Transportation Safety Board of Canada
Departmental Performance Report
for the period ending
March 31, 2004
|Charles H. Simpson
Transportation Safety Board of Canada
Queen's Privy Council for Canada
- List of Figures and Tables
- Section 1: The Chairperson's Message
- Section 2: Strategic Context
- 2.1 Mandate and Mission
- 2.2 Key Co-delivery Partners
- 2.3 Risks and Challenges
- Section 3: Departmental Performance
- 3.1 Performance Management Framework
- 3.2 Performance Accomplishments
- 3.2.1 Public Confidence in the Safety of the Transportation System
- 3.2.2 Implementation of Appropriate Safety Actions
- 3.2.3 Awareness of Safety Issues and a Strengthened Safety Culture on the Part of Government, Industry and the Public
- 3.2.4 Increased Level of Safety Through the Reduction of Risk
- 3.2.5 Effective Organizational Performance
- 3.3 Responding to Resource Pressures
- 3.4 Financial Performance
- Section 4: Other Information
List of Figures and Tables
- Figure 1: Accidents Reported to the TSB
- Figure 2: Investigations Started / In Progress / Completed
- Figure 3: TSB Historical Spending
- Table 1: Logic Model
- Table 2: TSB Score Card
- Table 3: TSB Productivity
- Table 4: Safety Outputs by the TSB
- Table 5: Safety Actions - Part I
- Table 6: Safety Actions - Part II
- Table 7: Assessment of Responses to TSB Recommendations - Current Year
- Table 8: Resource Pressure Commitments
- Table 9: Detailed Breakdown of 2003-2004 Total Authorities
- Table 10: Net Cost of Program by Operating Activities
- Financial Table 1: Summary of Voted Appropriations
- Financial Table 2: Comparison of Total Planned Spending to Actual Spending
- Financial Table 3: Historical Comparison of Total Planned Spending to Actual Spending
A review of transportation accident rates in Canada over the past 10 years reveals a progressive downward trend. Our investigators observe an increased attention to safety and signs of the development of a safety culture among government agencies and industry stakeholders. These tangible signs of progress in safety across all transportation modes confirm that the efforts of the Transportation Safety Board of Canada (TSB) toward advancing transportation safety, in concert with those of many others, are paying off.
The TSB continues to enjoy a solid reputation as a professional and technically competent organization that consistently contributes to the advancement of transportation safety in Canada and internationally. This was formally recognized in December 2003 when the members of the Swissair Flight 111 investigation team received the Head of the Public Service Award for Excellence in Service Delivery. The TSB is also recognized as a leader among small federal departments and agencies for its efforts on management renewal and for its contribution to the broader modernization of the Public Service. It is on this track record of excellence that the TSB will continue to build and to enhance its value for Canadians.
In 2003-2004, the TSB focussed its efforts on the improvement of its response to stakeholder needs, the improvement of its response to employee needs, and the improvement of its management frameworks. Significant progress was achieved in all three areas, due in part to the temporary incremental resources provided by Parliament. However, our work is not done and sustained efforts will be required over the current year to ensure the completion of our improvement agenda and the implementation of strategies to ensure the sustainability of our program over the longer term.
As we look to the future and the challenges that lie ahead, we are committed to sustaining our efforts and to contributing to a transportation system that is safe and reliable, one upon which Canadians can rely.
I submit, for tabling in Parliament, the 2003-2004 Departmental Performance Report (DPR) for the Transportation Safety Board of Canada.
This report has been prepared based on the reporting principles and other requirements contained in the 2003-2004 Departmental Performance Report Preparation Guide and represents, to the best of my knowledge, a comprehensive, balanced, and transparent picture of the organization's performance for fiscal year 2003-2004.
