The TSB and First Responders
Presentation to Fire-Rescue 2010
Transportation Safety Board of Canada
Saint John, New Brunswick
September 21, 2010
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Slide 1: Title Page
Good morning, and thank you for the invitation to speak today about the interactions of First Responders and the TSB.
Although TSB Board members do not participate actively in field investigations, I will speak about some of the issues that our investigators face in their daily work. I would also like to introduce Mr. Pierre Murray, Regional Manager (Marine) in our Dartmouth office. Pierre is here today to keep me out of trouble and, because of his extensive TSB experience, to help answer questions.
My own background is in the rail industry.
Slide 2: Outline
Today I'm going to talk briefly about the TSB: who we are, how and why we were created, and what our organizational goals are.
I'll briefly mention the people and groups with whom we regularly work. And, I'll also focus on the TSB approach to interactions in the field.
I'll identify a few of the common problems both of us encounter, and how we can address them.
Marine, pipeline, rail, and air-these are the four modes of transportation in our mandate. Each has unique challenges, and we'll talk a bit about that.
You will note we are NOT involved with motor vehicle or highway occurrences, except as they may involve the other modes of transportation.
To keep this from becoming too dry and theoretical, 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 when Parliament passed the Canadian Transportation Accident Investigation and Safety Board Act. Our mandate is to advance transportation safety by conducting independent, professional investigations in each of four modes: marine, pipeline, rail and air.
- 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.
- In order to obtain the information we need, the CTAISB Act grants our investigators some pretty wide powers. I'll outline them in greater detail shortly, but they include the ability to "freeze" accidents sites, restrict access, seize wreckage, and compel witness interviews.
Slide 4: TSB Offices
The TSB comprises approximately 230 employees located across the country. The Board itself is comprised of up to five Board Members, including the Chair.
Our Head office and engineering laboratory are in the Ottawa/Gatineau area.
We also have eight regional offices strategically located across the country from which our investigators can quickly deploy to the scene of an accident.
Slide 5: TSB Investigations
The TSB has established occurrence reporting requirements by regulation. Accordingly, we receive notice of approximately 4000 occurrences every year. Once these are reported to us, we make a decision as to the depth of investigation warranted based on several factors. Chief among these is whether an in-depth investigation has the potential to advance transportation safety. In 2009, that decision to investigate in depth happened 65 times but we still record and assess each and every reported occurrence. These decisions as to the specific type of investigation are made by our modal Directors of Investigation.
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 of 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. Last year, for example, we launched a special issues investigation into fishing vessel safety, looking specifically at the growing number of accidents aboard 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 which 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 6: 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 do 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 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 action. Recommendations are typically used to address the more difficult, systemic issues that pose a higher risk.
Slide 7: Communications-Outreach
As just mentioned, we believe it is in the best interests of safety if Canadians are kept aware of safety issues and necessary improvements. Therefore in March of 2010, we issued a "Safety Watchlist" derived from safety deficiencies identified in TSB investigation. It lists the 9 transportation issues currently posing the biggest risk to Canadians.
In addition, as part of an "outreach" program we also do the following:
- 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 8: Watchlist
Returning to the issue of that Watchlist I just mentioned, these are the 9 issues it identifies. They are based on TSB marine, rail and air modal investigations and include items such as collisions at railway crossings, landing accidents and runway overruns at Canadian airports, and the emergency preparedness of large passenger ferries.
I include them in this presentation because it's possible that the people in this room may be expected to deal with all of them.
Now, let me give you some background statistical data.
Slide 9: Statistics
"Reportable Occurrences" are those reported to TSB as mandated by regulation. However, it is important to note that there are also voluntary occurrences reported to the TSB by industry. These do not meet the criteria of reportable but they do get entered in our database for analysis or trend identification. etc.
The total average number of reportable occurrences annually is about 3,300 while voluntary reports number about 700 annually, for a total of about 4,000. I mention this for those who remember the earlier slide where I used the 4,000 number.
