Annual Report to Parliament 2006-2007
Transportation Safety Board Annual Report to Parliament 2006-2007
Transportation Safety Board of Canada
Place du Centre
200 Promenade du Portage
Gatineau, Quebec K1A 1K8
Minister of Public Works and Government Services
Cat. No. TU1-2007
ANNUAL REPORT TO PARLIAMENT 2006-2007
Place du Centre
200 Promenade du Portage
Gatineau, Quebec K1A 1K8
22 August 2007
The Honourable Rona Ambrose, P.C., M.P.
President of the Queen's Privy Council for Canada
House of Commons
Ottawa, Ontario K1A 0A6
In accordance with subsection 13(3) of the Canadian Transportation Accident Investigation and Safety Board Act, the Board is pleased to submit, through you, its annual report to Parliament for the period 1 April 2006 to 31 March 2007.
Wendy A. Tadros
- The Chair's Message
- Section 1: Overview
- Section 2: Activities
- 2.1 Occurrences, Investigations and Safety Action
- 2.2 Communicating Transportation Safety to Canadians and the Transportation Community
- 2.3 Marine Sector
- 2.4 Pipeline Sector
- 2.5 Rail Sector
- 2.6 Air Sector
- Figure 1 - Occurrences Reported to the TSB
- Figure 2 - Investigations Started, in Process, and Completed
- Figure 3 - Marine Occurrences and Fatalities
- Figure 4 - Canadian-Flag Shipping Accident Rates
- Figure 5 - Pipeline Occurrences
- Figure 6 - Pipeline Accident Rates
- Figure 7 - Rail Occurrences and Fatalities
- Figure 8 - Main-Track Accident Rates
- Figure 9 - Air Occurrences and Fatalities
- Figure 10 - Canadian-Registered Aircraft Accident Rates
- Table 1 - Safety Outputs by the TSB
- Table 2 - Board Assessment of Responses to Recommendations
- Table 3 - Marine Productivity
- Table 4 - Pipeline Productivity
- Table 5 - Rail Productivity
- Table 6 - Air Productivity
I am proud to assume the leadership of the Transportation Safety Board of Canada, an organization that is recognized worldwide for its professional competence and important contributions to transportation safety.
In a time where Canadians expect safe transportation, the TSB actively promotes a culture of safety by conducting independent accident investigations, by identifying safety deficiencies and by making recommendations we believe will advance safety in our marine, pipeline, rail and aviation sectors. One investigation at a time, the TSB has established its credibility with industry and regulators, and continues to build public awareness of our role in the transportation field and in the need for independent accident investigation.
The TSB recognizes that, in order to be effective, we must not only demonstrate technical competency but relevance to Canadians. The TSB was challenged this year by the need to complete an increasing number of very complex investigations while at the same time significantly reducing the number of investigations in progress. We understand the need to reduce the average time it takes to complete an investigation while ensuring we maintain the high quality Canadians expect in all of our work.
Our goal is to build upon well-established strengths while focusing on areas where improvements are required. This is a question of balancing the number of new investigations against the available resources. It also means that, to serve Canadians in a timely manner, we do not wait for the production of our final report into an occurrence. If we find unsafe conditions during the course of an investigation, we act immediately by communicating with those who can make transportation safer.
During the past year, the TSB achieved results for Canadians by identifying a broad range of safety deficiencies and by conveying key safety messages to the public, industry and regulators. In addition to making 57 investigation reports public, the TSB issued a total of 61 safety outputs to both the regulators and the transportation industry: 6 recommendations, 32 safety advisories and 23 safety information letters.
We are communicating safety knowledge to Canadians and to the international community better and more often. This not only makes transportation safer more quickly, it also raises awareness about the work we do. Notably, our participation at conferences, seminars and technical meetings on transportation safety has allowed us to influence opinion within the transportation industry and to keep abreast of technological change. Our website has proved a very effective way for the TSB to get the word out about what is needed to make the transportation system safer.
TSB recommendations continue to be positively received. The safety action taken as a result of our work underscores the important contribution made by this organization in the reduction of risks in the Canadian and international transportation system. We are convinced that our work will continue to contribute to Canada's excellent safety record.