Charles H. Simpson, Acting Chairperson
The Transportation Safety Board of Canada (TSB) is an independent agency created in 1990 by an Act of Parliament (Canadian Transportation Accident Investigation and Safety Board Act). Under this legislation, the TSB's only objective is the advancement of transportation safety in the marine, rail, pipeline and air transportation systems. This mandate is fulfilled by conducting independent investigations including, when necessary, public inquiries into selected transportation occurrences. The purpose of these investigations and inquiries is to make findings as to the causes and contributing factors of the occurrences and to identify safety deficiencies, which in turn may result in recommendations designed to improve safety and reduce or eliminate risks to people, property and the environment.
Our mission: to advance transportation safety
The jurisdiction of the TSB includes all federally regulated marine, rail, pipeline and air transportation occurrences in or over Canada. The Board also represents Canadian interests in foreign investigations of transportation accidents involving ships, railway rolling stock, or aircraft registered, licensed or manufactured in Canada. In addition, the Board carries out specific elements of Canada's transportation safety obligations to the International Civil Aviation Organization (ICAO) and the International Maritime Organization (IMO).
The TSB reports annually to Parliament on its activities, findings and recommendations through the President of the Queen's Privy Council. As such, the TSB is not part of any portfolio to which Transport Canada, the Canadian Coast Guard or the National Energy Board belong. The creation of the TSB as an independent agency eliminated any potential, real or perceived, for a conflict of interest within government bodies regulating or operating transportation activities, who were also investigating the failures associated with their own regulations and operations. The legislation gives the TSB the exclusive authority to investigate for the purposes of making findings as to causes and contributing factors and provides that other departments (such as Transport Canada and the National Energy Board) may investigate for any other purposes.
The TSB operates within the context of the very large and complex Canadian transportation system see the (Transport Canada web site and the National Energy Board site for details). Many individuals and groups cooperate with the TSB in the fulfilment of its mandate. During the course of an investigation, the TSB interacts directly with:
- Individuals, such as survivors, witnesses and next-of-kin;
- Other organizations and agencies, such as coroners, police, manufacturers, owners and insurance companies; and
- Other federal government departments and agencies.
Their cooperation is essential to the conduct of the TSB's business, whether they contribute as providers of information or of support services. For more details on the investigation process, visit the TSB web site.
The TSB is one of many Canadian and foreign organizations involved in improving transportation safety nationally and internationally. While it operates at arm's length from other federal departments involved in the transportation field, it can only succeed in fulfilling its strategic outcome through the actions of others. The TSB presents findings and makes recommendations that call upon others to act, but it has no formal authority to regulate, direct or enforce specific actions. This implies ongoing dialogue, information sharing and strategic coordination with organizations such as Transport Canada, the National Energy Board and the Canadian Coast Guard.
Similarly, the TSB must engage in ongoing dialogue and information sharing with industry and foreign regulatory organizations. Through various means, the TSB must present compelling arguments that will convince these "agents of change" to take action in response to identified safety deficiencies. The TSB can therefore be deemed successful when others, such as regulators, operators and manufacturers, implement actions to mitigate risks using the TSB outputs.
The TSB has established memoranda of understanding with a number of federal government departments for the coordination of activities and the provision of support services. These agreements provide the Board with access to a range of support services that can rapidly supplement internal resources (e.g. assistance for the recovery of wreckage, the documentation of information and the examination or testing of components). The agreements also define operating practices to ensure coordination of activities and to avoid potential conflicts that could arise from the simultaneous implementation of various organizational mandates. Such agreements are currently in place with National Defence, the Royal Canadian Mounted Police, the Canadian Coast Guard, Human Resources and Skills Development Canada and the National Research Council. Similarly, the TSB has established strategic cooperation alliances with provincial and territorial coroners/chief medical examiners.
Further alliances have been established with the TSB's counterpart agencies in other countries, such as the United States, Australia, the Netherlands, France and the United Kingdom. The TSB cooperates on a reciprocal basis with foreign safety investigation agencies through the ad hoc exchange of specialized services or the provision of assistance as a means of coping with capacity gaps. As a world leader in its field, the TSB regularly shares its investigation techniques, methodologies and tools. For example, the Recorder Analysis and Playback System (RAPS), developed by the TSB for decoding and analysis of flight data recorders and cockpit voice recorders, is now being used in more than 10 countries to aid in safety investigations. Similarly, the TSB has contributed to the training of safety investigators from numerous countries either by integrating foreign investigators into its in-house training programs or by sending senior staff to teach abroad. The TSB also shares data and reports with sister organizations and participates in international work groups and studies to advance transportation safety.
