Departmental Performance Report (2)

3.2.2 Implementation of Appropriate Safety Actions

Since its inception, the TSB has been acutely aware of the obligation to provide key safety information in a timely fashion to those who are in a position to implement changes. It is not uncommon for the TSB to provide, on an informal basis, critical safety-related information throughout the investigative process when it becomes apparent that important information should be shared with others. From time to time, when enough information is available, the TSB also produces recommendations before the conclusion of an investigation or the publication of the report. Nevertheless, a final investigation report, particularly one that contains safety recommendations, is one of the most anticipated of the TSB's products.

Again this year, a conscious decision was made in departmental plans to reduce the number of new investigations so that resources could be focussed on in-progress investigations and the renewal agenda. Only 75 new investigations were started in 2003-2004, compared with 89 last year (see Figure 2). This year 73 investigations were completed, compared with 109 last year. The number of investigations in process increased to 141 at the end of the fiscal year, from 139 at the start.

Figure 2 - Investigations started / in progress / completed

Figure 2. Investigations Started / In Progress / Completed [D]f2

For those investigations completed in 2003-2004, the average time to complete an investigation increased to 684 days, from 580 days the previous year (see Table 3). These results are directly attributable to the decision to focus on the completion of complex investigations that were more than two years old and on the allocation of investigation resources to a number of other initiatives aimed at improving performance over the longer term. Significant progress was made on reducing the backlog of very old cases, thereby temporarily increasing the average completion time. Good progress was also made on the various improvement initiatives. These efforts should translate into measurable productivity gains in future years. More details on the improvement results achieved to March 31, 2004 are available in section 3.3.1 of this report.

Table 3: TSB Productivity
  Marine Rail / Pipeline Air Total
2002- 2003 2003- 2004 2002- 2003 2003- 2004 2002- 2003 2003- 2004 2002- 2003 2003- 2004
Investigations started 13 14 20 14 56 47 89 75
Investigations completed 15 18 24 15 70 40 109 73
Average duration of completed investigations (number of days) 703 953 757 894 494 485 580 684

Note: Results can fluctuate significantly from year to year due to a number of factors such as staff turnover, the complexity of investigations and the investigation of major occurrences.

In 2003-2004, in addition to investigation reports, the TSB issued a total of 63 safety outputs: 11 safety recommendations, 22 safety advisories and 30 safety information letters (see Table 4 for a breakdown by mode).

Table 4: Safety Outputs by the TSB
  Recommendations Safety Advisories Safety Information Letters
Marine 7 6 11
Pipeline 0 0 0
Rail 4 7 11
Air 0 9 8
Total 11 22 30

These outputs led to concrete actions by other organizations that directly improved safety and/or reduced risks. For example, Transport Canada has targeted safety inspections, issued bulletins to inform industry about specific safety concerns, and introduced changes to safety regulations and procedures. Similarly, industry has reacted to the TSB's work by undertaking numerous safety actions, such as changes in operating practices and procedures, preventive modifications to equipment, replacement of parts, and the modification of training programs. Table 5 provides a few specific examples of such safety actions that were taken during 2003-2004.

Table 5: Safety Actions - Part I
Occurrences Investigated Safety Actions
While the Alex B.1 was dragging for scallops off Havre St. Pierre, Quebec, water was discovered in the engine room. Subsequently all compartments from the stern to the accommodation flooded.

The investigation revealed that the vessel was holed below the waterline on the port side as a result of inadequate hull protection while engaged in dragging operations. Watertight bulkheads were compromised after major alterations, and the owner was not aware of stability principles or applicable regulations.
A recommendation addressed to Transport Canada (TC) required that TC, Fisheries and Oceans Canada, fisher associations and training institutions develop a strategy for establishing and maintaining a safety culture within the fishing industry. Consultations are ongoing and initiatives are underway to enable more in-depth study for further analysis and recommendation development.
A VIA Rail passenger train travelling at 97 mph passed a signal indicating stop.

The investigation revealed that there is a need for a recording facility to confirm the effectiveness of in-cab voice communications. Had the controlling locomotive cabs been equipped with voice recording capability, it might have been possible to determine more definitively the effectiveness of the crew's communications as they approached the occurrence location.
Transport Canada committed to working with Canadian industry and U.S. government agencies to discuss options available for the establishment of specifications for performance of event recorders, including audio capabilities.
Beechcraft 99A loss of control.

