Departmental Performance Report
This year has been marked by a concern to continue to improve the efficiency of the Transportation Safety Board of Canada (TSB). We have continued to significantly reduce the number of investigations in process and the average time to complete an investigation. These achievements allow us to communicate the gained safety knowledge to Canadians and the international community more rapidly, and to reduce the risks within the transportation system. Our efforts to expand our communications activities were successful. The number of visitors to our website more than doubled over last year.
Although we have not fully achieved all of our objectives stated in the Report on Plans and Priorities, we have made good progress on all of our commitments. In particular, we have started to implement our TSB Investigation Information Management System. That system allows the TSB to meet government information and technology management requirements, while improving the efficiency required to achieve our mandate.
A substantial portion of this work was made possible by the efforts of the management team to ensure a good balance between the resources available and the uptake of new investigations. We therefore ensure that the organization does not overextend itself and that the high quality standards that Canadians expect are maintained in all of our work.
Once again this year, various indicators show that Canada maintains a very good transportation safety record. For example, a review of transportation accident rates over the past 10 years continues to reveal a progressive downward trend. We therefore believe that the efforts of the TSB toward advancing transportation safety, in concert with the work of many other organizations, are having a beneficial impact.
Canadians expect and demand a safe and sound transportation system. 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 - a system upon which everyone can rely and of which they are confident.
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). It operates at arm's length from other government departments and agencies such as Transport Canada, the Department of Fisheries and Oceans, and the National Energy Board to ensure that there are no real or perceived conflicts of interest. Under the legislation, the TSB's only object is the advancement of transportation safety in the federally regulated elements of the marine, pipeline, rail and air transportation systems. This mandate is fulfilled by conducting independent investigations that can include, if necessary, public inquiries into 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. Therefore, recommendations may be made to improve safety and reduce or eliminate risks to people, to property and to the environment. The TSB has the exclusive authority to make findings as to causes and contributing factors when it investigates a transportation occurrence.
A transportation occurrence is any accident or incident associated with the operation of an aircraft, ship, railway rolling stock, or pipeline. It also includes any hazard that could, in the Board's opinion, induce an accident or incident if left unattended.
The jurisdiction of the TSB includes all marine, pipeline, railway or aviation transportation occurrences in or over Canada that fall under federal jurisdiction. The TSB may also represent Canadian interests in foreign investigations of transportation accidents involving Canadian registered, licensed or manufactured ships, railway rolling stock or aircraft. In addition, the TSB carries out some of Canada's obligations related to transportation safety at the International Civil Aviation Organization (ICAO) and the International Maritime Organization (IMO).
I submit, for tabling in Parliament, the 2005-2006 Departmental Performance Report (DPR) for the Transportation Safety Board of Canada.
This document has been prepared based on the reporting principles contained in the Guide for the Preparation of Part III of the 2005-2006 Estimates: Reports on Plans and Priorities and Departmental Performance Reports:
- It adheres to the specific reporting requirements outlined in the Treasury Board Secretariat guidance;
- It is based on the department's approved accountability structure as reflected in the Management, Resources and Results Structure;
- It presents consistent, comprehensive, balanced and reliable information;
- It provides a basis of accountability for the results achieved with the resources and authorities entrusted to it; and
- It reports finances based on approved numbers from the Estimates and the Public Accounts of Canada.
Wendy A. Tadros,
The TSB is primarily funded by Parliament through a program expenditures vote and, as a departmental corporation, it has authority to spend revenues received during the year. The TSB operates within the context of Canada's very large, complex, dynamic and ever-changing transportation system. For more details on the operating context, see the Transport Canada website and the National Energy Board website.
Many individuals and groups cooperate with the TSB in the fulfillment 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 medical examiners, 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 information or support services. More details on the investigation process, on this website.
