received during the year and one request was brought forward from the previous year. Seventy requests were completed leaving 13 requests on hand at year-end. Of the 70 requests processed during the year, 48 were completed within the 30 day time limit, in 21 cases the TSB sought and was granted an extension, and in one case the TSB completed the request late. The average time taken to process a request during the 2002-2003 reporting period was 38.7 calendar days. In accordance with approved policies, the TSB collected $547.80 in application and reproduction fees related to these requests.

A total of 163 informal requests were also received and processed during 2002-2003. The TSB continues to encourage the public to access information through informal means by contacting the Communications Division or accessing the departmental web site. An increasing amount of information is pro-actively made available on the web site.

No complaints were filed against the TSB during the 2002-2003. Two complaints from the previous year are still under investigation by the Office of the Information Commissioner. Five applications for review by the Federal Court were made during the year. One application was withdrawn by the requester and the others will be reviewed at the same time as they all revolve around the subject of air traffic control tapes and transcripts.

 

1.4 Privacy
(Pursuant to section 72(1) of the Privacy Act)

The TSB's administration of its privacy activities is in accordance with the government's legislation and policies. An appropriate delegation of authority is in place. The TSB remains vigilant in protecting personal information under its control. Employees are cognizant of their responsibility to protect personal information they handle in the course of their duties and respect the code of fair information practice. Five formal requests for personal information were received and completed during 2002-2003. Four requests were processed within the 30 day time limit and one was processed within 60 days. No complaints were received during this period.

 

1.5 Employment Equity
(Pursuant to sections 21(3) and 21(4) of the Employment Equity Act)

The TSB is committed to employment equity in the work place. During 2002-2003 the TSB re-activated its departmental employment equity committee. This committee composed of members of the various designated groups will assist management to identify and implement measures that promote and sustain employment equity in the work place. An employee self-identification survey was conducted which resulted in an increase in the number of employees who identified as members of one of the designated groups. The TSB also participated in a number of inter-departmental activities aimed at promoting employment equity.

Overall, TSB employee representation in each one of the four designated groups exceeds the availability figures based on census data (see the Figure 16). However, gaps remain in certain occupational categories and groups. The biggest challenge for the TSB remains the recruitment of women in the technical category.

Figure 16 - Employment Equity Representation by Designated Group at March 31, 2003

Designated Group
Total Employees
Designated Group Representation
Availability (based on census)
Difference
 
#
#
%
#
%
#
Women
217
72
33.2
68
32.3
4
Aboriginal Peoples
217
2
1
2
1
0
Persons with Disabilities
217
12
5,5
7
4,5
5
Visible Minorities
217
19
8,8
17
8,7
2

Efforts continue to be made to recruit candidates from the designated groups. Investments have also been made to provide members of the designated groups with training and development opportunities. Information sessions on diversity in the work place were offered to employees and managers.

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2 - Other Reports of Interest

The TSB is also required by policy to report to other government departments in order to enable them to fulfill their mandate and to satisfy their own reporting requirements to Parliament. Some of that information is of potential interest to Parliament and the Canadian public. In the interest of transparency and accountability the TSB considers that information should also be disclosed on the following topics:

  • official languages;
  • multiculturalism;
  • contracting activities;
  • procurement from aboriginal businesses; and
  • use of alternative fuels.

The following pages provide a consolidation of the key information on each one of these topics

 

2.1 Official Languages
(Relates to the Official Languages Act)

Overall, 26.8% of TSB employees are francophones compared with 22.6% of respondents to the 2001 census who indicated French as their mother tongue. As to anglophone representation in Quebec, 21.4% of TSB employees are anglophones compared to 7.8% in the general population. The TSB therefore considers that it has met the requirements for equitable participation. All TSB senior executives are fully bilingual and meet the prescribed standards. Most other employees in bilingual positions also meet the language requirements of their positions. Only 13 employees do not meet the language requirements; five are exempted and the others are either currently on language training or there are plans for their training.