The investigation determined that the horizontal stabilizer trim actuator upper mounting bolts that attached the upper actuator lugs to the airframe had been improperly installed. Adjacent airframe structure, the body of the actuator, and the mounting lugs positioned ahead of the bolts make it difficult to identify the incorrect bolt installation during dual inspection.
Transport Canada communicated their concern to the U.S. Federal Aviation Administration (FAA) regarding this accident and a previous similar accident. Transport Canada informed the FAA that it was issuing a Service Difficulty Alert recommending that operators and maintainers of Beechcraft (Raytheon) King Air Model A100 and Airliner Model 99A aircraft exercise caution during the installation of horizontal stabilizer trim actuators, and ensure that a secondary review be carried out.

Safety information is also provided to key stakeholders throughout the investigation process, permitting them to take immediate safety actions where appropriate. It is common practice for industry and government to take safety actions during the course of TSB investigations. Such safety actions range widely in scope and importance. Operators will often take immediate remedial action after discussion with TSB investigators (e.g. to clear the line of sight at a railway crossing by trimming bushes and vegetation). Regulators, such as Transport Canada and the Federal Aviation Administration in the United States, regularly issue mandatory directives requiring inspections and/or component replacement based on the TSB's preliminary findings. In such situations, rather than issuing recommendations, the TSB can then report on the corrective actions already taken by industry and government agencies. The following table highlights a few specific examples of safety actions taken before the TSB investigations were completed.

Table 6: Safety Actions - Part II
Occurrences Investigated Safety Actions
Sinking of the amphibious passenger vehicle Lady Duck.

The investigation revealed that there was continuous water entry into the hull through various openings, pumps did not function as required, there was no effective safety management system in place, and the regulatory framework did not adequately address the risks involved. An overhead awning prevented the vertical escape of victims wearing personal flotation devices.
Transport Canada required that the operators of amphibious vehicles conduct passenger safety briefings. Information and inspection advice was forwarded to TC marine inspectors. The Small Passenger Vessel Inspection Course has been amended. General public announcements were made and posters distributed in tourist areas. All amphibious vehicles were inspected, including bilge pumping arrangements and alarms, and operators were advised of necessary precautionary measures. A lifebuoy manufacturer was contacted and its quality assurance and inspection procedures were reviewed.
Gazoduc TQM Inc. compressor station natural gas explosion.

The investigation revealed that there were no Canadian Standards Association (CSA) standards requiring quality management and quality assurance programs for any pipeline facilities being built, to ensure overall soundness of the installation and of ongoing operations.
CSA publication CSA Z662 has been amended to include ISO 9000 requirements for quality management and quality assurance for pipeline projects in Canada.
A319 approach to wrong airport.

The crew of an Air Canada Airbus A319, on a regularly scheduled flight to Kelowna, B.C., inadvertently conducted a visual approach to the Vernon airport before proceeding to their intended destination. Although the aircraft's navigation system was set up to provide bearing and distance information from the Kelowna airport, the crew misidentified Vernon as Kelowna airport and commenced an approach.
Transport Canada's Principal Operations Inspector for Air Canada will review the operator's Aircraft Operating Manual with the intent to incorporate the safety information contained in the Advisory. Transport Canada also intends to issue a Commercial and Business Aviation Advisory Circular on the hazards associated with this phenomenon.

The operator, Air Canada, initiated an awareness campaign within the company by publicizing this incident to crews. Air Canada also modified its Flight Operations Manual to enhance the guidance regarding visual approaches, and is developing new risk management models for visual approaches.
3.2.3 Awareness of Safety Issues and a Strengthened Safety Culture on the Part of Government, Industry and the Public

The TSB continues to promote awareness of safety issues and of a safety culture among transportation stakeholders. TSB investigators have observed a greater awareness of safety issues and signs of development of a safety culture among people with whom they interact in the course of their work. For instance, the TSB notes that governments and members of the transportation industry are cooperating to promote and implement solutions through legislation, regulation, programs and education.

"Canada is among the world leaders in safety management."