The TSB is one of many organizations involved in improving transportation safety nationally and internationally. Even if the TSB is operating at arm's length from other federal departments in the transportation field, it cannot achieve its strategic outcome without the cooperation of the other organizations. The TSB presents findings and issues recommendations in such a manner that other organizations feel compelled to act but it has no formal authority to regulate, direct or enforce specific actions. Its success implies ongoing dialogue, information sharing and strategic coordination with organizations such as Transport Canada, the National Energy Board and the Canadian Coast Guard.
The TSB must also continuously be in contact with industry and foreign regulatory organizations, and exchange information with them. Through various means, the TSB must present compelling arguments that will convince these "change agents" to take the necessary action in response to identified safety deficiencies.
The TSB has established memorandums of understanding with other federal government departments for the coordination of activities and the provision of support services. These agreements provide the TSB with access to a range of support services that can rapidly supplement internal resources (for example, assistance in the recovery of a wreckage, the documentation of evidence, and the examination or testing of components). The agreements also define operating practices to ensure good 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 the Department of National Defence, the Royal Canadian Mounted Police, the Canadian Coast Guard, Human Resources and Social Development Canada, and the National Research Council. Similarly, the TSB has established strategic cooperation alliances with provincial and territorial medical examiners and with certain provincial government departments for rail occurrences that fall under their jurisdiction.
Further alliances have been established with the TSB's counterpart agencies in other countries such as the United States, Australia, the Netherlands, New Zealand, 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 one of the world leaders in its field, the TSB regularly shares its investigation techniques, methodologies and tools with other organizations. For example, the Recorder Analysis and Playback System (RAPS), originally developed by the TSB for decoding and analyzing flight data recorders (FDRs) and cockpit voice recorders (CVRs), is now used for safety investigations in more than 10 countries. In cooperation with our partners, we are also pursuing our efforts to develop a vessel movement simulation system based on the information contained in voyage data recorders (VDRs). Similarly, the TSB has contributed to the training of 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 gives information and copies of its reports to sister organizations, and participates in international working 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 achieve its mandate. Rapid technological changes, development of new materials and increasing demands for services with diminishing resources make the task of investigations and safety analysis increasingly complex and challenging. Conscious of the new risks and challenges that could affect its capacity to fulfill its mandate, the TSB evaluates its strategic risks every year and introduces measures to mitigate them. The following paragraphs describe the TSB's most important challenges in 2005-2006.
Managing External Expectations
The TSB has a variety of stakeholders and clients with diverse information needs. Regulators and industry want information in order to fulfill their responsibilities in improving transportation safety. Next-of-kin want information about what happened to their loved ones in order to bring closure. Others want information from a business perspective. However, all agree that they would like safety information to be made available earlier and more effectively. Furthermore, stakeholders and the public would like the TSB to undertake more safety investigations than what is currently done. The TSB is therefore challenged to find the right balance between the level of activity to be undertaken, potential safety findings and the resources available. This implies an ongoing review of products, services and processes to ensure that resources are invested in the best possible way to achieve the optimum results. The TSB must also communicate effectively with its stakeholders and the public in order to convey its priorities and its limited capacity. The TSB must ensure that reasonable expectations are set through appropriate communication.
Maintaining Operational Capability
The success of the TSB and its credibility as an organization depend 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 capital asset infrastructure, 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 backed by adequate financial resources.
Increasing Awareness to Influence Positive Changes
To achieve its mandate and to influence stakeholders to take actions that lead to positive changes in transportation safety, the TSB must present compelling arguments for change in its reports and other communication products. This requires a solid understanding amongst stakeholders and the public about who we are, what we do and how we contribute to transportation safety. We believe that improving awareness about the TSB and its work will better position the TSB to influence key change agents. To that end, the TSB has approved a three-year Communications Plan, which is essentially a road map of how we want to improve communications. The Plan represents a more active approach to publicizing key safety messages to influence positive changes.