In addition to the modal breakout you can also see there are about 162 related fatalities annually.
Now let's focus on our relationships.
Slide 10: Who is a First Responder?
When on scene, our investigators interact a lot with first responders.
Fire and Police departments are often some of the first people on scene.
But, the term "first responder" applies to pretty much anyone who, in the normal course of their duties, could be the first on scene of an emergency and includes search and rescue, emergency services, ambulances, coroners, and Hazmat teams.
For marine occurrences, we can add Canadian Coast Guard to that list, just as, for aviation occurrences, you could add airport authorities, and so on�
Slide 11: Priorities
As we see it, at an accident site the priorities for first responders are:
1. Play it safe and determine what you're facing: fire, DGs, BLEVE, 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.
More specifically, here are eight (8) key actions that first responders can take in support of TSB investigations:
Slide 12: Key Actions
Above all, the top priority remains the safety of people - you, employees, the public. This is followed closely by property and the environment.
That may mean safely rescuing anyone in harm's way. Operational decisions, therefore, may have to be made on the spot without consultation with TSB personnel. Immediate fire fighting may be essential. But, under less urgent circumstances, though, first responders should ensure the following:
Secure the site. Once we investigate, the accident site temporarily becomes, for all intents and purposes, TSB property. However, to the extent possible, the help and cooperation of first responders is needed to accomplish the following:
- establishing a safe zone
- evacuating the area, as required
- cordon off the accident site, including as much of the wreckage area as possible
- provide emergency services and traffic control
- restrict access to the site by media, bystanders and any other unnecessary people.
To Preserve evidence: To the extent possible and consistent with priorities regarding the preservation of life and preventing further damage, every step should be taken to preserve evidence, to prevent the wreckage and debris from being disturbed or tampered with. In other words, unless you have to, don't move things without the knowledge and consent of TSB investigators. And if you have to move things around, document the evidence wherever possible. Take pictures, or video, of any objects and vehicles and their positions, as well as any evidence that may be "transitory," (such as ice or soot deposits). Essentially, survey or document as much of the site as possible.
Collect witness names: Local authorities should record the names and contact information of all witnesses whose testimony may aid in the investigation.
Media response: Refer questions about the investigation to TSB media relations (819-994-8053), or to the TSB investigator.
Contact the Canadian Transport Emergency Centre (CANUTEC): Ask if hazardous goods are involved (613-996-6666).
Contact the crew and / or transportation operator: (Eg: marine company, pipeline company, rail company, air company, etc.) They'll help identify any hazardous goods, or hazards specific to those goods.
Slide 13: Problems on Site
The top priority, always, is keeping people safe. Then you try to minimize damage to property and the environment, and preserve evidence where possible. Notwithstanding this, there are still a lot of other problems that can arise.
The most common is known as "Who does what?" Call it the 4 Rs: roles, responsibilities, rights, and rank) It's relevant as there are often many different groups that may be on scene.
Then there's the issue of returning the site to operability as soon as possible, as time costs money and impacts service. However, it is important that any evidence be preserved.
The remoteness of a location, and any accompanying modal-specific challenges, can complicate the availability of appropriate expertise on site.
Then there's the question of size. An accident scene can be overwhelming, and first responders may have limited experience with, for example, a multi-car train derailment involving hazardous materials.
There's also the problem of information being lost or not shared.
And even if all of those factors are overcome, sometimes there's the more pedestrian problem of: where do people sleep? Is there accommodation in the middle of nowhere for a major investigation team to arrive and set up operations?
Slide 14: Solutions
Many of these problems have, at their core, the issue of INFORMATION: getting it from the right people, to the right people. So that they can act on it.
Thus, the first task is to understand who does what-what job, what goal, what authority and/or responsibilities-and to communicate that information to everyone involved.
It is important that the recovery, under the leadership of the site commander, be developed, implemented, updated and worked to a coordinated plan.