The TSB faces many risks and challenges that could have a potentially significant impact on the organization's ability to fulfil its mandate. Recent announcements regarding government expenditure controls and the new expenditure review process call for flexibility among TSB managers, who must adapt to evolving accountability and management demands. Managers at all levels within the organization are expected to manage risks by applying established management principles. The most important challenges are described in the following paragraphs.
The TSB has a variety of stakeholders and clients with diverse information needs. The stakeholder needs analysis conducted in 2002-2003 provided important insights. Initial feedback indicated a preference for shorter and more timely reports and reflected a belief that safety information could be made available to stakeholders earlier and more effectively. The challenge is to respond to these needs with available resources. The ability to provide the information required by stakeholders, the industry and the public, when they need it, is key to successfully achieving the TSB's mandate.
The success of the TSB and its credibility as an organization depends largely on the expertise, professionalism and competence of its employees. Rapid technological changes in the transportation industry, along with the development of new materials, are making the task of investigation and safety analysis increasingly complex and specialized. The TSB must not only maintain an appropriate infrastructure of technical and scientific equipment, but must also keep up its technical expertise and knowledge base in order to maintain credibility within the industry. In recent years, the TSB has made a concentrated effort to "catch up" on essential training for employees and managers to ensure they have the knowledge and skills to meet mandatory job requirements. However, the challenge of retaining technical currency requires ongoing attention and allocation of resources.
To be successful, the TSB must recruit, train, develop and retain highly motivated and competent people. As a federal government organization, the TSB must also strive to achieve a diverse workforce representative of the Canadian population. However, the TSB has experienced significant staff turnover and it is expected that more will leave due to retirement or other career opportunities. Heavy workloads, limited career development and limited advancement opportunities are some of the reasons given for staff departures. The challenge for the organization is to make the TSB as responsive as possible to employees' career needs and aspirations, thereby encouraging people to remain with the organization longer. This challenge is particularly difficult to address in a small organization, where there are limited opportunities to move people around for development purposes.
The TSB's primary products are information and knowledge. The effectiveness and value of the TSB rest in its ability to collect and analyze factual information and to communicate new knowledge to those who need it. It is crucial that the TSB manage information in a responsive and timely way. However, it continues to struggle with the storage, retrieval, analysis and sharing of information used to support its business processes. With special funding received for the renewal of information management systems, it is expected that the TSB will adopt better tools to gather, create and control information. Improving the use of current applications and technologies will position the TSB to provide more effective and integrated tools to its investigators and to implement a more efficient process for producing investigation reports.
An important preoccupation for the TSB is communications at all levels. TSB employees and stakeholders have told us that the organization needs to improve its internal and external communications capabilities. Internal communications have become increasingly important in recent years as the TSB continues to manage its change agenda. At a minimum, managers at all levels are expected to communicate with employees in an open and collaborative manner in order to implement organizational goals and objectives. Employees, in turn, are expected and encouraged to provide managers with suggestions and feedback and to share important information within the organization.
With respect to external communications, significant work is underway on the development of a Corporate Communications Plan and subplans that will assist in the effective and efficient delivery of the redesigned communications products and services. These plans will clearly identify roles and responsibilities. In concert with the public awareness initiative, the Corporate Communications Plan will make the most of alliances, partnerships and linkages to advance the mission of the TSB.
In 2002-2003, the TSB undertook the development of an integrated performance management framework. The framework consists of five key documents. The five-year TSB Strategic Plan is used to set the strategic directions. The annual Business Plan is then used to set the short-term priorities and to guide the activities and resource allocation decisions for the coming year. The Report on Plans and Priorities, based on the Business Plan, defines the commitments to Parliament and Canadians. The Balanced Score Card defines specific performance indicators and is used by management to measure and monitor progress. Finally, the departmental Performance Report closes the accountability loop by reporting to Parliament on the results achieved.