Implementing Government-wide Initiatives
Over the past years, the Government has launched a number of government-wide initiatives and reviews that have had, and will continue to have, an impact on the TSB. For example, initiatives such as the proactive disclosure of information on travel and hospitality, position reclassifications and contracts have resulted in new work for the TSB with no additional resources being provided. The series of Government Operations Reviews (for example, shared corporate administrative services, IT services, procurement, institutional governance) has also had a significant impact on workload. As these reviews now come to conclusion and decisions are made, and as the TSB proceeds with the implementation of the required changes, further impacts are expected. The implementation of Human Resources Management Modernization also directly affects TSB resources. The challenge for the TSB is to continue to incorporate these cumulative requirements into daily activities within the resource envelope available, while maintaining a suitable balance between the fulfillment of the TSB's mandate and the implementation of the Government's overall agenda.
Balancing Resources and Results
The TSB, like all other government departments and agencies, must operate with a fixed resource base. Over time, this base is eroded by numerous external factors such as inflation, new service fees and general price increases. The TSB must therefore contend with diminishing resources as time passes. Furthermore, the Government has directed that new requirements be funded through reallocation rather than the provision of incremental funding. This results in a challenge for the TSB to maintain an appropriate balance between the level of operational activity in a context of increasing demand for services and diminishing resources.
For some time now, the TSB has been struggling with the issue of performance measurement. Progress has been made on the development of meaningful performance indicators. However, more work is required in this regard and particularly with respect to linking resources to results. Given that no two investigations are identical, and that some investigations lead to safety changes whereas others do not, it is very difficult to establish the return on investment in safety investigations. The direct and positive impact of TSB investigation activities can be readily demonstrated, but conveying the value for money using traditional financial measures is much more challenging.
The following table summarizes the total financial and human resources allocated to the TSB in 2005-2006, as well as the actual resources utilized for the delivery of the mandate. Section 3 of this report provides detailed information on the overall financial results of the TSB and Annex E provides the audited financial statements.
|Total Financial Resources (in thousands of dollars)|
|Planned Spending||Total Authorities||Actual Spending|
|Total Human Resources (full-time equivalents)|
In 2005-2006, the TSB over-expended approved authorities by $214,000. A part of this amount was used to deploy an investigation team to the site of the passenger ferry Queen of the North that sunk on March 22, 2006 near Prince Rupert, British Columbia.
In its 2005-2006 Report on Plans and Priorities, the TSB identified five priorities aimed at strengthening the organization from within. All were strategic investments to find ways to enhance the TSB's relevance and contribution to transportation safety in Canada and internationally thereby allowing communities to live in a safe and secure environment.
Overall, substantial progress was achieved against all priorities. However, not all objectives were fully achieved, due to our limited human resources capacity and events outside of our control. On many occasions throughout the year, managers were faced with the difficult choice of reallocating people from one project or investigation to another. Despite the challenges, positive results have been achieved and lessons have been learned with respect to project planning and resource allocation. The table below provides a quick overview of the results achieved this year against our priorities.
|TSB Strategic Outcome||To advance transportation safety, thereby reducing risks to people, property and the environment.|
|Alignment to Government of Canada Priorities||Social Affairs: safe and secure communities|
|TSB Priorities||Type||Perfromance Status||Planned Spending (in thousands of dollars)||Actual Spending (in thousands of dollars)|
|1) Continuous Improvement of Products and Services||Ongoing||Meets expectations in part||63||70|
|2) Sustainable Human Resources||Ongoing||Meets all expectations||210||227|
|3) Organizational Continuous Improvement Process||Previously Committed||Meets expectations in part||553||589|
|4) Awareness of the TSB and its Activities||Previously Committed||Meets expectations in part||75||71|
|5) Developing Partnerships||New||Meets expectations in part||85||69|
Continuous Improvement of Products and Services
The TSB had committed to pursuing the implementation of changes to its range of products and services, namely by implementing the TSB Investigation Information Management System. This system was designed to benefit from knowledge, skills and abilities, to eliminate disparities in processes and systems, and to provide employees with an integrated central repository of essential tools and information.
