Good evening Ladies and Gentlemen. I would like to thank the organizers of CASS 2000 for inviting me here to St. John's, Newfoundland. I'm sure that over the last few days you've heard many speeches and presentations and are now looking forward to a good meal, some relaxation, and some of that famous Newfoundland hospitality. So I'll be brief.
As a former Minister of Transport, I have a unique perspective on Safety Boards because it was during my tenure that I inherited the responsibility for what was, at the time, a very fractious Board, and had to come up with a way to solve the problem. I introduced new legislation to deal with the problems of that Board... by eliminating it...and creating a new one. Seven years after, on my return from Paris in 1996, and much to my pleasant surprise, I was asked, by the Prime Minister, to chair the replacement Board. I do admit that I was looking forward to see the results of my decision taken in 1989. And so far, I have to tell you, I'm very happy with those results. In fact, just a little over a month ago, on March 29th, we celebrated our tenth anniversary.
When Parliament created the TSB, it refocussed the way transportation safety was to be viewed in Canada. The TSB was given exclusive jurisdiction to investigate transportation accidents and incidents to make findings 'as to' their causes and contributing factors. The TSB was established as the independent and objective analyst of the safety failures in the transportation system.
The object of the TSB is to advance transportation safety. It conducts independent investigations, which may include public inquiries, into transportation accidents, incidents and hazards. It makes findings about causes and contributing factors; it identifies safety deficiencies; and it makes recommendations to address them. The Board reports publicly on its findings and recommendations.
The factors associated with transportation accidents are so complex that there are usually many elements that have something to do with causation or why it happened.
In Canada, our law does not ask us to find either cause or probable cause. We are instructed to make findings 'as to', or about, the causes and contributing factors and to identify safety deficiencies. Safety deficiencies can be thought of as risks within the system for which there are not adequate defenses. Attempts to determine the cause are almost inseparable from the assignment of blame - and this is something for us to avoid. It takes away from our mandate. When we get close to assigning blame, we tend to get our work drawn into the courts. Court processes are effective for determining who is at fault or who broke the law. Usually time is not a major issue in resolving court cases. In accident investigation, time is of the essence in identifying safety problems and making them known. We must have a system where people will come forward quickly with safety-related information. This will happen only if they do not have to worry about the consequences of having provided it. When we focus on cause we may end up keeping our investigations so narrow that we might miss those safety deficiencies unrelated to cause.
In a perfect world, the simple making of findings would disclose enough information that self-interest would lead those who could deal with the safety problems, to act. However, we live in a world where there are many pressures and many competing priorities. Unless the necessary action is highlighted and made known in the form of recommendations, it is likely to become lost among other pressures and priorities. Experience shows us that it is generally best not only to identify the safety deficiencies through clear analysis, but also to give compelling reasons for reducing or eliminating them. From that point, the safety investigator needs simply to recommend fixing the problem. If a safety agency prescribes the fix, it is likely to limit the discretion and innovation of those faced with fixing the problem. We believe that the accident investigation agency should be free to make whatever recommendations it sees as necessary to have the deficiencies attended to. The question of whether the accident investigator should be able to require action is clear to us. If the investigator describes and orders a specific fix, it is setting up a condition where that particular fix may be involved in a subsequent accident. If that happens, the safety investigator has created a conflict of interest in that the safety investigation agency has reason to be reluctant to find something that criticizes its earlier work.
Let me take you through a brief parable to illustrate the perils of investigating only to find cause.
An aircraft with jet engines mounted on its rear fuselage was on its take-off roll when the tires on the right side failed. Next the right engine failed. The aircraft swerved off the runway, and came to rest with the fuselage broken in several pieces. There was no fire. There were neither fatalities nor problems with evacuation and rescue. Investigators found a sharp piece of metal on the runway. It had fallen off a runway sweeper near the point where the tires failed. The piece of metal matched a cut in the inboard tire and the outboard tire was shown to have failed in overload. Pieces of the failed tires were found in the engine which suffered a serious but contained failure. The pilots were qualified, appropriately trained, and rested. The digital flight data and cockpit voice recorders were both recovered. These, together with statements provided by the crew, gave the investigators all that they could hope for to identify the cause.