In its 2003-2004 Report on Plans and Priorities, the TSB defined one strategic outcome and five intermediate outcomes. The following logic model identifies the linkages between the activities of the TSB and the achievement of its outcomes. The logic model is a road map showing the chain of results connecting resources and activities to outputs and to expected intermediate and final outcomes.
Advancements in safety through independent, objective and timely analysis of safety failures in the federally regulated transportation system.
- Increased and justified public confidence in the safety of the transportation system.
- Timely implementation of appropriate safety actions.
- Increased awareness of safety issues and a strengthened safety culture on the part of government, industry and the public.
- Increased level of safety through the reduction of risks.
- Effective organizational performance.
- Identification and communication of safety deficiencies.
- Safety actions taken by stakeholders.
- Responses to safety recommendations.
- Media pick-up and dissemination of safety messages.
Plans and Priorities
- Implement the key elements of a planning and resource management framework.
- Reshape the TSB's product and service mix based upon the results of the stakeholder needs analysis.
- Improve the quality and timeliness of TSB products.
- Establish the department as a learning organization.
- Ensure a responsive workplace atmosphere within the department.
- Implement required changes to the governance structure.
- Renew the management of information within the TSB.
Activities Outputs and Resources
||$25.6 million and 181 FTEs|
||$6.5 million and 46 FTEs|
As noted, the TSB has been working on the development of a balanced score card, which will be the main tool used to measure organizational performance in the future. This score card will track performance along four major perspectives: financial, client/stakeholder, internal business process, and learning and growth. Current plans call for the full implementation of this new tool for fiscal year 2004 2005, as described in the 2004-2005 Report on Plans and Priorities.
Although the indicators and data collection methodology are not yet finalized, some of the indicators are already being used. Various methods are used to identify and capture performance information. Most of the data used in the analysis came from TSB information systems, supplemented by Transport Canada information where appropriate. Information was also extracted from the stakeholder needs analysis report and TSB reports on media analysis of TSB investigation reports. Anecdotal evidence that supports the performance assessment was obtained from various sources such as magazine articles, press clippings and individual testimonials. Where sources of information external to the TSB are used, they are identified.
Proper care and attention to data quality and limitations were ensured throughout the production of this report. This report presents an accurate picture of the state of TSB business and affairs on March 31, 2004. The financial statements have been audited by the Auditor General of Canada, and her audit report is included in Appendix C. Other performance information is not currently subjected to an independent review or validation process. However, the TSB is in the process of implementing an internal audit function that will be able to provide such assurance services in future.
During the reporting period, there were no Parliamentary Committee recommendations addressed specifically to the TSB.
Canada's transportation system is considered one of the safest in the world. However, an average of 3,500 transportation occurrences are reported each year in accordance with federal reporting requirements. The TSB bases its decision to investigate on its Occurrence Classification Policy using a comprehensive risk management process aimed at evaluating the consequences of operational decisions. The prime criterion for deciding to investigate is whether an investigation is likely to lead to a reduction in risk to persons, property or the environment. Based on these considerations, the TSB does not investigate some accidents that are less likely to result in safety actions, even when they involve fatalities.
Approximately 141 investigations are currently in progress. Of that total, about 11% are more than two years old, representing a significant improvement over previous years. For a relatively small organization, it is an ongoing challenge to manage this backlog and the sustained opening of new cases in a way that meets the expectations arising from a high level of public interest and demand for investigations.
In 2003, 1,968 accidents and 1,388 incidents were reported in accordance with the TSB's regulations for mandatory reporting. The number of accidents in 2003 represented a 9% increase from the 1,812 accidents reported in 2002 (see Figure 1) but a 2% decrease from the 1998-2002 annual average of 1,999 accidents. There were also 670 voluntary incident reports. Fatalities totalled 172 in 2003, down from 187 in 2002 and the 1998-2002 average of 263.