Straight Ahead - A Vision for Transportation in Canada, Transport Canada, September 2003

Focus is increasingly being placed on the adoption of the safety management system concept (a formalized framework for integrating safety into the daily operations of a company). A safety management system includes safety goals and performance targets, risk assessments, clear responsibilities and authorities, rules and procedures, and monitoring and evaluation processes. Furthermore, significant events such as the crash of Swissair Flight 111 and the sinking of the Lady Duck have raised public awareness about transportation safety. Although it is difficult to measure the results of TSB activity in this area, the use of TSB safety messages by stakeholders demonstrates a degree of effectiveness in achieving the desired outcome.

The TSB takes every opportunity to reiterate its key messages and create awareness of safety issues. In 2003-2004, the TSB published 73 investigation reports, as well as monthly and annual statistical reports. Three issues of the Reflexions safety digest were published during fiscal year 2003-2004. These digests contribute to the advancement of transportation safety by reflecting on the safety lessons learned from accident and incident investigations. They also provide an effective tool to disseminate the results of safety investigations to a broad audience.

"We were surprised to receive so much information so quickly and were thankful for the TSB update."

Next-of-kin, Georgian Express Flight 126, Pelee Island, January 2004

The TSB has taken a proactive approach to dissemination of information. Information is made readily available to industry, next-of-kin, the media and the public throughout the investigation process. Investigative staff are encouraged to maintain a dialogue with key stakeholders, including the early communication of safety issues that arise during the investigation. In an effort to satisfy both the public and the media's thirst for up-to-date, factual information, the TSB responded to 1,357 information requests received through its web site and 424 media calls during the year, not including those inquiries handled at the scene of an accident or at a report release news conference. The TSB held one news conference and issued eight news releases. The TSB's Macro Analysis Division also responded to 632 requests for complex transportation occurrence database information.

The TSB uses its web site to increase awareness of safety issues and other transportation safety information. The site (, receives an average of more than 49,000 daily hits and 1,860 daily visits, an increase of approximately 35% over last year. The visitors are Canadians and people from all around the world. The increased traffic on the site can be attributed to the ease of access and the expanded volume of information made available. The site has proven to be a cost-effective and timely way of disseminating information.

The TSB contributes to the dissemination of safety information at the international level. Many TSB information products are distributed not only in Canada but also in the United States, Europe, and various other countries around the world. The TSB also assists in the distribution of information originating from foreign countries. Such cooperation between the TSB and foreign organizations contributes to greater public access to safety information worldwide.

The TSB's expertise and investigation methods are recognized internationally. For instance, the organization has been invited to teach investigative methodologies to air investigators in Singapore. The TSB was invited to attend national and international conferences and workshops to present the TSB methodology for investigating for human factors in transportation occurrences. Staff have also been asked to lecture annually at the International Maritime Academy in Trieste, Italy, where students are taught methodologies and legislation used by marine investigation organizations worldwide. By participating in such events and sharing methodologies, the TSB not only provides companies with its best practices for their own internal use, but also paves the way for a better understanding by industry of the rigour that the TSB applies to investigations.

The Integrated Safety Investigation Methodology training program developed by the TSB continues to draw significant interest from the transportation industry, including air carriers and railway companies, as well as from other safety organizations within and outside Canada, including the United States, the Netherlands, New Zealand and the United Kingdom. Although the TSB is not in the business of providing training to others, vacant seats in the investigator training sessions have been offered to other persons involved in transportation safety in either public or private organizations. The provision of such training has proven beneficial, as participants gain a better understanding of how the TSB works and acquire methodology and safety approaches they can apply toward achieving similar objectives of advancing transportation safety.

Given the high number of fishing accidents reported to the TSB (approximately half of the shipping accidents reported involve fishing vessels), the TSB is also involved in an initiative to promote a safety culture in the west coast marine community, particularly among operators of small vessels and fishing vessels. The Inter-Agency Marine Action Group brings together agencies from both the federal and provincial governments and provides an opportunity to collaborate to promote safety awareness, provide safety education and foster safe operating practices. The objective is to effect behavioural change within the marine community and thereby reduce the incidence of marine-related accidents and fatalities.

3.2.4 Increased Level of Safety Through the Reduction of Risk

In general, the TSB has been successful in identifying safety failures and in reducing risks in the transportation systems. TSB investigations result in reports identifying safety failures and, where appropriate, containing recommendations to reduce risks. Over this past year, in all cases where the TSB undertook an investigation, safety failures or factors contributing to the occurrence were identified and communicated. These results reflect a careful application of the TSB's Occurrence Classification Policy in deciding whether to investigate, and a thorough implementation of the investigation methodology. This systematic approach ensures that TSB investigation resources are invested in areas with the greatest potential safety payoffs.

