Speaking Notes, Operation Lifesaver Aylmer, Quebec
Martin Lacombe

Board Member
Transportation Safety Board of Canada
Aylmer, Quebec
15 September 2010

Thanks for the opportunity to come and speak with you.

I'll be keeping today's presentation pretty focused, beginning by outlining what we do at the TSB, then talking extensively about our current safety issues Watchlist.

I'll discuss those issues which are most relevant to the rail industry, and then talk about a few specific accidents to illustrate the points.

To keep the momentum and increase adoption of our recommendations though, we must keep pushing for action. We do that through stakeholder engagement and by pushing our message. To this end, we recently released our first ever Safety Watchlist, highlighting nine critical safety issues currently posing the biggest risk to Canadians. Tackling these issues, which cover the Marine, Rail and Air modes, will go a long way to making Canada's transportation system safer.

Several of these issues are critical to the aviation sector. There remains, for example, an ongoing risk from runway incursions. While these occurrences have been addressed in several TSB reports, it is only a matter of time before an accident occurs with potentially catastrophic consequences unless we improve procedures and warning systems.

Wider use of technology is the key to solving another problem. Pilots, for a variety of reasons-including darkness and poor weather-continue to fly perfectly good aircraft into the ground. Controlled flight into Terrain, or CFIT, account for just 5% of accidents yet they comprise nearly 25% of all fatalities. Terrain awareness warning systems or other technology that is currently already available, would significantly reduce these tragic losses.

Runway overruns are another Watchlist item where the problem has been recognized for some time, yet solutions have not been forthcoming. In short, when runways become contaminated by rain, snow ice or slush-or when a landing begins too far down the runway-aircraft simply run out of room.

Emergency safety areas, RESAs, are the easiest solution. However, at some airports, not only do these areas not exist, but the terrain beyond the runway can be downright dangerous. Two other important issues on our Watchlist items are what we call "multi-modal;" that is, they apply to the marine, rail and air transportation sectors. The first of those I'll address is the issue of data recorders.

As you know, the aviation industry has led the way for over 50 years in requiring crash-resistant cockpit voice and flight data recorders aboard aircraft. Information from these data recorders is vital in helping our investigators piece together why an accident occurred, and how we can prevent similar accidents from happening again. We are pleased that the industry continues to innovate and include more data parameters that are extremely helpful to accident investigators.

But, as we learned during the Swissair investigation and more recently with the runway overrun Air France Flight 447 in Toronto, this data is not always available to investigators, or it is sometimes incomplete. While investigators often rise to the challenge to find other information sources, especially as more electronic components make their way into aircraft, investigations become more complex.

To reinforce the lessons we learned from Swissair, the Watchlist calls for global efforts to build better recorders, recordings of greater quality and duration, and a means to ensure they keep recording when the aircraft's power supply fails. This will ensure that air accident investigators will have the objective data they need to get their job done.

Another multi-modal Watchlist issue concerns the implementation of Safety Management Systems, or SMS. SMS is a powerful management tool to help organizations foresee what might go wrong so they can take pre-emptive action. In other words, to find trouble before trouble finds them.

By and large, SMS appears to be working well with our carriers. However, we have found in some accident investigations that the transition towards implementing an effective SMS can be a significant challenge. This is why we have called for the regulator to closely monitor the industry to ensure all are on board and that there is a smooth transition.

So what does SMS have to do with flight data analysis?

Flight recorder data analysis is an important element of a thorough accident investigation and an essential source of information for organizational safety management. Detailed flight recorder data gives us a good understanding of what the machine was doing leading up to an accident and flight path animations derived from FDR data are valuable in illustrating the sequence of events when we release our investigation reports. For operators, it is a rich source of information for organizational learning, risk assessment, and risk management.

While we all agree that flight data analysis is very useful tool, we cannot just stop there.Flight data only show what the aircraft and its crew were doing, but we often need to look deeper to answer "why?" Thorough accident investigations always consider human and organizational factors. We must analyze this and other information to learn more about the context in which people acted and why they did what they did. In accident investigations and within an SMS context, it is important to closely look at behavioural patterns, medical issues, training, organizational standards and procedures, and the company management's goals and expectations.

Enough about the Watchlist and back to our 20th Anniversary.

One of the TSB's proudest and most innovative accomplishments over the years is the Recorder Analysis and Playback Software. While development was initiated by the TSB's predecessor, the TSB further developed and refined the software. As no similar tool was commercially available at the time, the software was both pioneering and innovative, so much so that it attracted the attention of other investigative agencies from other countries that approached the TSB to use it. In the interests of international collaboration, the TSB shared the software with its counterparts, notably the German military flight safety investigators, the Australian Transport Safety Board, the US NTSB, the French BEA, and German civil investigation authorities, some of whom are represented here today.

Recognizing that others like airlines and aircraft manufacturers could benefit from the same technology, the TSB decided in late 2001 to commercialize the software. We are proud to know that many different users, from accident investigators to aircraft manufacturers and operators, now use the original TSB technology to not only piece together what happened during an accident but to also use it to analyze the safety and efficiency of their operations.

TSB investigators continue to be innovative in finding new ways to gather information as the technology aboard vehicles evolves. As I mentioned before, electronic components aboard aircraft are becoming a rich source of information to investigators, especially when flight recorder data is not available. For example, when the flight recorder stopped functioning aboard Cougar Helicopters Flight 491 last year in an accident off Canada's East Coast, our investigators worked with the manufacturer and successfully retrieved information from the aircraft's Health and Usage Monitoring System (HUMS) and flight control computer (FCC). This allowed them to piece together most of Cougar 491's flight profile. GPS units and even images from digital cameras aboard aircraft have also been useful during other investigations. We have also been successful in using these sources of information in our investigations of marine and railway occurrences to piece together sequences of events and vehicle trajectories leading to accidents.

I will conclude by expressing my hope that the information that I have shared this morning, along with the knowledge and experiences you will share together during this conference will lead to a greater understanding of how best to use flight data analysis. Je suis convaincu que le partage d'information qui se fera pendant cette conf�rence va contribuer � promouvoir la s�curit� du transport a�rien.

Thank you, Merci, and enjoy the conference.