The TSB is compliant with the requirements of the Official Languages Act. Supervision of employees is done in the language chosen by each employee. Personal and central services are provided to all employees in the language of their choice. Where required, administrative arrangements are in place to compensate for employees who do not currently fully meet the language requirements of their position. Most work tools are available in both official languages. Services to the public are available in both official languages. All TSB publications are available in both languages and all information on the TSB web site is fully bilingual. On-going monitoring is conducted to ensure compliance with the legislation and policy requirements.

 

2.2 Multiculturalism
(Relates to the Multiculturalism Act)

Due to the nature of its mandate the TSB has very limited direct involvement with the Canadian public. The TSB conducts its business primarily with the transportation industry and regulators. There is therefore limited opportunity for the TSB to contribute to the promotion and development of multiculturalism within Canadian society. However, the TSB always ensures that its communications products and messages are sensitive and responsive to multiculturalism. Furthermore, the TSB ensures that all its employees are provided with awareness sessions on diversity so that they are well prepared to interact with Canadians from diverse cultural backgrounds in the course of their duties. The TSB also ensures that, whenever appropriate, measures are taken to provide translation and/or interpretation services when people are interviewed in the course of safety investigations.

 

2.3 Contracting
(Relates to Government Contracting Regulations, World Trade Organization Agreement, North-American Free-Trade Agreement and Agreement on Internal Trade)

In 2002-2003, the TSB issued 228 contracts worth a total of approximately $4.2 million. Figure 17 provides a breakdown of these numbers. Most contracts were issued under the delegated authority of the TSB, however some non-delegated contracts were issued through Public Works and Government Services Canada. Contract requirements are normally tendered competitively either through the on-line government tendering system or using TSB supplier lists. Non-competitive contracts are awarded only for low dollar value requirements or when urgent operational requirements must be met. All provisions of the World Trade Organization Agreement, the North-American Free-Trade Agreement and the Agreement on Internal Trade have been respected. No complaints were filed against the TSB on its contracting activities.

Figure 17 - TSB Contracting Activities

 
Contracts Below $25,000
Contracts Above $25,000
Total
Competitive
Non-Competitive
Competitive
Non-Competitive
# 000 $ # 000 $ # 000 $

#

000 $ # 000 $
Goods 82 129 4 62 6 1018 0 0 92 1209
Services 64 175 65 764 7 2041 0 0 136 2980
Total 146 304 69 826 13 3059 0 0 228 4189

 

2.4 Procurement from Aboriginal Businesses
(Relates the Procurement Strategy for Aboriginal Businesses)

The TSB actively support this government initiative aimed at helping aboriginal communities develop viable commercial enterprises. In 2002-2003, the TSB had a published objective of directing $50,000 worth of purchases or contracts to aboriginal businesses. This objective was surpassed with a total of $392,000 in transactions being awarded to aboriginal businesses over the course of the year. As a result the TSB has reviewed and increased its objectives for future years. Despite its successes in this area, the TSB is committed to continuing its efforts at promoting the use of aboriginal businesses who can provide support services required in the delivery of its mandate.

 

2.5 Use of Alternative Fuels
(Relates to Alternative Fuels Act)

The Alternative Fuels Act requires that government departments and agencies purchase alternative fuel powered motor vehicles wherever economically and operationally feasible. During 2002-2003, the TSB purchased 7 motor vehicles, none of which were powered by alternative fuels. In each case, an analysis was conducted and it was determined that the use of a vehicle powered by alternative fuels was not economically and operationally viable. The TSB currently has one hybrid gas/propane powered vehicle in its fleet and is exploring the acquisition of further hybrid vehicles and of vehicles equipped to use E-85 ethanol blended fuels.

