Presentation to the Institute for Defense and Government Advancement
Search and Rescue Canada Conference 2011
Martin Lacombe
Transportation Safety Board of Canada
April 13, 2011

Click here to see PowerPoint Presentation  [4834 KB]

Check Against Delivery

Slide 1: Title Page

Good morning, and thank you for the invitation to speak today at the Search and Rescue Canada Conference.

My background is in the rail industry. I am accompanied by Mr. Brian Macdonald who has extensive experience in air investigations.

Slide 2: Outline

Today, I'm going to talk about the TSB: who we are, how and why we were created.

I'll also talk about our Watchlist safety issues, as well as about some Search and Rescue issues / challenges.

I'll occasionally include a few anecdotes to support my points, before wrapping up with a Q & A session.

Slide 3: About the TSB

  • The Transportation Safety Board was formed in 1990. Our mandate is to advance transportation safety by conducting independent, professional investigations.
  • Marine, pipeline, rail, and air—these are the four modes of transportation in our mandate.
  • Our goal is to find out what happened, why it happened, and then make recommendations – to the regulators, manufacturers, and operators – about what needs to be done, or what can be done, to reduce or eliminate the identified risks. As a federal government agency, we also report publicly on our findings so that lessons learned are shared.

Slide 4: TSB Investigations

The TSB receives notice of approximately 4,000 occurrences every year. Once these are reported to us, our decision to launch a full investigation is based on several factors. Chief among these is whether an in-depth investigation has the potential to advance transportation safety. In 2010, that decision to investigate in depth happened 62 times, but we still record and assess each and every reported occurrence.

If, for example, a fishing boat sinks outside St John's Harbour and it's clear that the vessel was neither certified nor crewed by a master with any experience, and that perhaps it already had a number of stability issues … well, we've investigated a lot of similar cases before, and we've made several recommendations about each of those issues.

However, even if we do not launch a full investigation, we still track all that information in our database. We can analyze the numbers to spot trends, and then target issues that continue to be a problem. That Newfoundland fishing boat I just mentioned? We didn't drop the issue, but rather we launched a special issues investigation into small fishing vessel safety, which is still ongoing and looking specifically at the number of accidents and casualties aboard these vessels across Canada.

So, with a broad mandate, and such a large number of occurrences reported to us, there is a lot that we can accomplish. However, there are a number of things that we do NOT do, and it's important to be clear about those, too. For instance:

  • We do not assign blame, nor do we determine civil/criminal liability.
  • TSB findings are not binding on parties to any legal or disciplinary hearings.
  • It is important to understand that the TSB is NOT empowered to require or regulate corrective measures. We identify safety deficiencies that require attention and we make these known through various means of communication to specific parties as appropriate and to the public.
  • There are also times when we do not investigate. If it's a criminal occurrence, we leave matters to, for example, the RCMP. Neither do we investigate occurrences that are strictly military; they investigate their own accidents.

Slide 5: TSB's Methodology

The TSB practice is not to wait until an investigation is complete before making important safety-critical information public. When we identify a safety deficiency, we act quickly by communicating it to those who can make transportation safer, allowing for timely and appropriate safety action.

The really big safety payoff occurs when everyone agrees during the course of an investigation about what needs to be done and safety deficiencies are quickly addressed. All we need to do then is to document in our final report the action already taken.

The Board uses various safety communications to address deficiencies that require action. The purpose is to ensure that identified deficiencies are communicated to those best able to effect change, and to convince them to take remedial action. This depends on the level of risk, the urgency of required action, who is the change agent, etc.

In addition to our accident reports, the Board issues Safety Information Letters, Advisories, Concerns, and Recommendations as well as other publications such as the recent Watchlist.

Formal recommendations draw attention to particular safety deficiencies that involve significant risk and require particular attention. Recommendations are typically used to address the more difficult, systemic issues that pose a higher risk.

Slide 6: TSB Communications—Outreach

At the TSB, we also have an "outreach" program aimed at keeping Canadians aware of key safety issues and improvements in transportation safety. We do this via:

  • Interviews, speeches
  • Newspaper and magazine articles & Op-Eds
  • Presenting at conferences such as this one.

In other words, we try to communicate in advance with groups we may encounter in the field.

