News release

TSB completes its independent review of the ATSB’s investigation methodologies and processes

Gatineau, Quebec, 1 December 2014 – Today, the Transportation Safety Board of Canada (TSB) released its independent peer review of the Australian Transport Safety Bureau’s (ATSB) air investigation methodologies and processes.

The ATSB requested a review after its investigation report (AO-2009-072) into the November 2009 ditching of a Westwind 1124A aircraft near Norfolk Island, Australia, received public and political criticism. The review did not include an actual reinvestigation of the Norfolk Island occurrence, but rather examined how that investigation, along with two other investigations similar in scope, was conducted.

“We saw the potential for mutual learning when we accepted the review request,” said Kathy Fox, Chair of the TSB. “We will now examine if any ATSB investigation best practices should be adopted here in Canada.”

The TSB review compared the two organizations' methodologies against the standards and recommended practices outlined in Annex 13 to the International Civil Aviation Organization and found they met or exceeded the intent and spirit of those prescribed.

However, while there were some ATSB best practices identified in the review, the TSB also found that there was some room for improvement, and has made 14 recommendations in the following four areas:

  • Ensuring the consistent application of existing methodologies and processes
  • Improving investigation methodologies and processes where they were found to have deficiencies
  • Improving the oversight and governance of investigations
  • More effectively managing communications challenges

“We have communicated our findings and recommendations to the ATSB for their consideration and action as appropriate,” added Ms. Fox. “Sharing our experiences and expertise is part of our commitment to advancing transportation safety, and when called upon by international partners, the TSB is prepared to assist when feasible.”


The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

For more information, contact:
Transportation Safety Board of Canada
Media Relations
Telephone: 819-994-8053
Email: media@tsb.gc.ca