A total of 4,026 occurrences were reported to the TSB in fiscal year 2003-2004, of which the TSB decided to investigate 75. All reported occurrences were examined in accordance with the Occurrence Classification Policy to identify those with the greatest potential for advancing transportation safety. Information on all reported occurrences was entered in the TSB database for historical record, trend analysis and safety deficiency validation purposes.

"Transport Canada has made considerable changes to its regulations, inspection and certification of small passenger vessels following the sinking of the True North II. The department has addressed the TSB's concerns and recommendations, and has nearly completed related regulatory changes and initiatives."

David Collenette, Minister of Transport, March 2003

One way to measure the quality of TSB findings and recommendations is by assessing its effectiveness in convincing others of the need for change to improve safety. The TSB therefore assesses the responses to its recommendations to establish the extent to which the underlying safety deficiency has been or is being redressed. Logically, the extent of the planned implementation of safety actions will be predicated upon the degree to which the addressee has accepted the existence of a particular unsafe condition and the magnitude of the associated risks. In 2003-2004, the

TSB received responses to 19 safety recommendations. The TSB assessed two responses as "fully satisfactory," eight as having a "satisfactory intent" to address safety deficiencies identified in the recommendations, and four as "satisfactory in part." Five responses were assessed as "unsatisfactory." The results of this assessment are shown in Table 7.

Table 7: Assessment of Responses to TSB Recommendations - Current Year
2003-2004 (Year response received) Fully satisfactory attention to safety deficiency Satisfactory intent to address safety deficiency Attention to safety deficiency satisfactory in part Unsatisfactory attention to safety deficiency To be assessed Total
Marine 2 0 2 1 5 10
Pipeline 0 0 0 0 0 0
Rail 0 0 2 1 2 5
Air 0 8 0 3 0 11
Total 2 8 4 5 7 26

In 2004-2005, the TSB will undertake a comprehensive reassessment of responses to all recommendations issued since its creation in 1990. This review will provide a longer-term view of the outcomes achieved by the TSB's recommendations. The results of this reassessment will be included in the 2004-2005 departmental Performance Report.

3.2.5 Effective Organizational Performance

Fiscal year 2003-2004 saw the completion and implementation of a new integrated planning and resource management framework fully synchronized with the government-wide planning and reporting cycle. This new framework permitted the identification of priorities and plans directly aligned with the strategic plan, and led to the allocation of resources based on these plans and priorities. This has permitted a more strategic and focussed use of resources in order to optimize results for Canadians. Furthermore, clear linkages were established between corporate plans and priorities and the individual key commitments of senior managers, thereby ensuring accountability for results.

Progress was also made on performance measurement and reporting. A more robust process was implemented to monitor results and the use of resources through periodic reports and senior management reviews. Work on the development of the balanced score card continued, and appropriate linkages were made to the Treasury Board's Management Accountability Framework. Full implementation of the balanced score card as the principal tool for performance measurement is planned for the 2004-2005 fiscal year.

In 2003-2004, the TSB also implemented a formal internal audit program for the first time. A departmental audit committee was created. Using the corporate risk profile, the audit committee identified internal audit priorities and approved the execution of two audits. The first audit was initiated in March 2004 and completed in early 2004-2005. This audit report, along with the management action plan, will soon be published on the TSB web site.

A particular focus of the Business Plan was employee learning. In 2003-2004, the TSB completed the development of competency profiles and learning standards for all its occupational groups. The organization invested approximately $1.3 million, or 3.7% of its total operating costs, in employee training and education. A new automated tool was acquired and implemented to facilitate the task of developing individual learning plans for all employees. In future years, the TSB expects to maintain its high level of investment in employee learning but will ensure that these investments are better targeted through the use of the new tool now available to employees and managers.

The principal formal mechanism for defining workplace issues was the Public Service Employee Survey conducted in 2002. Participation in this survey by TSB employees was encouragingly high, identifying a variety of issues to be addressed. In 2002-2003, the TSB created an employee-management committee mandated to develop an action plan for management approval and to assist management with the implementation of the approved plan. During 2003-2004, the committee met on a periodic basis to assess progress against the action plan and reported to the senior management committee. Overall, good progress has been made on most issues identified for action over the past year, and work is ongoing on residual action items. Employee and management response to this approach has been extremely positive. Given this success, the committee's terms of reference were reviewed and modified to make the committee permanent and to add an element of collaboration in internal communications to its mandate.