However, in examining the wreckage, an investigator noticed serious corrosion in an area that is normally inspected at long intervals. If the investigator's mandate is to find the cause of the accident, he has little scope to worry about the corrosion, and the investigation report will highlight the cause. If, on the other hand, the investigator's mandate includes the identification of safety deficiencies, he will take enough interest in the corrosion to arrange to have a few more aircraft checked. If there are indications of a fleet-wide problem, there is safety information to be shared throughout the transportation system. The investigation report will likely, in this circumstance, highlight the corrosion problem. It will also deal with any safety deficiencies associated with the accident. The report writers will not have to worry whether the actual cause was the foreign object on the runway, the unexpected failure of the second tire, the ingestion of the tire fragments into the engine, or the actions of the crew. It will not be important to distinguish among what was causal, what was contributory and what simply elevated risk levels. Those items that are cause-related can be identified, but the real focus can be on those risks that were shown to be present and what needs to be done to eliminate them.
Whether one should stop at cause or go beyond cause and look for safety deficiencies seems to be a question that answers itself.
There will be times when the accident investigation agency and the regulator want the same information. We try and share this information, but we have different reasons for wanting that information. We want the information to identify safety deficiencies, the regulator wants the information to prosecute violations of the regulations. If there is disagreement between the Safety Board and the regulator, the Board's needs are considered paramount. The underlying principle is that it is more important to gather information for the quick identification of safety problems than it is to prosecute violators. This is reflected in our legislation.
Most of you here are probably more than well aware of the investigation into the very serious accident of Swissair Flight 111on the night of the second of September 1998, just off the picturesque coast of Peggy's Cove, Nova Scotia. It's been more than a year and a half since the MD-11 crashed into the ocean, and the investigation continues.
The wreckage recovery or field phase of the TSB's investigation has been safely completed. Approximately 98 per cent of the aircraft by weight has been recovered. The detailed examination of the recently recovered items is under way. Although over a million new pieces were recovered in the final operation, many of the pieces are small and difficult to identify the work is time-consuming.
While that work is continuing in Hangar A in Shearwater, Nova Scotia, other investigation activities have been undertaken: airflow testing on board an MD-11 to help determine the airflow pattern within the front ceiling area of the aircraft; additional wire testing is continuing to try to extract as much information as possible from the 20 arced wires that have been found. We do not yet know what the analysis of these results will yield.
Integration of individual pieces of data from various sources is under way to help us in the analysis phase. This is the phase where the investigation team looks at all the material and information that has been gathered, and integrates it to assess what it is telling us about what occurred on board Flight 111, and what additional safety deficiencies we can identify.
Of ongoing interest to the TSB investigation team is the identification of any potential sources of heat in the proximity of materials that may support ignition. In this regard, information has recently come forth regarding a potential safety deficiency associated with the flight crew reading light installations (usually referred to as map lights) in the cockpit area of MD-11 aircraft. Recently, we issued an Air Safety Advisory concerning these map lights. We have been informed that the Boeing Commercial Aircraft Company has issued an Alert Service Bulletin and the Federal Aviation Administration has issued an Airworthiness Directive concerning the subject of this TSB Safety Advisory. At this time, the investigation has not established any direct connection between the issues identified in this Safety Advisory and the circumstances of Flight 111.
This is the second Safety Advisory the Board has released on this investigation along with two sets of Interim Safety Recommendations. The first recommendations dealt with the adequacy of power supplies to recorders, the introduction of 120-minute CVRs, and backup power to CVRs to give operation for up to 10 minutes after a power outage. The second set of recommendations dealt with the risk of using metalized Mylar thermal acoustic insulation blankets. Our investigation has shown that the Mylar covering is flammable and in fact will support combustion. All of these safety advisories and recommendations have lead to safety action on the part of the regulators and the industry.
