Working together to reduce fatalities

Chief Coroners and Chief Medical Examiners of Canada Conference

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Jean L. Laporte, Chief Operating Officer
Transportation Safety Board of Canada
Edmonton, Alberta, 6 June 2013

Check against delivery.

Slide 1: Title page

Slide 2: Outline

  • About the TSB
  • How we work
  • Accident rates and fatalities by mode
  • Working together

Slide 3: Who we are

  • An independent agency that consists of up to five Board members, including a chairperson, and approximately 220 employees
  • Head office in Gatineau, Quebec, 8 regional offices and laboratory in Ottawa, Ontario
  • TSB currently reports to Parliament through the Leader of the Government in the House of Commons and is independent from other governmental agencies and departments.

Slide 4: Our mission

To advance transportation safety in the marine, pipeline, rail and air modes of transportation that are under federal jurisdiction by:

  • conducting independent investigations;
  • identifying safety deficiencies, causes and contributing factors;
  • making recommendations;
  • reporting publicly.

It is not the function of the TSB to assign fault or determine civil or criminal liability.

Slide 5: TSB investigations

  • Approximately 3 200 transportation occurrences (accidents and incidents) are reported annually to TSB
  • TSB Regulations define what is a reportable occurrence.
  • TSB undertakes, on average, 75 investigations per year.

Slide 6: TSB investigations (cont’d)

  • Decision to investigate is based on potential to advance safety.
  • TSB Occurrence Classification Policy serves as a guide for decision-making.
  • Once an investigation is started all resources / efforts required are invested to ensure a complete and thorough analysis of what happened.

Slide 7: Jurisdiction

Within Canadian territory or waters:

  • All accidents and incidents associated with the operation of federally regulated transportation (marine, rail, pipeline and air)
  • Any situation or condition that the Board has reasonable grounds to believe could, if left unattended, induce an accident or incident

Under international conventions:

  • May participate in investigations of all accidents or serious incidents involving Canadian operators, crew, passengers or equipment in any country
  • May investigate any accidents or serious incidents involving Canadian operators, crew, passengers or equipment in international waters / territories

Upon request of a province or territory:

  • May investigate accidents or incidents involving provincially regulated transportation (e.g., short-line railways)

Slide 8: Investigator powers

Section 19 of the CTAISB Act provides investigators with the powers to:

  • Enter and search a place
  • Prohibit or restrict access to an area
  • Seize wreckage / impound equipment
  • Compel witnesses to interviews
  • Compel the production of documents
  • Obtain search warrants
  • Conduct testing, including destructive tests if necessary
  • Require medical examinations
  • Require the provision of medical / health information
  • Require an autopsy or post-mortem medical examination

Slide 9: Investigator powers (cont’d)


  • Must have reasonable grounds
  • Must minimize disruptions
  • Must return seized material
  • Must protect medical / personal information
  • Cannot submit a person to any procedure involving surgery, perforation of the skin or entry into the body of any drug or foreign substance
  • Cannot use force unless accompanied by a peace officer and use of force is specifically authorized in warrant

Slide 10: Investigator powers (cont’d)

Failure to comply or provision of false or misleading information

  • TSB can go to court and person can be found guilty of an indictable offence punishable by a term of imprisonment up to two years.

Slide 11: Protection of information

TSB is subject to Access to Information Act and Privacy Act

  • Personal information is protected
  • Third-party proprietary information is protected
  • National security related info is protected
  • Info protected « during the conduct of a lawful investigation »

Slide 12: Protection of information (cont’d)

CTAISB Act also protects some information:

  • Witness statements
  • Medical and health information
  • On-board voice and video recordings
  • Draft investigation reports and representations by designated reviewers

The Board may release privileged information if necessary in the interest of transportation safety.

The court or coroner may access privileged information but information cannot be used against the individuals in any legal, administrative or disciplinary proceedings.

Courts must also weigh public interest in proper administration of justice vs the privilege.

Slides 13: Safety communications

  • Deployment notices
  • Investigation web pages
  • News releases
  • Investigation updates
  • Safety advisories
  • Safety information letters
  • Letters to coroners
  • Investigation reports
  • Safety recommendations
  • Safety concerns
  • Assessments / reassessments of responses to recommendations
  • Watchlist

Slide 14: Reported occurrences (all modes)

Slide 15: Marine accidents per 1,000 vessel movements

Slide 16: Pipeline accidents per exajoule

Slide 17: Rail accidents per million main-track train miles)

Slide 18: Canadian-registered aircraft accidents per 100,000 hours flown

Slide 19: Fatalities

Slide 20: Where are the most fatalities/mode?

  • Marine = Fishing vessels
  • Air = Small operators
  • Rail = Trespassers and crossings

Slide 21: Working together to reduce fatalities

Slide 22: TSB Watchlist 2012

  • Loss of Life on Fishing Vessels
  • Marine Safety Management Systems
  • Landing Accidents and Runway Overruns
  • Air Safety Management Systems
  • Risk of Collisions on Runways
  • Collisions with Land and Water
  • Passenger Trains Colliding with Vehicles
  • On-Board Video and Voice Recorders
  • Following Signal Indications

Slide 23: TSB studies and analysiss

  • Fishing vessel safety investigation
  • Analysis of railway occurrences involving trespassers or grade crossings

Slide 24: TSB Outreach program

  • Presentations
  • Articles in specialized publications
  • Meetings with stakeholders
  • Videos
  • Website
  • Social media

Slide 25: What YOU can do

Promote and support our key messages

Help us connect with regional & local first responders to build awareness.

Review and finalize new collaborative agreements with the TSB.

Slide 26: Memorandum of Understanding (MOUs)


  • Define how we coordinate our activities before we get to an accident site.
  • Define what information we can share and how.
  • Define dispute-resolution mechanism.

The operating environment has changed since last MOUs were put in place.

Need to review and update them to reflect changes in federal and provincial legislation, as well as changes in our respective operating practices.

Slide 27: Conclusion

Slide 28: Questions?

Slide 29: Canada wordmark