As I report to Parliament on this year and as I look to the future, I am confident that the TSB is up to meeting the challenges that lie ahead. Rest assured that everyone at the TSB remains firmly committed to advancing transportation safety for Canadians.
Wendy A. Tadros
Chair Wendy A. Tadros
Transportation and legal experience includes Director of Legal Services for the National Transportation Agency of Canada; Inquiry Coordinator for "The Road to Accessibility: An Inquiry into Canadian Motor Coach Services"; and counsel to the Canadian Transport Commission before the Commission of Inquiry into the Hinton Train Collision.
Member Jonathan Seymour
Transportation policy and marine management experience includes Executive Director of International Maritime Centre-Vancouver; chartering, commercial and general manager for several shipping companies; marine policy advisor to the British Columbia government; and policy and economic consultant.
James P. Walsh
Was the Member of the House of Assembly in Newfoundland and Labrador for the district of Conception Bay East-Bell Island from 1989 to 2003. Served as Minister of Works, Services and Transportation, and also served as Minister of Tourism and Culture, Parliamentary Secretary to the Minister of Finance and Treasury Board, and Parliamentary Secretary responsible for the Newfoundland and Labrador Housing Corporation. Also served as Caucus Chairman and Vice-Chair of the Public Accounts Committee. In 2003, received the distinction of Honorary Life Member of the Transportation Association of Canada.
Member R. Henry Wright
Management and consulting experience includes auditor for the Ontario Ministry of Community and Social Services; senior management administrator of several non-profit organizations; and consultant in government and public relations.
|Executive Director||G. McDonald|
|General Counsel||A. Harding|
|Director General, Investigation Operations||T. Burtch|
|Director General, Corporate Services||J. L. Laporte|
|Director, Marine Investigations||Y. Myers|
|Director, Rail/Pipeline Investigations||I. Naish|
|Director, Air Investigations||N. Stoss|
|Director, Engineering||N. Cerullo|
We conduct independent safety investigations and communicate risks in the transportation system.
To encourage public confidence in transportation accident investigation, the investigating agency must be, and be seen to be, objective, independent and free from any conflicts of interest. The key feature of the TSB is its independence. It reports to Parliament through the President of the Queen's Privy Council for Canada and is separate from other government agencies and departments. Its independence enables it to be objective in arriving at its conclusions and recommendations. The TSB's continuing independence and credibility rest on its competence, openness, integrity and the fairness of its processes.
In 2006, a total of 1921 accidents and 1326 incidents were reported in accordance with the TSB's regulations for mandatory reporting of occurrences.1 The number of accidents in 2006 decreased by 6 per cent from the 2046 accidents reported in 2005 and by 1 per cent from the 2001-2005 annual average of 1946 accidents. The number of reported incidents decreased to 1326 in 2006, down from 1371 in 2005 and the 2001-2005 average of 1414. There were also 564 voluntary incident reports. Fatalities totalled 168 in 2006, down 20 from the 2005 total and 21 from the 2001-2005 average.
All reported occurrences were examined in accordance with the Board's Occurrence Classification Policy to identify those with the greatest potential for advancing transportation safety. Information was entered into the TSB database for historical record, trend analysis and safety deficiency validation purposes. Investigations were undertaken for 68 of the approximately 4000 occurrences reported to the TSB in fiscal year 2006-2007. In that same period, 57 investigations were completed, compared to 75 in the previous year.2 The number of investigations in process increased to 119 at the end of the fiscal year from 105 at the start. Average time to complete an investigation increased to 573 days in fiscal year 2006-2007 from 464 days in the previous year.
While overall report timeliness has shown some improvements in past years, there was a significant increase in 2006-2007. The reduction in the number of investigations completed and the increase in the average time to complete investigations were the result of a combination of factors. The increase in the number of major investigations, a concerted effort to complete older investigations as well as unanticipated management and staff shortages all contributed to this increase. In order to ensure continuing improvement in performance, the TSB has recently completed staffing of a number of key positions, including short-term hiring to address this concern. In addition, the organization is undertaking a full review of its operations to ensure optimal allocation of available resources for the achievement of our mandate and goals.
Overall, the TSB has been successful in identifying safety deficiencies and in reducing risks in the transportation system. TSB investigations result in reports identifying safety deficiencies and, where appropriate, containing recommendations to reduce risks. Over this past year, in all cases where the TSB undertook an investigation, safety deficiencies or contributing factors were identified and communicated. These results reflect 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.