This year, we tested almost all the components in the Reference Centre of this system, whose purpose is to collect in one place all the policies, guides and other reference tools that employees need to do their work. Investigation teams also tested the modules containing the main tools they need to manage and conduct investigations into transportation occurrences. However, implementation of these modules was delayed because of staff turnover within the project team.
Sustainable Human Resources
The TSB continued to put sustained emphasis on the strategic management of human resources to ensure that it recruited competent, devoted employees who remained with the organization, while offering a workplace atmosphere that promoted learning and professional development for all. The following observations contained in the Final Report on the Safety Oversight Audit of the Civil Aviation System of Canada1 show that the efforts were successful: "The TSB has established adequate qualification criteria for the recruitment of its investigators and has full control over the recruitment of its personnel. Investigators are provided with the appropriate initial, recurrent and specialized training as may be deemed necessary to acquire and maintain the level of expertise required." These results are also corroborated by the TSB results to the 2005 Public Service Employee Survey, where 83 per cent of respondents said that they believed that, in their work unit, people were hired who could do the job, and 74 per cent said that they got the training they needed to do their job. The competency of the TSB's employees and the quality of their investigation reports and safety communications were also recognized last March by the International Aeronautical Federation. The federation gave an award to TSB investigators for their contribution to the multidisciplinary and complex international investigation into the Swissair Flight 111 accident off the coast of Nova Scotia on September 2, 1998.
The TSB also met all requirements of the Public Service Modernization Act (PSMA) on time. The TSB first developed and implemented a communications and training strategy on the PSMA for employees and managers, and set up monitoring mechanisms. It also developed and implemented the prescribed policies, processes and guidelines, and initiated consultations with unions, employees and managers.
Organizational Continuous Improvement Process
For the past few years, the TSB has made significant progress to become a better-managed, more innovative organization. In the last year, the TSB completed an important step in its continuous improvement process by implementing certain key components of its new TSB Investigation Information Management System, as mentioned above. Management also developed different measures to mitigate the risks associated with this project and to ensure its success, which included increasing employee awareness of the project through communication and training. In addition, the TSB undertook to integrate risk management more closely into management decision making. A departmental risk profile was developed to use as a point of reference in this respect.
Awareness of the TSB and its Activities
Over the past few years, the TSB has undertaken a number of communications initiatives to enhance the visibility of the organization and its programs among the public and stakeholders. The TSB must nevertheless manage its communications resources carefully and focus on activities that offer the greatest potential with respect to results. This year, it dedicated its resources to developing a video to promote its role and activities and the way it contributes to improving transportation safety. Sustained efforts to increase the amount of information available to the public on its website also helped to more than double the number of visitors to the site compared to the previous year.
Sustained efforts regarding internal communications were also introduced to ensure that all employees were fully up to date on TSB products and services and the results achieved for Canadians. The TSB stood out from the Public Service as a whole in this respect, since 90 per cent of TSB respondents in the 2005 Public Service Employee Survey said that they could clearly explain to others the direction of their organization. The percentage for the Public Service of Canada as a whole was 73 per cent.
The TSB cooperates with many other agencies in the course of its operational and administrative activities. In the context of an evolving environment, and in order to optimize its limited resources and fulfill its mandate efficiently, the TSB conducted a study to explore these partnerships from a strategic angle.
The study allowed it to explore which of its activities could benefit from a partnership approach. It also examined means for managing the risks that such partnerships could present, in light of potential obstacles such as the need to remain independent and avoid conflicts of interest. Finally, the policy and guidelines for establishing the partnerships that were proposed at the end of the study are currently under review by management in preparation for imminent implementation.
The TSB has developed and implemented an integrated performance management framework. This 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 Scorecard 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 2005-2006 Report on Plans and Priorities, the TSB had only one strategic result and one program activity. The five priorities mentioned in the first section of this document are aimed at supporting and enhancing the TBS's ability to conduct safety investigations and to communicate safety information.
In order to optimize the use of resources and to effectively respond to its stakeholders, the TSB has defined four key service areas based on the four transportation modes included in its mandate: marine, pipeline, rail and air. This approach enables alignment with the transportation industry and the way it operates.
