TSB Transportation Safety Summit

In April 2016, the TSB held a Safety Summit that brought together senior Canadian transportation executives from government and the transportation industry, along with some of their bargaining agents.

The objective of the meeting was to share best practices—notably for capturing and using safety data in a proactive, non-punitive way—and to identify ways of strengthening organizational safety culture and safety management.

TSB investigations have frequently shown that organizational factors—conflicting priorities, inadequate risk analysis, or ineffective operational oversight, for instance—contribute to accidents.

And although not typically highlighted in the final reports (which tend to focus on safety deficiencies), investigations have uncovered good practices as well.

Companies sometimes share good practices with other companies in the same mode of transportation, but there is no sharing across modes. The Summit addressed that gap.

Participants left the meeting with practical approaches to implement in their own organizations to improve safety and help mitigate risks.



Proceedings of the TSB Transportation Safety Summit
Read the proceedings



First-ever Transportation Safety Summit highlights importance of organizational information flow and safety culture
Read the news release


First-ever multi-modal TSB Transportation Safety Summit promotes important discussions on key Canadian transportation safety issues
Read the news release



Transportation Safety Summit [April 2016]
View the poster



Thursday, 21 April 2016—Information flow and safety culture

Kathy Fox, Chair, Transportation Safety Board of Canada: Opening remarks

The Transportation Safety Summit brings together a broad cross-section of senior Canadian transportation executives from government, and from the marine, pipeline, rail and aviation industries, including some of their bargaining agents.


Read the Chair's opening remarks

Information flow

Ron Westrum, Eastern Michigan University: Getting information flow

Using multiple examples, this presentation demonstrates how information flow is key to effective safety management. Dr. Westrum identifies three (3) key problems preventing proper information flow and recommends ways to best avoid them.


Faye Ackermans, TSB Board Member: Statement of safety issue support: review of findings and systemic risks

Information flow was thoroughly reviewed in a sample of TSB investigations. This presentation summarizes the contributing factors that prevent effective information flow.


Moving organizations towards a co-operative, trust-based relationship

Marc Beaulieu, VIA Rail: Just Culture

This presentation provides an overview of VIA Rail's efforts to establish a Just Culture, as well as an explanation of the strategies used by VIA Rail to assess discipline, enhance safety, and maintain situational awareness. VIA Rail's exemplary collaboration with the unions plays an important role in its success.


Larry Lachance, NAV CANADA: Just Culture

NAV CANADA's strategy to implement a Just Culture framework is to remove the barriers to safety reporting, which has proven to be very effective. This presentation provides a list of key leadership elements, and describes NAV CANADA's own experience with safety management.


Jamie Marshall, BC Ferries: SailSafe

This is a detailed presentation on the importance of safety management systems in the BC Ferries organization. It also demonstrates how the organization's members have learned, from personal experience, how to transform their safety culture into a Just Culture.


Maintaining confidence in your system while encouraging information flow

Jack Davis, Mobile Inc.: "Disciplinary" case study from health care

This presentation provides a detailed analysis of a drug-related error that lead to patient fatalities, involving Calgary Health Region. It illustrates how an organization's culture has a direct impact on safety, and how to implement safety management systems in order to enhance safety.

Friday, 22 April 2016—Information flow and safety management

Using leading indicators or data source processes for a more proactive and predictive approach

Norrie Ramsay, TransCanada Pipelines: Pipeline integrity and safety: leading indicators

This presentation provides an overview of how TransCanada Pipelines manages pipeline integrity and safety through full life-cycle management, including through the use of: system-wide risk assessments, threat management, in-line inspections, and damage prevention.


Paul Spring, Phoenix Heli-Flight: A business case for data recording technology

This presentation demonstrates how Phoenix Heli-Flight was able to learn from its own experience and implement data recording technologies, in order to increase safety and ensure compliance with policies and procedures.


Scott Wilson, WestJet: Safety Management

A clear demonstration that the building blocks of effective safety management are strong safety culture and in-depth data analysis.


On-board voice and video recorders

Kirby Jang, TSB Director of Investigations, Rail/Pipeline: Expanding the use of on-board voice and video recorders

On-board recorders play a critical role in occurrence investigations; this presentation provides an update on the ongoing study of locomotive voice and video recorders. It offers concrete examples of situations in which the use of locomotive voice and video recorders is critical, and explains how these recorders would be used in various situations.


Jean L. Laporte, TSB Chief Operating Officer: Usage of voice and video recorders: balancing rights and obligations

This presentation provides a detailed comparison of the rights and obligations that operators must face regarding the use of voice and video recorders in today's society.