Slide 7: Watchlist

In March 2010, we issued a safety Watchlist identifying the nine transportation issues currently posing the biggest risk to Canadians.

These nine issues were selected in part because they had proven stubborn. In investigation after investigation, these were the ones that kept coming up. This meant that not enough was being done, despite numerous recommendations, safety concerns, safety advisories, safety information letters, investigative findings and occurrence trend analyses.

Some of these issues are mode-specific, but some apply to all the modes.

When we issued our Watchlist, we had four main objectives:

  • To build on existing credibility, stimulate dialogue and trigger action by change agents to make transportation safer.
  • To demonstrate how concrete action will advance transportation safety.
  • To raise public and media awareness about significant  safety risks in transportation.
  • To deliver messages about the TSB and its role.

In other words, we wanted greater acceptance of our findings and recommendations by regulators and industry leaders. And then we wanted to make sure they took action.

Slide 8: The Watchlist – One Year Later

The Watchlist was launched a year ago. What's happened since?

Initially, we received extensive media coverage. Not only did Board members conduct numerous interviews from coast to coast, but the same day the Watchlist was published, the Minister of Transport issued Transport Canada's response. These announcements helped bring even greater focus to the Watchlist.

In the past 12 months, we've also held numerous meetings with industry stakeholders, and TC has pledged to give these issues the "highest priority."

The real measure of success, however, is in terms of concrete results.

Here, then, is the score so far.

Slide 9: Where are we now?

A total of 42 TSB recommendations in the various modes underpin the Watchlist.

The figure on screen shows the percentage of these recommendations, and what their status is.

A total of 10 recommendations out of the 42 recommendations of the Watchlist are now rated as "Fully Satisfactory." A year ago, before the Watchlist, just five were Fully Satisfactory.

So, we're making progress. But given that our goal is 100 per cent implementation of all outstanding 42  Watchlist recommendations, there's still a long way to go.

Eventually, we want these issues—every single one—to become non-issues.

To do that, the TSB will work with Transport Canada, industry and other stakeholders to get each and every issue resolved.

Now I'll talk about specific SAR issues encountered when conducting TSB investigations.

Slide 10: What are the Priorities for First Responders?

SAR organizations are often the first people on scene.

When on scene, our investigators interact a lot with first responders including SAR organizations.

Let me talk a bit about specific issues we all face.

As we see it, at an accident site, the priorities for first responders are:

  1. Be safe and determine what you're facing: fire, dangerous goods, etc. Use the appropriate resources available to you.
  2. The protection of people - and let me stress this includes yourself, because you can't minimize injury to others or loss of life if you get hurt or incapacitated.
  3. Protect property, and the environment.
  4. Prevent loss of clues and preserve perishable evidence regarding the factors that contributed to the accident.

Slide 11: Preparedness in the Arctic

The TSB wants to test its operational readiness in an especially remote location. That is why it will participate in the Arctic accident simulation this August called Operation Nanook. This simulation is led by DND and many federal departments and organizations will participate. The TSB wants to learn as much as it can from that experience. We will ensure situational awareness between ourselves and other departments or organizations. It will be a great opportunity to enhance coordination and response to real-life occurrences.

The Arctic is large and isolated. Air and sea temperatures remain relatively cold, even in the summer, which means survival time for people in the water or in a liferaft can be limited, underscoring the importance of timely SAR response.

For example, eight people died in 1994 when the pleasure craft Qasaoq sank in Frobisher Bay (TSB Report M94H0002). The TSB's investigation identified timeliness issues in notification of the Joint Rescue Coordination Centre in Halifax. Later, personnel from key SAR agencies, along with representatives from local authorities, met to review mandates and to discuss procedures relating to SAR operations. They agreed that, in future, JRCC Trenton and JRCC Halifax would be immediately notified of marine accidents.

Slide 12: Emergency Locator Transmitters (ELTs)

Emergency locator transmitters, or ELT, in aircraft, can expedite SAR response and save lives.

Transmission failure of ELTs is often an issue in SAR. In many accidents, the ELT wasn't working properly, was damaged in the crash, or the antenna adapter was severed.

The TSB is encouraged to see that new models are available with internal antennas.