In 2006-2007, in addition to investigation reports, the TSB issued a total of 61 safety outputs: 6 recommendations, 32 safety advisories and 23 safety information letters (see Table 1 for a breakdown by sector).
|Table 1: Safety Outputs by the TSB|
|Sector||Recommendations3||Safety Advisories||Safety Information Letters|
Note: In 2006-2007, a total of 3 marine safety concerns, 3 rail safety concerns and 6 air safety concerns were identified.
Safety information is also provided informally 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 (for example, to clear the sight-lines 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.
In accordance with the Canadian Transportation Accident Investigation and Safety Board Act, a federal minister who is notified of a TSB recommendation must, within 90 days, advise the Board in writing of any action taken or proposed to be taken in response, or the reasons for not taking action. The Board considers each response, assessing the extent to which the related safety deficiency was addressed. When a recommendation generates responses from within and outside Canada, the Board's assessment is based primarily on the Canadian response. This year, the TSB continued to publish on its website its assessment of industry and government organization responses to its recommendations made after January 1, 2005.
|Responses Received in Fiscal Year 2006-2007||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|
2.2 Communicating Transportation Safety to Canadians and the Transportation Community
One of the central challenges in advancing transportation safety has been convincing the many actors in the industry that change is necessary to lessen the risk. This has led the TSB to adopt a number of tools to convey the findings achieved through investigations. During the past year, the TSB identified a number of safety deficiencies and delivered key safety messages to the public, industry and regulators. As in past years, that approach has proved to be quite effective and continues to be supported to increase effectiveness. In an effort to improve the uptake of its recommendations, the TSB has begun to target its safety messages to narrower and more specialized audiences who are in a position to act directly. The Outreach Program was developed to promote safety where specific departments, elected officials and industry leaders have an important role to play. To that end, the TSB has identified the need to become more active with its Outreach Program and is striving to increase the number of outreac opportunities that are undertaken each year by the Chair, Board members, senior executives and staff. We anticipate that this effort will be rewarded in years to come as we expand the reach of our messages and the safety of Canada's transportation system continues to improve.
In June 2006, a new Executive Director of the TSB was appointed. One of his first challenges was to meet with representatives from the transportation industry and other interested parties. Over four months, the Executive Director met with various airline companies, rail operators, manufacturers, transportation associations and councils, airport authorities, and medical examiners. He made a presentation to the Railway Association of Canada and attended a number of safety association meetings and conferences.
TSB staff and Board members also participated in various conferences and technical meetings pertinent to transportation safety to keep abreast of technological change and to make presentations on safety issues of particular interest to the audiences. To complement these meetings, the TSB wrote and distributed technical and feature articles that have been published in specialized magazines. In these ways, the TSB has taken advantage of various forums as opportunities to share lessons learned from its investigations.
In 2006-2007, the TSB published 57 investigation reports, as well as monthly and annual statistical reports, and continues to maintain a proactive approach to the dissemination of information. Pertinent information is made readily available to industry, next-of-kin, the media and the public throughout the investigation process. Investigators are encouraged to maintain a dialogue with key stakeholders, including the early communication of safety issues that arise during the investigation. The TSB tries to satisfy both the public and the media's expectation for up-to-date factual information. In 2006-2007, 631 subscribers joined its website for a total of 2065 subscribers, and the TSB responded to 749 information requests received through its website and 643 media calls, not including those inquiries handled at an accident site or at a report release news conference. The TSB attended 3 outreach events, held 6 news conferences and issued 19 news releases. The TSB Macro-Analysis Division responded to 370 requests for complex transportation occurrence database information.
The TSB also uses its website to increase awareness of safety issues and other transportation safety information. The TSB website received an average of more than 92 930 daily hits and 6409 daily visits, a 31 per cent increase in daily visits over the previous year. The visitors are Canadians and people from all around the world. The increased traffic can be partly attributed to the media coverage given to certain accidents, the press releases issued by the TSB, the ease of access to the site and the vast amount of information found.
