Presentation to Canadian Marine Advisory Council

John Clarkson
Board Member
Transportation Safety Board of Canada
Ottawa, ON
6 November 2012

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Speaking notes for the presentation

Slide 1: Title page

Thank you for that introduction, and thank you very much for this opportunity to speak today.

John Clarkson addressing the Canadian Marine Advisory Council

Slide 2: Outline

Today I'd like to talk briefly about who we are at the TSB—what and how we do what we do. I'll look at our mandate, our investigation process, and especially at our recent safety Watchlist. After that I'll touch briefly on one of this year's high-profile studies, a Safety Issues Investigation into fishing vessel safety, before wrapping up with a few questions if we have time.

Slide 3: About the Transportation Safety Board of Canada

The Transportation Safety Board is an independent agency charged with advancing transportation safety by conducting independent investigations in each of four modes: marine, pipeline, rail and aviation, under the auspices of the Canadian Transportation Accident Investigation and Safety Board Act.

Our goal is to find out what happened, why it happened, and then make recommendations—to the regulators, to manufacturers, and to operators—about what needs to be done, or what can be done, to reduce or eliminate the identified risks. As a government agency, we also report publicly on our findings so that lessons learned are shared.

Note, however, that there is a limit to our powers and role as set out by the Act that created us. We're not a court, nor are we the regulator. As such, we do not assign blame, nor do we determine civil/criminal liability. Nor can TSB findings be construed as assigning fault or determining civil or criminal liability.

Slide 4: Transportation Safety Board of Canada investigations

The TSB comprises approximately 230 employees located across the country. The Board itself is comprised of up to five Board Members, including the Chair.

The TSB as a whole receives notice of approximately 4000 occurrences every year, spread across all modes. Once these are reported to us, we make a decision as to the depth of investigation warranted—a decision which is based on several factors. Chief among these is whether an in-depth investigation has the potential to advance transportation safety.

However, even if we do not launch a full investigation, we still assess each and every reported occurrence and track that information in our database. That way, we can analyze the information to spot trends, and then target issues that continue to be a problem.

Within the TSB Marine Branch, during the 2011 calendar year, there were a total of 544 reportable accidents and incidents. Groundings make up the most accidents with 72 occurrences, followed by strikings (55), and fire/explosions (52). A total of 20 fatalities resulted from 19 occurrences.

The Marine Branch began 10 investigations in 2011 of which two involve other flag States, the Marshall Islands and Liberia. We produced 14 safety information/advisory letters and the Board published 2 recommendations.

Slide 5: Board responsibilities

The TSB's practice is not to wait until an investigation is complete before making important safety-critical information public. When we identify an urgent safety deficiency, we communicate it to those who can make transportation safer—right away—thereby allowing for timely and appropriate safety action.

Every investigation report is reviewed by the Board, in draft, before it goes out to official “Designated Reviewers.” These are people and organizations from whom the Board solicits feedback based on considerations such as their ability to comment on the technical accuracy of the report, and whether their interests may be affected by the report. Transport Canada, as you can assume, is a frequent designated reviewer.

Once the TSB receives this feedback, the Board reviews every comment and approves every report before it is made public.

For difficult, systemic issues, the Board may issue recommendations. These are meant to draw attention to particular safety deficiencies that involve substantial risk and require immediate action. When we issue a recommendation, the government has 30 days to formally respond.

The TSB also issues Safety Advisories and Safety Information Letters. These notify industry and regulators as soon as possible when significant safety risks are found during an investigation.

Slide 6: Watchlist

The TSB also has another tool at its disposal, our safety Watchlist, which we launched in 2010, and then updated earlier this year. This document highlights the nine transportation safety issues posing the greatest risk to Canadians—the ones that have proven toughest to solve, the most stubborn to eradicate, and which keep coming up in investigation after investigation.

Two of these issues, shown here, are related specifically to marine transportations. These are: “Marine Safety Management Systems,” and “Loss of Life on Fishing Vessels.”

When we first published the Watchlist, back in 2010, we envisioned it as a “blueprint for change,” and that's exactly what happened. Over the next two years, we saw some positive action to make transportation safer. In fact 14 of the 41 original Watchlist recommendations—34% of them, have been assessed as Fully Satisfactory by the Board.

Because of this change, this progress on the part of both regulators and industry, we were able to remove some issues from the Watchlist. One of these was the issue of “emergency preparedness on ferries,” where we feel that sufficient progress has been made.

However, even with our new iteration of the Watchlist, and all of the associated progress, there are still several issues that have been … stubborn. Several of them are in aviation, where we have made very little progress, but one of them is relevant to many of the people in this room.

Slide 7: Marine safety management systems

Implemented properly, safety management systems (SMS) allow vessels and marine transportation companies to identify hazards, manage risks, and develop and follow effective safety processes. In other words, it lets people find trouble, before trouble finds them.

In the marine community, the value of SMS has long been recognized, and the TSB has repeatedly emphasized its advantages, in addition to citing deficiencies in many occurrences over the last 14 years. Following a 2002 investigation of four fatalities, we recommended that TC ensure small passenger vessels have an SMS. In addition, after a 2006 investigation into the loss of a crew member aboard a sail-training vessel, the TSB advocated the adoption of effective SMS for both domestic and foreign sail-training vessels.

Strong initiatives are required to address the issue of risk awareness and risk mitigation—both of which can be addressed through a formal, systematic approach to safety. TC, vessel operators, and marine management companies must work together to ensure that operating risks are identified and reduced to a minimum through the introduction of effective SMS.

We'd like TC to require all commercial vessels to have SMS, and for all SMS to be certified and audited.

Slide 8: Loss of life on fishing vessels

The TSB issued its first recommendation on fishing vessel safety in 1992, and since then has issued 41 more. Yet we continue to lose an average of just over one fisherman per month.

Every time the TSB investigates an occurrence, we make conclusions about causes and contributing factors, but many of these factors are bigger than any one event: they are systemic problems, which need systemic solutions. Concerns also remain about issues such as vessel modifications and their impact on stability; the use and availability of lifesaving equipment; the impact of fishery resource management plans, operational practices, and training on fishing vessels.

Concerted and coordinated action is required by leaders in the fishing community to implement a safety culture approach to fishing operations, recognizing the interaction of safety deficiencies.

Slide 9: Fishing vessel safety (Safety Issues Investigation)

Earlier this summer, we released a very special investigation report, one several years in the making. We spoke to fishermen and industry associations from coast to coast, to find out why an average of one person a month was dying in fishing related accidents. I'll just show you a brief two-minute video outlining the bare bones of what we learned, and how we are communicating that to the Canadian fishing industry.

Before I do that, though, I'd also like to mention that there will be a guided tour of the TSB's Laboratory on Thursday afternoon at 15:00. Please see me afterward if you wish to attend, and we'll get your name on a list. But if you are unable to go today, don't worry: we'll have another tour again at the next CMAC meeting.

Slide 10: Fishing safety video

Note: This video discusses loss of life on fishing vessels, which is one of the nine safety issues identified by the Transportation Safety Board as posing the greatest risk to Canadians. To find out more about these safety issues, see the Watchlist 2012.

Slide 11: Canada wordmark

Thank you. If we have a few minutes, I'd be pleased to take any questions.