Slide 15: Powers and Authority
So, let's talk about our "authority" to carry out our responsibilities. How has Parliament empowered TSB to fulfill its mandate?
Let's first recall that among the list of potential problems we identified earlier, one of them was the four Rs: roles, responsibilities, rights, and rank.
Unless the police/RCMP etc is investigating a possible criminal occurrence, the CTAISB Act grants TSB investigators wide powers. Section 19 defines these powers, and lists a number of conditions under which an IIC may exercise authority. In particular, he or she is allowed to:
1. Enter or restrict access to the area
2. Seize any wreckage/impound equipment
3. Compel witness interviews
4. Obtain search warrants, sometimes even over the phone
5. Require a medical examination or coroner's examination
So, our investigators have fairly broad powers. However, our approach is to nonetheless work very cooperatively with the people on site.
Here are several very specific reasons why.
Slide 16: Liaising with on-site Command
#1. We're not first responders, and we aren't operators. We're investigators, not firefighters, so it would be a waste of resources - not to mention dangerous - to take over when the site is unsafe.
However, if there's wreckage, we need to see it. And if there are witnesses, we need to talk to them. So once we arrive, the investigator's first task is to find the on-scene commander and establish coordination. We let all those involved know who we are, and what our goals are.
#2. People may not know who we are. Liaising with on-scene command helps to establish the ground rules.
#3. People don't like being told to "get out of the way." It clogs the lines of communication. And less information complicates our investigation process. That's why we practice fitting in with on-scene command.
So � how do we approach a site?
Slide 17: Communications at the Site
Once at the site, here are four key actions we take:
1. The IIC or his/her designated representative will liaise with on-scene commanders and obtain a briefing on the status of the emergency operations, as well as on hazards and dangerous goods identified.
2. Before initiating investigation activities, the IIC will, in consultation with the other agencies involved, ensure the site is inspected and made safe to the extent possible.
3. The IIC will decide which sections of the site will be under TSB authority and communicate this decision to the agency in charge of the site.
4. The IIC may interview first responders to determine their activities during the response and their recollections of the site, recording of information, and emergency activities.
Slide 18: Privileged Information
So we interview people, take possession of voice and data recorders, etc � all in order to carry out a comprehensive investigation.
Frequently, people want to know: " If TSB investigators can interview whoever is required, can other organizations have access to our information/files/transcripts, etc." ?
And the answer is - No.
The law is very clear, because the CTAISB Act is very clear. TSB information is confidential and privileged. This applies to things like witness statements-verbal, video, or written-and it also applies to on-board recordings from sources like event data recorders on trains, voyage data recorders on ferries, and airplane "black boxes."
Because keeping our information confidential give us the best possible chance at improving safety. Study after study shows that people are more willing to talk when talking won't get them punished.
NOTE - Police may wish to conduct their own investigation afterwards, or coincident with ours. Nothing stops them from interviewing the same witnesses, asking the same questions, taking photos of the scene-just like we do. But our information cannot be used in court. We are not a court. We do not determine civil or criminal liability.
Slide 19: (Picture of Sinking Boat)
As I've mentioned earlier, the basic priorities of first responders don't change too much: Once you've assessed the situation, you need to secure the safety of people, property, the environment, and then ensure the preservation of evidence to the extent possible.
However, every mode of transportation poses challenges unique to its area of operation. The site of a marine accident, for example, is very different from the site of a train derailment.
Let's look at some specifics.
Slide 20: Modal Challenges (Marine)
1. Securing a marine site can be challenging:
Vessels vary in size and configuration, and cargo can be very diverse (ex: petroleum, dangerous goods). The location can also make it hard to establish a safety perimeter.
Securing the occurrence site of a dangerous goods incident may be done by the ship's crew, by Transport Canada or Canadian Coast Guard personnel, or by first responders.
Vessel's operational situation: Is it aground? At sea under power, or drifting? Is it berthed at a busy port, near populated areas?