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Appendix E
Financial Statements and Auditor's Report

Appendix E - Financial Statements and Auditor's Report


Appendix E - Auditor's Report

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Canadian Transportation Accident Investigation and Safety Board
Statement of Financial Position

As at March 31
(in thousands of dollars)

  2003 2002
ASSETS  
  Financial Assets
 
Due from the CRF
$3,152 $2,735
  Receivables and Advances (Note 4) 765 115
  Total Financial Assets 3,917 2,850
 
  Non-Financial Assets
  Prepayments 69 25
  Inventories not for Re-Sale 130 166
  Capital Assets (Note 5) 4,122 4,119
  Total Non-Financial Assets 4,321 4,310
 
Total Assets   $8,238 $7,160
 
LIABILITIES
 
Accounts Payable and Accrued Liabilities
$3,317 2,742
  Accrual for Employee Vacation and Overtimes 910 814
  Employee Severance Pay 3,242 3,099
  Total Liabilities 7,469 6,655
 
NET ASSETS 769 505
 
Total Liabilities and Net Assets $8,238 $7,160

Contingent Liabilities and Commitments (Note 9 and Note 10 respectively)
The accompanying notes form an integral part of these Financial Statements.

Camille H. Thériault
Chairman Senior
  Jean L. Laporte, CGA
Financial Officer

Gatineau, Canada
June 3, 2003

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Canadian Transportation Accident Investigation and Safety Board
Statement of Operations and Net Assets
for the year ended March 31
(in thousands of dollars)

 
2003
2002
Revenues
  Sales of Goods and Services
$27
$69
  Other Non-Tax Revenues
86
8
  Total des produits
113
77
 
Expenses
  Salaries and Wages
17924
18151
  Employee Benefit Plans
4489
7718
  Professional and Special Services
4384
3860
  Transportation and Communications
1892
1892
  Accommodation
1700
1566
  Information
1481
666
  Amortization (Note 5)
1050
912
  Utilities, Materials and Supplies
654
601
  Purchased Repair and Upkeep
541
452
  Construction and/or Acquisition of Machinery and Equipment
184
138
  Rentals
112
107
  Loss on Disposal of Assets
43
-
  Miscellaneous Expenses
30
3
  Total Expenses
$34,484
$33,066
 
Net Operating Results
(34 371)
(32 989)
  Other Income (Note 6)
326
237
  Other Expenses (Note 6)
326
237
Net Results
(34,371)
(32,989)
Net Assets, Beginning of Year
505
466
Net Cash Provided by Government (Note 3)
31 211
28 251
Change in Due from the CRF
416
1 758
Services Provided Without Charge
3,008
3,019
Net Assets, End of Year
$769
$505

The accompanying notes form an integral part of these Financial Statements.

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Canadian Transportation Accident Investigation and Safety Board
Statement of Cash Flows

for the year ended March 31
(in thousands of dollars)

 
2003
2002
Operating Activities
  Net Results
$34,371
$32,989
 
  Non-Cash Items Included in Net Results
   
Services Provided Without Charge (Note 8)
3,008
3,019
    Amortization of Capital Assets
1,050
912
    Employee Severance Pay
143
-
    Loss on Disposal of Capital Assets
41
5
    Revenues from Other Government Departments
38
-
   
4,280
3,936
  Statement of Financial Position Adjustments
    Change in Liabilities
671
1876
    Change in Receivables, Advances, Prepayments and Inventories
-656
(81)
   
15
1,791
Cash Used in Operating Activities
30,076
27,262
 
Investing Activities
  Acquisitions of Capital Assets
1,135
989
Cash Used in Investing Activities
1,35
989
Net Cash Provided by Government
$31,211
$28,251

The accompanying notes form an integral part of these Financial Statements.