Resources are therefore allocated and managed separately for each of these key service areas. Table 3 below shows information on planned and actual spending on financial and human resources for the key service areas in 2005-2006. Sections 2.7 to 2.10 provide detailed financial information on each key service area of our program activity.
|Financial Resources (in thousands of dollars)|
|Planned Spending||Actual Spending|
|Human Resources (FTE)|
The TSB developed a balanced scorecard to track its performance and the progress accomplished regarding its strategic objective, and thereby demonstrate the usefulness of its program for Canadians. The scorecard provides information on the organization's performance according to four perspectives: financial, clients and stakeholders, internal business processes, and learning and growth, and links them with the priorities for the current year.
In fiscal year 2005-2006, the TSB continued its process to acquire a structured approach to measure its performance. However, it should be mentioned that progress with respect to performance measurement was more limited this year because of key staff turnover within the Corporate Services team. The table below illustrates the existing linkages between its strategic objective, program activity and the results that can be expected by Canadians, as well as its performance indicators. The TSB does not report on all of its performance indicators because some baseline data are not yet available.
Most of the data used in this report comes from TSB information systems, supplemented by Transport Canada information where appropriate. Anecdotal evidence that illustrates the performance assessment was obtained from various sources such as stakeholder feedback, magazine articles, press clippings, individual testimonials, survey results and audit reports. Where sources of information external to the TSB are used, they are identified.
In 2005, a total of 2,037 accidents and 1,371 incidents were reported in accordance with the TSB's regulations for mandatory reporting of occurrences.2 The number of accidents in 2005 increased by 5 per cent from both the 1,945 accidents reported in 2004 and the 2000-2004 annual average of 1,946 accidents. The number of reported incidents decreased to 1,371 in 2005, down from 1,483 in 2004 and the 2000-2004 average of 1,414. There were also 615 voluntary incident reports. Fatalities totalled 189 in 2005, up 3 from the 2004 total but equal to the 2000-2004 average.
Table 4 presents data on accident rates by mode for the current year, as well as the five-year average. Even if these rates are based on limited data, activity level indicators provide a general point of reference on transportation safety. Overall, Canada continued to maintain a good safety record in 2005. The 2005 accident rates, per activity level for all modes, reflect a downward trend from the five-year average.
Table 4: Accident Rates in Transportation by Mode in 2005 Compared to the Previous Five-Year Average (2000-2004)
1 Canadian-flag shipping accidents for vessels of 15 grt or more (excluding passenger vessels, passenger ferries and fishing vessels) per 1,000 movements.
2 Per exajoule.
3 Accidents (other than crossing or trespasser accidents) that occur on a main track or spur per million main-track train-miles. Since April 1, 2005, the accidents that occurred on former BC Rail's network are included.
4 Canadian-registered aircraft accidents (excluding ultralights, gliders, balloons and gyrocopters) per 100,000 hours.
Reported accidents and incidents provide indicators of the transportation system's safety performance and help focus efforts on those initiatives and activities that have high safety benefits. Table 5 presents the statistics on transportation occurrences by mode, including comparisons with the five-year average. Taking into account the level of activity in each mode, the number of accidents for 2005 continued to exhibit a general downward trend in the marine, pipeline and air modes. However, an increase of 18.1 per cent in the number of rail accidents from the previous five-year average is observed. Another indicator of the safety performance of the transportation system is the number of fatalities. In 2005, the air and marine modes showed a decrease in fatalities compared to the five-year average. However, there was a 10.8 per cent increase in the number of fatalities in the rail mode over the previous five-year average. A reduction in accidents and fatalities would be expected to positively influence the public's confidence in the safety of the transportation system.
Table 5: Transportation Occurrences by Mode in 2005 Compared to the Previous Five-Year Average (2000-2004)
*Since April 1, 2005, occurrences on the former BC Rail's network are included in the number of occurrences.