2. Ship design/access to cargo: By their nature, ships are constructed of many subdivided and enclosed areas. This can present not only physical barriers to first response but represents a considerable risk of localized oxygen depletion.
3. On a container ship, identifying the products involved can be a challenge. In theory, the vessel's cargo manifest and loading plan should be found with the master or the shipping company. However, containers have been found to hold cargo other than that advertised on the manifest.
4. Quantity of product involved: One very large crude oil tanker can carry more than 250,000 tonnes of oil (more than 250 million litres). While a "small" chemical carrier might transport more than 8,000 tonnes of benzene or other dangerous products.
5. Experience: Not all first responders may have the relevant experience to deal with the task at hand. Shore-based firefighters, for example, may not have experience fighting fires aboard ships-a task which is markedly different from on-shore firefighting.
Slide 21: Picture of Pipeline
People tend to forget how much of an impact pipelines can have on the population. That's because they're usually buried, although they nonetheless carry phenomenal amounts of material - billions of cubic feet per day.
Like the other modes, the site of a pipeline accident often brings a similar set of problems:
Slide 22: Modal Challenges (Pipeline)
1. As I mentioned earlier, the number one challenge at any accident site is interfacing with all of the various groups. We all have jobs to do.
2. The #2 challenge, of course, is managing - and sharing - all the information that's swirling around. At a big accident site, the IIC is often buried under an avalanche of material and time constraints. This complicates information sharing, even though we try to let people know their concerns are heard, and that they're being addressed.
One solution that has proven effective, and which will likely be known to you, is the Incident Command system.
If those on scene have received training in Incident Command, things are much easier for our investigators. This is true for all modes.
The good news is that many authorities and operators are moving toward this type of system, because it is BY FAR the number 1 methodology for management and coordination of emergencies. It sets out clearly defined roles-efficiently, and without ruffling feathers (too much).
Let me show you an example of what can happen when a pipeline fails.
Slide 23: Picture of Explosion
This picture was taken when a pipeline blew in Stewart Lake, Ontario. It was 11:30 at night, and this truck was approximately 2.5 kilometres away from the blast. Even though the blast was 165 metres away from the highway, there were trees and brush on fire all around the area. When the local fire department was notified, and told that there were burning trees all along the highway and that they needed to respond right away, they thought it was a joke.
Because it was the middle of December. And there was a snowstorm going on.
Slide 24: Picture of Derailment
Now let's turn our attention to rail accidents.
A variety of factors can cause a derailment, but one key area that the TSB has singled out on the Watchlist is the problem of collisions between passenger trains and road users at Canada's 20,000 federal railway crossings. Crossing accidents are also a cause of injuries, fatalities and fuel leaks.
Also, as today's trains grow longer and heavier, pulling up to 25% more tonnage than even a few years ago, the risks associated with any derailment can be high.
Here, then, are a few specific concerns when dealing with a train derailment.
Slide 25: Modal Challenges (Rail)
1. As I mentioned earlier, setting up an effective on-scene command structure is vital: In most cases, the railways themselves have personnel or contractors trained to set up an Incident Command system.
2. Potentially dangerous cargo: Trains transport a variety of goods, some of them dangerous. These can include: flammable liquids, toxic/infectious substances, spontaneously combustible materials.
3. Large quantities: a single tank car can carry thousands of litres of product. In event of a derailment, a very large area can be affected. This can, in some cases, result in a large-scale evacuation, which can last for an extended period of time.
4. Identifying products: This is often complicated due to the destructive nature of a derailment. A derailment can cause the cars to wind up almost anywhere and any markings or placards might be destroyed.
5. Tank cars can contain significant amounts of product and yet still be classified as "residue." The figure is actually 10 per cent. This means that a car with a 150,000 gallon capacity might still contain 15,000 gallons of product and still be labeled residue. This does not mean "empty," and first responders need to be aware of that.