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Canadian Transportation Accident Investigation and Safety Board
Notes to the Financial Statements

for the year ended March 31, 2003

 

1. Authority and Objectives

The Canadian Transportation Accident Investigation and Safety Board (CTAISB) was established in 1990 under the Canadian Transportation Accident Investigation and Safety Board Act and is a departmental corporation named in Schedule II to the Financial Administration Act. In its day-to-day activities the CTAISB is more commonly known by the name Transportation Safety Board of Canada, or simply the TSB. The objective of the CTAISB is to advance transportation safety. It seeks to identify safety deficiencies in transportation occurrences and to make recommendations designed to eliminate or reduce any such safety deficiencies. In addition to investigations, including where necessary public inquiries into selected occurrences, the CTAISB may conduct studies into more general matters pertaining to transportation safety. The CTAISB has the exclusive authority to make findings as to causes and contributing factors when it investigates a transportation occurrence. The CTAISB's operating expenditures are funded by a budgetary lapsing authority whereas contributions to employee benefit plans are funded by statutory authorities.

 

2. Summary of Significant Accounting Policies

(a) These financial statements have been prepared in accordance with Treasury Board of Canada Accounting Standards based on Canadian generally accepted accounting principles.

(b) Parliamentary appropriations - the CTAISB is primarily financed by the Government of Canada through Parliamentary appropriations. Appropriations provided to the CTAISB do not parallel financial reporting according to Canadian generally accepted accounting principles. They are based in large part on cash flow requirements. Consequently, items recognized in the Statement of Operations and in the Statement of Financial Position are not necessarily the same as those provided through appropriations from Parliament. Note 3a) to these financial statements provides information regarding the source and disposition of these authorities. Note 3b) provides a high-level reconciliation between the two bases of reporting. Note 3c) presents the reconciliation to Net Cash Provided by Government.

(c) Due from the CRF - As a departmental corporation, the CTAISB operates within the Consolidated Revenue Fund (CRF). The CRF is administered by the Receiver General for Canada. All cash receipts are deposited to the CRF and all cash disbursements made by the CTAISB are paid from the CRF. Due from the CRF represents the amount of cash that the CTAISB is entitled to draw from the CRF, without further appropriations, in order to discharge its liabilities.

(d) Revenues - these are accounted for in the period in which the underlying transaction or event occurred that gave rise to the revenues. Revenues that have been received but not yet earned are disclosed in the Statement of Financial Position as deferred revenue.

(e) Employee severance benefits - are calculated using information derived from the results of the actuarially determined liability for employee severance benefits for the Government as a whole. Employee severance benefits on cessation of employment represent obligations of the CTAISB that are normally funded in future years as they are paid.

(f) Vacation pay and overtime - are expensed in the year that the entitlement occurs.

(g) Contributions to Superannuation plans - are recognized in the period that the contributions are made. The calculation of contributions is an estimate based on a government-wide average adjusted annually.
Actuarial surpluses or deficiencies are not recorded in the CTAISB's books but are recognized in the consolidated financial statements of the Government of Canada.

(h) Services provided without charge by other government departments - are recorded as operating expenses. Note 8 provides estimates of the more significant types of services provided to the CTAISB without charge.

(i) Receivables - these are stated at amounts expected to be ultimately realized. A provision is made for receivables where recovery is considered uncertain.

(j) Inventories not for re-sale - these comprise spare parts and supplies that are held for future program delivery and are not intended for re-sale. They are valued at cost. If they no longer have service potential, they are valued at the lower of cost or net realizable value.

(k) Capital assets - all assets plus leasehold improvements having an initial cost of $2,000 or more are recorded at their acquisition cost. The capitalization of software and leasehold improvements has been done on a prospective basis from April 1, 2001. Amortization of capital assets is done on a straight-line basis over the estimated useful life of the capital asset as follows:

 

Asset Class Amortization Period
Buildings 30 years
Furniture 10 years
Office equipment 5 years
Laboratory equipment 10 years
Informatics hardware 4 years
Informatics software 3 years
Motor vehicles 7 years
Other vehicles 15 years

Leasehold improvements lesser of useful life or term of the lease

(l) Foreign currency transactions - transactions involving foreign currencies are translated into Canadian dollar equivalents using rates of exchange in effect at the time of those transactions. Assets and liabilities denominated in foreign currencies are translated using exchange rates in effect at year-end.