This year was marked by increases in the number of accidents reported in all the modes except pipeline (see Appendix A for details). There were 546 marine accidents reported to the TSB in 2003, a 13% increase from the 2002 total of 485 and a 2% increase from the 1998-2002 average of 537. In the pipeline sector, 20 accidents were reported to the TSB, equal to the 2002 total and the 1998-2002 average, and no serious injuries resulted. The last fatal pipeline accident in the portion of the industry under federal jurisdiction occurred in 1988. A total of 1,030 rail accidents were reported to the TSB in 2003, a 5% increase from the previous year's total of 984 but a 3% decrease from the 1998-2002 average of 1,062. Aircraft were involved in 372 accidents reported in 2003, an increase of 15% from the 2002 total of 323. However, this is a 2% decrease from the 1998-2002 average of 380. Despite fluctuations in the number of accidents and incidents reported on an annual basis, the trend over the past 10 years shows a progressive decline in accident rates in all modes (see the graphs in Appendix A). These reductions cannot be directly attributed to the efforts of any specific organization. Improvements in transportation safety are the result of the combined efforts of many participants including manufacturers, carriers, crews and regulators, as well as the TSB.
It is virtually impossible to accurately measure the impact of the TSB on transportation safety. No two investigations are identical. Some lead to significant safety improvements, and others do not. There is also no good way to link costs incurred by the TSB directly to specific improvements in transportation safety. However, the TSB has certainly been successful in achieving its strategic outcomes over the past year, as evidenced by the numerous safety actions taken by change agents within the transportation sector using the TSB's findings and outputs.
The next few pages summarize the results and outcomes of the TSB's work over the past year as measured against the stated performance indicators.
|Increased and justified public confidence in the safety of the transportation system.|
|Timely implementation of appropriate safety actions.|
|Increased awareness of safety issues and a strengthened safety culture on the part of government, industry and the public.|
|Increased level of safety through the reduction of risks.|
|Effective organizational performance.|
|Implementing modern comptrollership|
|Modernization of human resources management|
|Responding to resource pressures (see Table 8 for details)|
= exceeded expectations
= successfully met expectations
= not yet fully met expectations
Canada has one of the safest and most secure transportation systems in the world. A threat to the safety and security of the transportation system could affect Canada's economic prosperity and its ability as a nation to trade effectively, as well as affecting Canadians' ability to travel.
Reported accidents and incidents provide indicators of the transportation system's safety performance and also help focus efforts on those initiatives and activities that have high safety benefits. As demonstrated in the tables of Appendix A, Canada continued to maintain a good safety record in 2003. The 2003 accident rates, per activity level for all modes, reflect a downward trend from the five-year average. Another indicator of the safety performance of the transportation system is the number of fatalities. In 2003, the air, marine and rail modes showed a decrease in fatalities from the five-year average. A reduction in accidents and fatalities will positively influence the public's confidence in the safety of the transportation system.
The TSB cannot claim that the reduction in transportation occurrences is solely related to its work, The safety and security of the transportation system are a shared responsibility. The TSB works with governments, transportation industries, agencies, associations and international organizations to further improve the system. It also collaborates with other government departments and agencies whose programs and services may be affected by transportation activities.
Last year's stakeholder needs analysis indicated that stakeholders expect the TSB to take on a more formal and active role in the transportation safety system, including engaging in continuous communications. In 2003-2004, the TSB initiated a public awareness program designed to foster dialogue and share information more broadly with the industry, operators and regulators. TSB Board Members and senior managers have consequently participated in an increased number of meetings, presentations and dialogues with various stakeholders. This program is intended to forge more meaningful relations and result in wider understanding of the TSB's contribution to the advancement of transportation safety. This, in turn, will lead to improved public confidence in the safety of the transportation system, as members of the public observe the enhanced visibility of the TSB and how it works with its key stakeholders.
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