Although it is difficult to measure the results of TSB activity in this area, tangible signs continue to point toward a certain degree of effectiveness in achieving the desired outcome. For instance, requests for TSB safety information continue to increase year after year. Stakeholders and the media make use of TSB safety messages in their activities. There is a sustained level of interest, both in Canada and around the world, in TSB techniques and methodologies.
In all, 467 marine accidents were reported to the TSB in 2006, a 4 per cent decrease from the 2005 total of 489 and an 8 per cent decrease from the 2001-2005 average of 506. Marine fatalities totalled 18 in 2006, down from both the 2005 total of 20 and the 2001-2005 average of 25.
Shipping accidents, which comprised 90 per cent of marine accidents, reached a 30-year low of 419 in 2006, down from 444 in 2005 and from the five-year average of 455. Nearly half of all vessels involved in shipping accidents were fishing vessels. Accidents to persons aboard ship, which include falls, electrocution, and other types of injuries requiring hospitalization, totalled 48 in 2006, a 7 per cent increase from the 2005 total of 45 but a 6 per cent decrease from the five-year average of 51.
Marine activity for Canadian commercial non-fishing vessels (excluding passenger vessels and cruise ships) increased by 1 per cent from the 2001-2005 average, resulting in a 7 per cent decrease in the accident rate from 3.6 to 3.3 accidents per 1000 movements. Although marine activity for foreign commercial non-fishing vessels remained relatively unchanged compared to the 2001-2005 average, accidents increased, yielding an 11 per cent increase in the accident rate from 1.6 to 1.8 accidents per 1000 movements.
In 2006, shipping accidents resulted in 12 fatalities, down from 13 in 2005 and the five year average of 16. Accidents aboard ship resulted in 6 fatalities, down 1 from the 2005 total and down 3 from the five-year average.
Thirty-one vessels were reported lost in 2006, up from the 2005 total of 26 but down from the five-year average of 34.
In 2006, 212 marine incidents were reported to the TSB in accordance with the mandatory reporting requirements. This represents a 7 per cent decrease from the 2005 total of 227 and a 5 per cent decrease from the five-year average of 222.
One indicator of marine safety in Canada is the Canadian-flag shipping accident rate. This accident rate has decreased from 3.7 accidents per 1000 movements in 2005 to 3.3 in 2006, but no significant statistical trend was found.
In 2006-2007, 8 marine investigations were started and 8 investigations were completed. This represents a decrease (from 12 to 8) of the number of investigations completed compared to 2005-2006. The decrease is still linked to the delay to staff vacant positions. The average duration of completed investigations increased to 801 days compared to 651 days the year before and to 797 days between 2002-2003 and 2005-2006. This is attributable to concentrated efforts to complete older investigations.
Table 3: Marine Productivity
|Average Duration of Completed Investigations (Number of Days)||703||953||881||651||801|
|Safety Information Letters||14||11||8||8||8|
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.
2.3.3 Safety Actions Taken
The Marine Branch reassessed responses to 42 recommendations issued in previous years. With Board approval, 9 recommendations went from active to inactive status and 33 recommendations remained active. The Board's reassessments were communicated to the appropriate change agent(s) for information and action.
No marine safety recommendations were issued in 2006-2007.
22.214.171.124 Assessment of Responses to Marine Recommendations Issued in 2005-2006
|Capsizing and Loss of Life, Small Fishing Vessel Ryan's Commander off Cape Bonavista, Newfoundland and Labrador, 19 September 2004
Report No. M04N0086
The Department of Transport ensure that the Board's previous recommendations M03-05 and M03-06 are immediately implemented.
|RESPONSE||The Minister of Transport, Infrastructure and Communities agrees with the intent of the recommendation. Until such time as the new Fishing Vessel Safety Regulations come into force, Transport Canada (TC) has established an interim measure for determining, based on a list of risk factors, whether a small fishing vessel requires a stability booklet. This interim measure will take effect immediately, and will also serve to remind vessel owners of their responsibility to make safe operational decisions that ensure an adequate margin of safety.|
|BOARD ASSESSMENT OF RESPONSE||TC issued Ship Safety Bulletin 04/2006 (Safety of Small Fishing Vessels: Information to Owners/Masters about Stability Booklets). The bulletin describes the interim safety measure and the process for determining whether a small fishing vessel requires a stability booklet and what to do if it does. The bulletin applies to all owners and operators of fishing vessels, new and existing, that are between 15 and 150 gross tons, or not more than 24.4 m in length.|
|BOARD ASSESSMENT RATING||Fully Satisfactory|
The Department of Transport require Canadian passenger vessels over 500 gross tonnage to meet a standard of structural fire protection that ensures a level of safety equivalent to International Convention for the Safety of Life at Sea (SOLAS)-compliant vessels.
