Advancing transportation safety,one investigation at a time

By Wendy A. Tadros

This article was published in the spring 2013 issue of The Shipper Advocate.

Photo of Wendy A. Tadros

Wendy A. Tadros

The phone rings in the middle of the night. A cargo vessel has run aground in the St. Lawrence Seaway, blocking all traffic and choking one of the country's most vital shipping arteries. Emergency personnel are notified and, within hours, investigators from the Transportation Safety Board of Canada (TSB) are en route to assess the situation, interviewing witnesses and examining evidence to answer three key questions: what happened, why, and how can we stop it from happening again?

For over two decades, TSB experts have investigated thousands of occurrences along our waterways, our pipelines, our railways and in our skies, always with the same goal: to advance transportation safety by uncovering safety lessons, and then communicating those lessons for the benefit of Canadians.

Since its inception in 1990, the TSB has been recognized as a world leader in transportation safety. In the marine mode, for example, our investigations and recommendations have prompted international regulators to require survival suits for all crew members on commercial vessels. Domestically, small passenger vessels now need a float-free liferaft, larger operators are increasingly carrying voyage data recorders, and all passengers on Canada's ferries must now receive a safety briefing prior to each voyage.

Rail travel has seen similar safety benefits.

Following a derailment caused by defective wheels, a TSB investigation led to prompt action to remove these from service. Other TSB findings have led to new crash-worthiness standards for data recorders, improved delivery of emergency information to passengers, tougher standards for maintenance rails, computerized records to assist with track repairs, and safer storage of dangerous goods near our cities. Elsewhere, cooperation between our investigators and international aviation regulators and manufacturers has led to improved inspection techniques for aircraft parts made from composite materials. The TSB has also been influential in reducing the risk of contaminated insulation materials and debris that can propagate fires; in prohibiting pilots from landing where visibility is poor; and ensuring that planes land at the first sign of smoke from an unknown source.

None of these improvements would have been possible without qualified, dedicated professionals. TSB experts come from such diverse backgrounds as airline pilots, rail and pipeline experts, computer technicians, journalists, lawyers, engineers, fishermen, marine nautical officers and engineers, and members of the Canadian Forces to name just a few! Whether they are painstakingly putting together the pieces of a shattered airliner, computer-modeling the inside of a lifeboat locking mechanism, or mounting convincing arguments for change, these men and women have worked diligently to ensure that our conclusions sit securely on a base of sound science and hard facts.

That's a big responsibility and, in order to carry it out properly, the Canadian Transportation Accident Investigation and Safety Board Act grants our investigators some pretty wide powers, including the ability to freeze accident sites, restrict access, seize wreckage, and compel witness interviews. That doesn't mean we're out to point fingers - far from it. The TSB never assigns fault or determines civil or criminal liability. Moreover, our interviews are not just confidential, they're protected by law. This allows witnesses to say what they need - without fear of reprisal or prosecution - so that safety always comes first.

The BBC Steinhoeft (Photo: René Beauchamp)

(Click to view larger image)

We're also independent, which enables us to say what needs to be said, and keep the focus on safety, not politics. So what does that mean for Canada's transportation industry? How about this: When something goes wrong, you can expect to find us on the scene, such as the accidental grounding described at the beginning of this article. In that occurrence, the cargo vessel BBC Steinhoeft ran aground near Saint-Lambert, Que., in March 2011. Our experts subsequently looked at a whole range of issues, including the voyage data recorder, the automatic identification system, parallax error, the effect of bank suction-even the lighting in the South Shore Canal! And following our investigation, the corporation that manages the Seaway repaired the lighting below the Saint Lambert lock, in addition to modifying its instructions to operators to restrict the flow increase for downbound vessels in the area.

That's just one example. In 2012, the TSB also released an update to its inaugural safety Watchlist. The list, which identifies the issues posing the greatest risks to Canada's transportation system, has served as a blueprint for change, leading to numerous improvements in the marine, rail and air modes of transportation. And by combining the Watchlist with a series of videos explaining each issue, we're working harder than ever to advance safety from coast to coast to coast.

And we're not done. Looking ahead, the TSB will continue to investigate accidents, striving to find out what happened, and why. We do this, and all our work, because a safe transportation system is vital to all Canadians, whether it be on our waterways, along our pipelines and railways, or in our skies.

Wendy A. Tadros is Chair of the Transportation Safety Board of Canada. She is a lawyer with extensive experience in the transportation sector, and has been a member of the TSB since 1996. She has been the chair since 2006.