In 2003-2004, the TSB senior management team undertook a series of discussions to review the internal governance structure. These facilitated discussions led to the adoption of a new decision-making structure to be implemented in 2004-2005. The new structure will focus the efforts of key managers on the areas of greatest importance to them and enable more management time to be spent on the broader strategic issues. Decision-making processes will also be streamlined, incorporate the elements of modern comptrollership and provide for greater transparency.

Overall, the TSB has made significant progress toward improving its internal management frameworks and optimizing the use of its resources. During the year, the TSB was cited by Treasury Board Secretariat officials as a model of effective organizational performance for others to follow. TSB senior managers have also been invited on a number of occasions to share their experience with their colleagues in other organizations. Implementing Modern Comptrollership

The multi-year modern comptrollership initiative is aimed at modernizing management activities within the Public Service, thereby providing for better performance information, sound risk management and appropriate control systems, as well as reinforcing values and ethics and improving the government's accountability to Parliament and to Canadians.

In late 2001, the TSB conducted an assessment of its management practices against 33 criteria of sound organizational management. The resulting Capacity Assessment report, issued in March 2002, identified a number of areas of the management framework where important changes were needed in order to achieve a state of modern comptrollership.

Understanding the value of modernizing management practices, as well as the risks to the organization if strong comptrollership capabilities were not entrenched in daily operations, the TSB identified modern comptrollership as a management priority and integrated modern comptrollership activities and projects into its annual Business Plans.

During the 2002-2003 fiscal year, much of the work done in the context of modern comptrollership was developmental. The TSB developed a business planning framework that integrates all TSB planning activities in a coherent manner and that coincides with the government-wide planning cycle. This framework, now fully implemented, improved and facilitated resource allocation decisions for the 2003-2004 fiscal year and ensured that resources were linked to corporate plans and priorities.

In 2003-2004, work was done on the development of two new management tools: a performance measurement tool and a risk-based internal audit plan. The TSB has also defined the specific knowledge and skills required by managers and functional specialists in the context of modern management. Competency profiles and learning standards have been developed. These will be used to assess current management competencies and to design learning plans to support the implementation of modern management and human resources modernization. Core training for managers was also initiated through a combination of formal in-house and external courses.

As the modern comptrollership initiative came to a close as a project, the TSB ensured the sustainability of its efforts over the longer term by creating a permanent corporate planning and reporting officer position. The role of this new position is to assist the senior management team in ensuring that the planning and performance management frameworks continue to be used to support decision making. This person will also ensure that the frameworks and supporting tools are kept current and relevant to meet the needs of the organization.

In line with its modern comptrollership priorities and with corporate preoccupations, the TSB was also actively involved in working with other departments and agencies on modern comptrollership projects, sharing best practices and finding solutions to minimize costs and efforts. For example, the TSB has led three interdepartmental innovation projects touching upon cultural change within organizations, the integration and streamlining of performance information, and values and ethics as they apply to partnerships between organizations. TSB staff have been recognized by the Treasury Board Secretariat and the small-agencies community for their leadership in this regard.

The TSB has also undertaken the use of the Treasury Board's Management Accountability Framework (MAF). The MAF was introduced to all managers and their administrative assistants as a management tool. Work was also initiated on the mapping of Business Plan activities and balanced score card performance indicators against the MAF elements. Modernization of Human Resources Management

The approval by Parliament of the Public Service Modernization Act will have an impact on all federal institutions, including the TSB. This new legislation, aimed at modernizing the management of human resources in the Public Service, will be implemented over the next two years. In 2003-2004, the TSB reviewed the potential implications of the legislation and ensured that resources were set aside in its 2004-2005 and 2005-2006 budgets to facilitate the implementation of the required changes. Work was undertaken in a proactive manner to create a labour-management consultation framework and to initiate the training of managers on values-based staffing. TSB representatives have also participated in a number of interdepartmental working groups led by the Public Service Human Resources Management Agency of Canada to develop policies, guidelines and tools for departments and agencies.

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