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 figures for each mode in sections 2.7 to 2.10). Therefore, Canada has one of the safest transportation system in the world and continues to work diligently to further improve it. These improvements in transportation safety are the result of the combined efforts of many stakeholders including manufacturers, carriers, crews, regulators, and the TSB. All these efforts are also reflected in the results of a survey conducted by EKOS in March 2005 where 95 per cent of those Canadians who had an opinion on the subject have rated the air, rail and marine transportation modes as moderately or very safe and secure.3 More comprehensive information is available on the TSB website or in Chapter 4 of the Transportation in Canada 2005: Annual Report published by Transport Canada.
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 78 of the approximately 4,000 occurrences reported to the TSB in fiscal year 2005-2006. In that same period, 75 investigations were completed, compared to 115 in the previous year.4 This result can be attributed partly to the fact that the TSB was investigating major occurrences that required a high degree of effort and tight management of resources. It was nonetheless offset by the fact that smaller investigations were completed more rapidly.
The number of investigations in process increased to 105 at the end of this fiscal year from 102 at the start. Of the 105 investigations in progress at year end, 7 were more than two years old, 33 were between one and two years old and 65 were less than one year old. The average time to complete an investigation decreased to 464 days in 2005-2006 from 619 days in the previous year because of the TSB's continuous effort to improve its efficiency.
|Average duration of completed investigations (Number of Days)||881||651||1,081||922||618||519||524||404||619||464|
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.
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 2005-2006, in addition to investigation reports, the TSB issued a total of 55 safety outputs: 12 recommendations, 21 safety advisories and 22 safety information letters (see Table 7 for a breakdown by mode).
|Mode||Recommendations||Safety Advisories||Safety Information Letters|
Note: In 2005-2006, a total of 12 marine safety concerns, 1 rail safety concern and 2 air safety concerns were identified.
These outputs led to concrete actions by other organizations that directly improved safety and/or reduced risks. For example, Transport Canada submitted an information paper on incident prevention to the International Maritime Organization, worked with a manufacturer to improve the safety of its products, revised one of its training programs, amended a Management, Operation and Maintenance Agreement with a corporation to ensure an appropriate emergency response, issued alert bulletins to inform industry about specific safety concerns, and introduced changes to safety regulations and procedures. Similarly, industry has reacted to the TSB's work by undertaking numerous safety actions such as changes in operating practices and procedures, preventive modifications to equipment, replacement of parts, and the modification of training programs. Sections 2.7, 2.9 and 2.10 provide specific examples of such safety actions that were taken during 2005-2006.
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 started 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 2005-2006||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|
* includes recommendation M02-04, which was issued in 2002-2003
The TSB continues to promote awareness of safety issues and of a safety culture among transportation stakeholders. Every opportunity is taken to reiterate key messages and create awareness of safety issues. In 2005-2006, the TSB published 75 investigation reports, as well as monthly and annual statistical reports. One issue of the Reflexions safety digest was published during fiscal year 2005-2006. This digest contributes to the advancement of transportation safety by reflecting on the safety lessons learned from accident and incident investigations. It also provides an effective tool to disseminate the results of safety investigations to a broader audience
The TSB maintains 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 2005-2006, it had 1,434 subscribers to its website, it responded to 1,284 information requests received through its website and 431 media calls, not including those inquiries handled at an accident site or at a report release news conference. The TSB attended 8 outreach events, held 3 news conferences and issued 46 news releases. The TSB's Macro-analysis Division responded to 593 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 86,700 daily hits and 4,870 daily visits, a 112 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.
As part of the TSB's efforts to keep abreast of technological change and to maintain contact with the transportation industry in Canada, TSB staff and Board members attend and participate in various conferences and technical meetings pertinent to transportation safety. A list of these activities is presented in Appendix A.
The TSB's mandate is to advance transportation safety, not only in Canada, but worldwide. This cooperation comes in many forms, through participation in safety symposiums, international safety organizations and international investigations. A list of these activities is presented in Appendix B.
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.
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