(m) Measurement Uncertainty - the preparation of financial statements requires management to make estimates and assumptions that affect the reported amounts of assets, liabilities, revenues and expenses reported in the financial statements. At the time of preparation of these statements, management believes the estimates and assumptions to be reasonable. The most significant items where estimates are used are the useful lives of capital assets, employee severance pay and the assessment of contingent liabilities.

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3. Parliamentary Appropriations

a) Reconciliation to Parliamentary Appropriations Voted

(In thousands of dollars)
2003
2002
Parliamentary Appropriations Voted:
  Vote 25 - CTAISB Operating expenditures
$21,510
$21,038
  Supplementary Vote 25a
3,395
480
  Supplementary Vote 25b
1,353
4,059
  Transfer from Treasury Board -Vote 10
406
469
  Transfer from Treasury Board -Vote 15
1,415
1,579
  Total Parliamentary Appropriations Voted
$28,679
$27,625
Less: Lapsed Appropriations
562
873
   
$28,117
$26,752
Statutory Authorities:
  Spending of proceeds from disposal of surplus Crown assets
39
18
  Spending of revenues as per FAA section 29.1
22
68
  Contribution to employee benefit plans
3,098
3,213
  Total Statutory Authorities Used
3,159
3,299
Total Authorities Used
$31,276
$30,051

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b) Reconciliation of Net Results to Appropriations Used

(in thousands of dollars)
2003
2002
Net Results

$34,371

$32,989
Adjustments for Items Not Affecting Appropriations
  Less:  
    Services Provided Without Charge
$3,008
$3,019
    Amortization
1,050
912
    Employee Severance Benefits
143
71
    Vacation Pay
96
53
    Inventory Used
81
17
    Prepayments
44
26
    Loss on Disposal of Assets
41
5
     
4,463
4,103
  Add:  
    Spending of Cost Recovery
22
68
    Refund of Prior Years Expenditures
7
5
     
29
73
Adjustments for Items Affecting Appropriations
  Add:  
    Capital Acquisitions
1,135
989
    Receivables and Advances
210
115
    Inventory Purchased
41
74
    Leasehold Improvements
14
-
     
1,400
1,178
  Less:  
    Proceeds from the Disposal of Surplus Crown Assets
39
18
    Receipts of Re-spendable Revenue
22
68
     
61
86
Total Appropriations Used
$31,276
$30,051

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c) Reconciliation to Net Cash Provided by Government

(In thousands of dollars)
2003
2002
Net cash provided by government
$31,211
$28,251
Revenues
113
77
Net change in non-cash working capital balance charged to the vote
-48
1,723
Total Appropriations Used
$31,276
$30,051

 

4. Receivables and Advances

(In thousands of dollars)
2003
2002
GST refundable
$554
$38
Other Government Departments
165
1
External Parties
38
65
Advances to Employees
8
11
Total
$765
$115

 

5. Capital Assets (In thousands of dollars)

Asset Class
Historical Cost April 1, 2002
Additions
Disposals
Current Year Amortization
Accumulated Amortization March 31, 2003
Net Book Value March 31, 2003
Net Book Value April 1, 2002
Buildings
$2,715
-
-
$112
$1,708
$1,007
$1,119
Furniture
937
132
-
55
706
363
285
Office equipment
358
47
-
30
318
87
70
Laboratory equipment
3,698
4
-
99
3,287
415
511
Informatics hardware
4,490
618
-
591
3,788
1,320
1,293
Informatics software
215
157
-
75
89
286
204
Motor vehicles
915
162
204
75
326
547
540
Other vehicles
113
-
-
5
41
72
78
Leasehold improvements
19
15
-
8
8
26
19
Totale
$13,460
$1,135
$204
$1,050
$10,269
$4,122
$4,119

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6. Other Income / Expenditures

The CTAISB is responsible for coordinating the financial management of funds for the networks of small agencies. The revenues consist of contributions from all agencies to the cost sharing. The expenditures are the disbursements made on behalf of the group. Each government department will report its respective portion of expenditures in its financial statements.