Slide 13: Programmable Dongle Issues

As has been mentioned, an ELT unit can be serviceable and activate at impact without a signal being detected. However, transmission of incorrect information in an emergency situation because current data had not been programmed in a dongle constitutes an issue for SAR operations.

Some ELTs can have a programmable dongle; a device which is essentially a connector plug with a microchip, programmed with the current aircraft identification information. A characteristic of the dongle is that, when the ELT is switched from the "OFF" to the "ARM" position, identification information programmed in the dongle's non-volatile memory will download to the ELT.

This is fairly new technology that is useful when an aircraft's ELT requires servicing or replacement. The ELT can easily be replaced, avoiding aircraft down time, and avoiding having to reprogram the replacement ELT as the dongle stays with the aircraft. When first installed in an aircraft or when ownership changes, the dongle needs to be reprogrammed with the new information (country code and ID code). If not updated or if not programmed since new, it will transmit incorrect information whenever switched from "OFF" to "ARM". For example, a new dongle without having been programmed with current information may transmit in Test User Protocol mode an incorrect country code from the manufacturer.

Any transmission in the Test User Protocol mode or with incorrect data may be of limited or no use to SAR resources and significantly delay response times.

Slide 14: Emergency Position Indicating Radio Beacons (EPIRBs)

Emergency position indicating radio beacons, or EPIRBs, can also be problematic.

In some marine accidents, there were problems with distress identification and confirmation. The TSB is pleased to note that the Canadian Beacon Registry was amended. The form now includes a note that the primary and secondary 24/7 contacts not include the owner, unless the owner is not on board.

Also, before 2002, some vessels were not equipped with EPIRBs and were not required to by regulations. As of April 2002, small commercial vessels more than 8 metres long operating more than 20 miles from shore are required to carry an EPIRB.

Slide 15: SAR Issues / Challenges: Radio Communications (Air)

In the Robinson R44 helicopter accident near Grande Cache, Alberta, in 2009 (TSB Report A09W0021), the lack of common radio communications frequency between SAR ground and air crews resulted in confusion and contributed to delays in reaching survivors. After the accident, the Ground Search and Rescue Council of Canada gave its support to renewed efforts to adopt the SAR Interagency Frequency (SAR-IF). Some operators have started installing SAR-IF capability, but work is still ongoing.

Slide 16: SAR Issues / Challenges: Common Radio Frequencies (Marine)

In the Qasaoq occurrence in 1994, which I mentioned earlier (TSB Report M94H0002), the vessel could not contact the Iqaluit Marine Communications and Traffic Services, or MCTS, because the vessel's radiotelephone could not transmit on the designated marine frequencies. Therefore, the MCTS did not receive a distress call, which obviously delayed communications and response time. Following this accident and as discussed earlier, it was agreed that, JRCC Trenton and JRCC Halifax would be immediately notified of marine accidents.

After a passenger fell overboard the Miss Gatineau on the Ottawa River in 2000 (TSB Report M00L0043), various radio communications problems were encountered. Although not required by regulation, a marine VHF radio was on board the Miss Gatineau at the time of the occurrence. However, it had not been installed. Several crew members had cellular telephones. The Hull fire department was equipped with a marine VHF radio; however, the Ottawa fire department water rescue unit was not. Furthermore, the Ottawa and Hull fire departments did not have a common radio frequency with which to communicate with each other. They therefore communicated with each other and with the Miss Gatineau through their respective dispatchers, each using a proprietary radio system and, with varying degrees of success, cellular telephones. After the occurrence, the Ottawa fire department water rescue unit equipped its rescue vessels with marine VHF radios. Transport Canada advised the TSB that the Ship Station (Radio) Regulations, 1999 now require all passenger vessels to have reliable means of communicating with the shore.

Slide 17: Summary

So today, we spoke about:

  • The TSB – what it is, what it does, and how it does it;
  • The TSB Watchlist – the safety issues it identified, what has happened since, and where we now are;
  • Some of the many challenges both the TSB and SAR have in dealing with occurrences including
    • The Arctic in the various modes of transportation.

Thank you for the opportunity to speak here today and now we'll try to answer any questions.

Slide 18: Questions

Slide 19: END