|RESPONSE||The Minister of Transport, Infrastructure and Communities agrees with the intent of this recommendation. The proposed Fire Safety Regulations will require that new passenger vessels over 150 gross tons meet and in some areas exceed the SOLAS standards for structural fire protection. The proposed regulations will also address modifications made to existing vessels. As a result, any major modification will have to comply with the most recent requirements for structural fire protection.|
|BOARD ASSESSMENT OF RESPONSE||It is anticipated that TC will undertake a review as indicated in its initial response to verify that the proposed regulations meet all necessary requirements. TC has begun work to develop the proposed Fire Safety Regulations.|
|BOARD ASSESSMENT RATING||Satisfactory in Part|
BC Ferries implemented additional procedures to ensure that bridge officers and quartermasters are familiarized with new bridge equipment. TSB Marine Safety Advisory 07/06 on the adequacy of crew familiarization of equipment was sent to BC Ferries following the sinking of the ferry Queen of the North (TSB Occurrence M06W0052).
BC Ferries implemented a new procedure for establishing passenger manifests to ensure that the passengers on board its vessels on northern routes are accurately reflected in the passenger manifests maintained ashore. TSB Marine Safety Advisory 09/06 on the adequacy of current guidelines for creating ferry passenger manifests was sent to Transport Canada (TC) and copied to BC Ferries following the sinking of the ferry Queen of the North (TSB Occurrence M06W0052).
TC met with industry and government representatives to discuss updating current port procedures for the handling of dangerous cargo at the Port of Saguenay, Quebec. A small explosion had occurred on board a vessel unloading a cargo of explosives (TSB Occurrence M06L0045). TC decided to deploy an inspector to the site when notified of a shipment of dangerous cargo at the port. Also, TC informed the Swedish and German Port State Authorities involved (where the vessel was loaded) of the incident and of the handling and loading of the cargo at the port of loading. TSB Marine Safety Advisory 08/06 on the inadequate explosive cargo handling practices was sent to TC and the Port of Saguenay.
In 2006, 8 pipeline accidents were reported to the TSB, up from the 2005 total of 5 but down from the 2001-2005 average of 15. Pipeline activity is estimated to have increased by 2 per cent from the previous year. The last fatal pipeline accident in the portion of the industry under federal jurisdiction occurred in 1988, and the last accident involving serious injury occurred in 2000.
In 2006, 63 pipeline incidents were reported to the TSB in accordance with the mandatory reporting requirements, down from 79 in 2005 but up from the five-year average of 52. In all, 88 per cent of those incidents involved uncontained or uncontrolled release of small quantities of gas, oil and high-vapour-pressure products.
One indicator of pipeline transportation safety in Canada is the pipeline accident rate. This rate increased to 0.6 pipeline accidents per exajoule in 2006, up from 0.4 in 2005 but down from the 2001-2005 average of 1.2. The trend line also indicates a clear downward direction.
In 2006-2007, one pipeline investigation was started and one investigation was completed. The completed investigation required 407 days, a significant decrease from 922 days in 2005-2006 (the latter being a very complex investigation that required a high degree of effort to gather and analyze the data).
Table 4: Pipeline Productivity
|Average Duration of Completed Investigations (Number of Days)||410||0||1081||922||407|
|Safety Information Letters||1||0||0||0||1|
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.
No pipeline safety recommendations were issued in 2006-2007.
In response to the Pipeline Safety Information letter, the National Energy Board issued a Safety Advisory to all companies under its jurisdiction, as well as to the Canadian Energy Pipeline Association, the Canadian Association of Petroleum Producers and provincial regulators. The Safety Advisory outlined safety issues related to potential employee injury from ejection of pipeline pigs that have been lodged in receiving traps. Additionally, it itemized actions for organizations to take to address that risk in the future.
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