In 2003, the CTAISB entered into a joint Government on-line project with Transport Canada. Under the terms of this project agreement Transport Canada contributed an amount of $220,000 to the CTAISB for the development of various interfaces between transportation safety databases, amount included in other income and other expenses. Transport Canada will report the related expenditures in its financial statements.

 

7.

Expenditures Related to the Swissair Flight 111 Accident Investigation

On September 2, 1998 Swissair Flight 111 crashed in the Atlantic Ocean at approximately 5 nautical miles from Peggy's Cove, Nova Scotia. Under Canadian legislation and international conventions, the CTAISB has the responsibility to conduct a thorough investigation of the accident. This investigation is very complex and involves considerable resources, much of which were provided by National Defence, Fisheries and Oceans and the Royal Canadian Mounted Police. Supplementary funding was obtained from Parliament as normal CTAISB appropriations were insufficient to cover such a large and complex investigation. The current year expenditures relating to the investigation are included in the Statement of Operations and are detailed below. Although the investigation is now completed a number of residual activities remain to be completed. Additional expenditures are therefore expected in the 2003-2004 financial year.

Swissair Flight 111 Investigation Costs
(In thousands of dollars)
2003
2002
Information
$1,168
$298
Salaries and Wages
864
1,281
Professional and Special Services
803
911
Transportation and Communications
200
210
Employee Benefit Plans
75
353
Rentals
43
59
Utilities, Materials and Supplies
29
50
Amortization
28
26
Accommodation
21
31
Purchased Repair and Upkeep
12
3
Construction and/or Acquisition of Machinery and Equipment
9
26
Total
$3,252
$3,248

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8. Related Party Transactions

The CTAISB is related in terms of common ownership to all Government of Canada departments, agencies and Crown corporations. The CTAISB enters into transactions with these entities in the normal course of business and on normal trade terms applicable to all individuals and enterprises except that certain services, as defined in Note 2(h), are provided without charge.

Services Provided Without Charge (In thousands of dollars)
Department Type of Services Type de service
2003
2002
Public Works and Government Services Canada Accommodation, accommodation alteration and other services
$1,700
$1,566
Treasury Board of Canada Employer's contributions to the health insurance plans
1,221
1,413
Auditor General of Canada External Audit
60
19
Human Resources Development Canada Administration of workers' compensation
27
21
Total  
$3,008
$3,019

As stated in Note 6, CTAISB also received an amount of $220,000 from Transport Canada.

 

9. Contingent Liabilities

In the normal course of its operations, the CTAISB becomes involved in various legal actions. Some of these potential liabilities may become actual liabilities when one or more future events occur or fail to occur. To the extent that the future event is likely to occur or fail to occur, and a reasonable estimate of the loss can be made, an estimated liability is accrued and an expense recorded on the government's consolidated financial statements. These estimated liabilities are not recognized on the CTAISB's financial statements as a liability until the amount of the liability is firmly established.

For the year ended March 31, 2003 there are various outstanding legal actions against the Board. No liability has been recorded in the financial statements since management of the CTAISB consider them unlikely to be successful.

 

10. Commitments

From time to time, the nature of the CTAISB's activities results in some large multi-year contracts and obligations whereby the CTAISB will be committed to make some future payments when the services/goods are rendered. Presently, such commitments apply only to the next two years. Major commitments that can be reasonably estimated are as follows:

(In thousands of dollars)
Commitments
2004
2005
Total
Acquisition of Other Goods and Services
$1,774
$35
$1,809


Updated: 2004-08-03

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Important Notices