News release

TSB annual assessment of outstanding safety recommendations: more timely action needed to address key safety issues

Gatineau, Quebec, 13 June 2023 — Today, the Transportation Safety Board of Canada (TSB) released its annual assessment of responses to 62 of its outstanding safety recommendations in the air, marine, and rail transportation sectors. There are currently no outstanding recommendations in the pipeline transportation sector.

These assessments indicate that some progress has been made across Canada’s transportation system, with the responses to four recommendations receiving the highest rating of Fully Satisfactory: three in the air transportation sector and the fourth in the rail transportation sector. However, there has been minimal movement on some key safety issues across all three sectors, which continues to raise concerns by the Board.

The TSB issues safety recommendations as a call to industry and regulators to address systemic problems that pose a serious safety risk to Canada’s transportation system. Each year, the TSB assesses progress on outstanding recommendations as part of its ongoing efforts to urge the regulators or industry to act on the safety issues identified in TSB investigations.

This exercise brings the total of responses to TSB recommendations assessed as Fully Satisfactory to 83.5%. As of March 31, 2023, 87 recommendations remain outstanding, less than half of which date from 10 years ago or more, including nine new recommendations issued in the 2022-23 fiscal year.

Air transportation sector

In the air transportation sector, among the 30 recommendations assessed, three that dated back to the TSB’s investigation into the Swissair 111 accident near Peggy’s Cove, Nova Scotia, almost 25 years ago (A98H0003) are now closed.

Recommendation A00-19 related to deficiencies regarding in-flight odour/smoke checklists. In the time since this recommendation was issued, many actions have been taken by Transport Canada and industry that should assist flight crews in optimizing their response to conditions of smoke, fire, or fume events of unknown origin, and thus reduce the risk of an in-flight fire being ignited or sustained.

Recommendation A01-03 related to material flammability test requirements for aircraft wiring. Transport Canada and the United States Federal Aviation Administration have taken action to mandate a certification test regime that evaluates aircraft electrical wire failure characteristics under realistic operating conditions, with the goal of mitigating the risk of ignition.

Recommendation A01-04 related to evaluating all aircraft systems in the pressurized portion of an aircraft to ensure that systems whose failure could exacerbate a fire in progress are designed to mitigate the risk of fire-induced failures. Many regulatory and industry actions have been taken over the years that have addressed the safety deficiencies identified in this and other TSB recommendations issued as part of the Swissair investigation.

Despite these successes, some recommendations related to TSB Watchlist 2022 continue to be active. Recommendation A16-12 called for all commercial air operators to be required to have a formal safety management system. While a policy review is underway at Transport Canada, it is unclear whether it will address the safety deficiency identified in the recommendation. Therefore, the Board considers the response to Recommendation A16-12 to be Satisfactory in Part.

The issue of runway overruns is also on TSB Watchlist 2022 and is the subject of Recommendation A07-06. The Board is encouraged to see that activity to meet the International Civil Aviation Organization’s (ICAO’s) 150 m runway end safety area (RESA) standard has begun at some airports. However, the Board is not convinced that the residual risk at airports with runways not required to comply with ICAO’s standard is as low as reasonably practicable. Therefore, the Board considers the response to Recommendation A07-06 to be Satisfactory in Part.

Marine transportation sector

In Canada’s marine transportation sector, 18 marine recommendations were assessed, though none were closed as Fully Satisfactory.

Several fishing vessel recommendations remain active. Transport Canada is taking too much time to complete the Fishing Vessel Safety Regulations, where only 1 of 3 phases of regulatory development are complete. The updated regulations are to include requirements such as structural suitability standards for vessels operating in ice (M08-04), stability information on large fishing vessels (M16-01), and the mandatory use of personal flotation devices (M16-05), but there is no target date for the final completion of the regulations. Additionally, the TSB is disappointed that not all small fishing vessels will be required to have a stability assessment (M16-03). Until these long-standing safety deficiencies are addressed, the lives of fish harvesters will continue to be at risk.

Rail transportation sector

As for the rail transportation sector, 14 rail recommendations were assessed in the 2022-23 fiscal year.

The response to recommendation R14-01 from the Lac-Mégantic investigation (R13D0054) – which called for enhanced protection standards for tank cars carrying flammable liquids – was assessed as Fully Satisfactory and closed. Given the significant improvements to the tank car standards and the performance seen to date, the Board considers that the risk of product loss when Class 117 tank cars transporting flammable liquids cars are involved in accidents has been reduced.