Reassessments of outstanding safety recommendations highlight both progress and continued need for action
Gatineau, Quebec, 13 May 2021 — The Transportation Safety Board of Canada (TSB) released its annual reassessment of responses to 62 of its outstanding safety recommendations in the aviation, marine, and rail sectors. There are currently no outstanding recommendations in the pipeline sector.
These reassessments show some progress across Canada’s transportation system with responses to 12 recommendations receiving the highest rating of Fully Satisfactory: five in aviation, four in marine and three in rail. This brings the total of TSB recommendations assessed as Fully Satisfactory to 84.5%, up from 82.9% in 2020.
However, there has been minimal movement on some key safety issues across all three sectors, which continues to raise concerns from the Board.
“Each year, the TSB reassesses outstanding recommendations as part of its ongoing efforts to urge industry and regulators to address systemic problems that pose a serious safety risk to Canada’s transportation system”, explains Chair Kathy Fox. “We want to see change agents, especially regulators, take action on the safety issues identified in our investigations.”
Canada’s aviation sector showed improvement, with 57% of the reassessed recommendations receiving one of the two highest ratings of Fully Satisfactory or Satisfactory Intent. Of the five aviation recommendations that were closed as Fully Satisfactory in 2021, four were issued in 2016 as part of TSB investigation A13H0001 into the fatal crash of a Sikorsky S-76A helicopter in Moosonee, Ontario. These four recommendations all touch on issues related to emergency locator transmitters.
However, the Board believes that additional actions are required in response to some recommendations. Among those are Recommendation A13-03, which calls for Transport Canada (TC) to require that all seaplanes in commercial service certificated for nine or fewer passengers be fitted with seatbelts that include shoulder harnesses on all passenger seats; and Recommendation A15-02, calling on TC to work with industry to develop age- and size-appropriate child restraint systems for infants and young children travelling on commercial aircraft, and mandate their use to provide an equivalent level of safety compared to adults.
Some progress was also seen in Canada’s marine sector, with almost 20% of active recommendations being closed as Fully Satisfactory, and 33% receiving the second highest rating of Satisfactory Intent. Through safety actions taken on those recommendations, progress was made on various issues such as passage planning for pilotage authorities, mandating of the carriage of anti-exposure worksuits, and having a means to automatically alert the search and rescue system in the event of an emergency for small vessels, including fishing vessels.
However, Transport Canada’s response to commercial fishing safety Recommendation M16-03 related to stability requirements for small fishing vessels indicates that the department is proposing a voluntary approach which, the Board is concerned, will not fully address the identified safety deficiency. Therefore, the response to this recommendation was reassessed as Unsatisfactory. The Board believes that significant safety risks associated with the fishing industry remain, including a lack of education about stability requirements for smaller vessels and enforcement of these requirements. Commercial Fishing Safety has been an issue on the TSB Watchlist since its inception in 2010.
As for Canada’s rail sector, 23% of the recommendations reassessed in 2021 received a rating of Fully Satisfactory, including one that pertained to locomotive data recorders standards and that had been outstanding for over 17 years. None of the active recommendations were reassessed as Unsatisfactory for the seventh year in a row.
Nonetheless, the Board expressed some concerns reassessing the response to Recommendation R13-01, which touches on physical fail-safe train controls and is related to the TSB Watchlist 2020 key safety issue of following railway signal indications. The Board is very concerned that there are still no specific strategies or timelines in place to address the risk of train collision or derailment in the absence of additional backup safety defences.
“Over the next year, the Board will continue to carefully examine the persistent and longstanding safety deficiencies that support these active recommendations”, concludes Chair Fox. “We will keep pushing for concrete and timely safety actions where needed.”
The TSB is an independent agency that investigates air, marine, pipeline, and rail 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