All of this safety action is of little comfort to the shattered lives of the next of kin and beloved of the 229 persons who died that night. And this brings me to an aspect of accident investigation that is largely overlooked by the public at large: ensuring that the survivors, and the families and beloved of accident victims are treated with dignity and respect.
Whenever there is a major accident in Canada, a major consideration in the response to the accident is ensuring that the survivors, and the families and beloved of the victims have access to the critical services they need during this stressful time.
In the aftermath of this terrible accident, Swissair and Delta, who had passengers on the aircraft through a codeshare agreement, had action plans in place to look after such an eventuality. These plans are mandated by the Family Assistance Program in the US. The American federal government has mandated that all airlines in the US and all foreign airlines flying into the US must have a plan for handling an aircraft disaster. Such a program does not formally exist in Canada at the present time, but work is under way to ensure that there is compassionate assistance when there is a major accident in the federally regulated transportation system.
When there is a major accident, like the crash of Swissair Flight 111, the next-of-kin and the beloved of the victims need help. Who do they turn to? At the moment, it's an ad hoc group of federal, provincial, and municipal agencies. And I must say that in the case of the Swissair Flight 111 accident this ad hoc operation worked out very well. We now want to build on this knowledge, and the knowledge of the operation in the US, to determine what is appropriate in Canada. At high-stress times like this, the families and beloved of the victims need to know that there are people they can go to directly, to a Compassionate Assistance Program, to get information and help.
Canada isn't the only country working on this problem. ICAO has issued a call to its members to develop family assistance programs, and the European Civil Aviation Conference is meeting this fall to address the need for family assistance programs in Europe. In Canada, we are thinking about extending this type of program to other federally regulated modes of transportation as well.
Our experience with the Swissair Flight 111 accident would indicate that there is considerable effort required to provide information to the families and beloved, not just after the accident, but in keeping them informed of the progress of the investigation as well.
The more I have become involved with how transportation accidents are investigated, the more I realize how those investigations are important not only in this country, but globally. Safety deficiencies that we at the TSB find in our transportation systems crop up in transportation systems in other parts of the globe and vice versa. This makes sharing of that information imperative.
A number of years ago, this agency and four other independent safety investigation boards formed a group called the International Transportation Safety Association ITSA for short. It was set up to exchange information on the findings of accident investigations, safety studies, recommendations, accident data and investigation methodology. There are now nine members of ITSA, and from what I know, there will soon be more. So far the countries involved besides Canada and the US, are the Netherlands, Sweden, Finland, India, New Zealand, Great Britain, and the Commonwealth of Independent States (Russia).
The number of independent safety investigation boards is growing as more and more countries realize the advantage of such agencies. In fact, we regularly get calls and visits from accident investigation agencies from around the world looking for more information on how we operate in Canada and how our legislation works. For example, we had a delegation from an Asian country visit just last month. They are in the process of setting up their own independent accident investigation agency and wanted to find out how the TSB operates.
Our founding legislation, the Canadian Transportation Accident Investigation and Safety Board Act, is being used as the basis for a number of other independent boards around the world. I guess we did something right back in 1989 when we passed the first act creating the TSB.
It's not often in a politician's career that you get to head an organization that you were responsible for creating. For me it has been a humbling experience to work with such a professional hard-working group who have made this legislation work. This is a group of people that is looked at with respect around the world. A group of people who have earned that respect from the work they have accomplished conducting independent and objective analysis of safety failures in the transportation system and advancing transportation safety. Without compromising their independence or objectivity, I know TSB staff will continue working with industry to make transportation as safe as humanly possible for Canadians, and through international agencies, for travellers around the world.
And now it's time to relax and enjoy this great Newfoundland hospitality.
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