6. There are various types of rolling stock, many of which can carry dangerous goods. Knowledge about different types of tank cars, for example, can help identify what type of car is being dealt with and what type of dangerous goods they are carrying.
Slide 26: Photo of Firdale
This photo was taken at a derailment in Firdale, Manitoba, in 2002.
A loaded tractor trailer collided with a train at a public crossing, derailing 2 locomotives and 21 freight cars - including 5 tank cars carrying dangerous goods. There were no significant injuries to either the train crew or the truck driver, but 156 people were evacuated from the vicinity.
Due to the magnitude of the fire and the resources necessary to bring it under control, the Office of Fire Commissioner assumed the role of Incident Commander for the duration of the firefighting. Residents within a two-mile radius were evacuated, the RCMP established road blocks, TC established a no-fly zone, and a ground reconnaissance team of DG technicians surveyed the site with binoculars from a safe distance.
A firefighter in the area observed the large smoke plume and responded prior to receiving notification. Arriving on the scene, he climbed over the derailed cars to check the truck driver's condition. A fire was in progress approximately 200 feet to the east. The firefighter was not wearing any personal protective equipment (PPE). After observing that the tractor was intact and that the driver had exited safely, he climbed back over the cars and met with the train crew.
Although the firefighter had some training, he had neither received refresher DG training nor responded to a rail DG incident since his initial training approximately six years previously. The subsequent TSB report made 2 recommendations, one of which was specific to first responders:
We recommended that Transport Canada, "in consultation with other federal, provincial, and municipal agencies, implement consistent training requirements" to make sure that emergency first responders maintain competencies when they are responding to rail accidents involving dangerous goods. (R04-03)
Slide 27: Modal Challenges (Air)
In the aviation mode, many of the problems with respect to accidents involve location. As you can see in this photo of the US Airways flight 1549, which ditched in New York's Hudson River in January 2009, even though the passengers were able to escape, the investigators were clearly going to have their work cut out for them when they wanted to examine the wreckage.
And that was in the middle of New York, with all sorts of machinery and expertise in close proximity. Just imagine what happens when a plane goes down in the middle of remote wilderness. Which leads us to �
Slide 28: Modal Challenges (Air)
When planes crash, it can be in remote locations, where just finding the site is sometimes hard.
Then there is the question of getting to it. Some sites are almost inaccessible, or accessible only via helicopter or hiking in.
Even then, it may be difficult or impossible to access or retrieve the wreckage. This is particularly true if the aircraft went down in deep water.
Finally, there is the fact that not everything can be � well, anticipated. Consider the following:
On 25 May 2010, a TSB Air investigator deployed to the accident site at Buttonville Airport in Markham, Ontario. Shortly after the crash, the aircraft caught fire, and the heat activated the Ballistic Recovery System (BRS). This system is essentially a rocket-propelled parachute that can be deployed by the pilot in the event of a loss of control.
Once it overheated, the BRS fired. The canister ricocheted off a small wall, bounced across the roof, hit the edge of the building, and then flew off the roof-landing a few feet away from a police car. The officers were quite surprised by the whole event. This underlines the importance of getting as much advance info as possible with regard to the hazards you could face.
Slide 29: Summary
As we have stressed, at any accident site the safety of people, property and the environment are the top priorities. The preservation of evidence is also very important.
So, to summarize, in an accident investigation TSB's goals are;
- To determine the causes and contributing factors and to identify any systemic safety deficiencies. In other words, find out what happened, why it happened, what may be necessary to mitigate the risk of recurrence, and then communicate that knowledge to the appropriate change agents and to the Canadian public.
To this end, we rely on first responders to help with:
- Secure the site
- Preserve the evidence
- Share information
- Collect witness names
- Inform CANUTEC
And because there are often multiple layers of government, and numerous organizations on scene, it is vital that there be coordination among them, and a command system that is flexible, and yet still meets everyone's needs. TSB investigators do their best to make sure that this happens.
Slide 30: Questions
Slide 31: END
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