Disclosure of internal audits 2006-2007

TSB Management Response and Action Plan Value For Money Internal Audit Field Phase of the Air France Accident Investigation January 2007

TSB management accepts the findings of this audit and generally agrees with the recommendations made by auditors. The detailed management responses and action plans are described in the following tables.

Recommendation 1 The Director General Investigation Operations should:

a) put a process in place to ensure that new investigators, who receive their certificate of appointment on their first day of employment, are informed that the certificate does not entitle them to exercise the powers of an investigator until they have been so authorized, as specified in MOI Volume 1; and

b) review the validity of the process described in MOI Volumes and ensure its implementation once validated or updated.
Management Response Management agrees with the importance of having a clear process in place and that the approved process must be effectively implemented.
Actions Planned 1. A coordinated review of Manual of Investigation Operations, Volume 1, Section 3.8 will be conducted to ensure the adequacy of the guidance contained in these manuals.

2. In the interim, a memo regarding the provisions will be sent out to all managers, reminding them of the requirements, as well as to the need to inform new investigators regarding any limitations.

3. Training and/or information regarding the use of investigator powers specified in the CTAISB Act will also be provided to all new staff that may be required to exercise the powers of a TSB investigator.
Persons Responsible Director General, Investigation Operations
Timeline 1. Completed by February 28, 2008

2. Completed by February 28, 2008

3. Completed by March 31, 2008

Recommendation 2 The Director of Investigation with the assistance from the Director General, Corporate Services should:

a) issue instructions to all divisions of TSB to the effect that all costs incurred to be charged to the investigation budget must be pre-authorized by the IIC or DOI who have delegated financial authority under section 34 of the FAA for a distinct major investigation responsibility centre budget;

b) ensure that Financial Officers exercising payment authority under section 33 are knowledgeable of the name of officers who have been given financial authority under section 34 for major investigations assigned with a distinct responsibility centre; and,

c) establish clear procedures on what type of indirect costs can be charged to an investigation's budget and disseminate such procedures to those who need to know.
Management Response Management agrees with the need for clear guidance in this area.
Actions Planned 1. Finance will develop and issue clear guidance on this problem area.
Persons Responsible Director General, Corporate Services
Timeline 1. Completed by March 31, 2008

Recommendation 3 The Director of Investigation and the Director General of Corporate Services should agree on the supporting role to be played by the Corporate Services Directorate as part of a major investigation in order to relieve the investigation team from spending too much time on budgeting and recording of transactions, allowing the IIC and Deputy IIC to concentrate on managing efficiently the investigation.
Management Response Management agrees to undertake a review of the relevant documentation and training programs to determine if any adjustments are required.
Actions Planned 1. A coordinated review of Manual of Investigation Operations, Volume 1, Section 6 and the Air Branch Major Occurrence Investigation Checklist, Section 8 will be conducted to ensure the adequacy of the guidance contained in these manuals.

2. Manuals and checklists will be amended where required.

3. The adequacy of training for investigation team administrative officers and Investigators-in-charge will also be reviewed.

4. Corporate Services will establish a standard protocol to facilitate the provision of functional support services for major investigations.
Persons Responsible Director, Air Investigations
Director General, Corporate Services
Timeline 1. Completed by March 31, 2008

2. Completed by March 31, 2008

3. Completed by November 30, 2008

4. Completed by November 30, 2008

Recommendation 4 The Director General of Corporate Services should develop an investigation budget template that would be included in the MOIC and become part of the Go Kit of the Administrative Support Group and provide training to those expected to play a role in the development of major investigation's budget.
Management Response Management agrees with the benefits of providing budget templates and will take appropriate actions in this regard.
Actions Planned 1. The recent update to the Air Branch Major Occurrence Investigation Checklist, Section 8 contains an example spreadsheet, as well as preliminary guidance on its use.

2. Finance will develop appropriate budget templates and related guidance material and make them available to all investigation branches.

3. The adequacy of training on major investigation budget preparation for administrative officers and investigators-in-charge will be reviewed.
Persons Responsible Director General, Corporate Services
Director, Air Investigations
Timeline 1. Completed by January 8, 2007

2. Completed by November 30, 2008

3. Completed by November 30, 2008

Recommendation 5 The Director General of Investigation Operations should document a policy that would provide guidance with respect to overtime worked by the various participants during the field phase of an investigation as well as during subsequent phases. These guidelines should aim at striking a balance between the need to work rapidly to collect the necessary evidences before they naturally disappear while also exercise a greater control of overtime and limit the risk to the health and safety of participants during the field phase of the investigation.
Management Response Management recognizes the importance of good management of overtime and agrees to review the guidance provided to investigators-in-charge and managers.
Actions Planned 1. As a first measure, additional guidance on the management and monitoring of work hours and overtime has been incorporated into the investigator-in-charge Section 2 of the Air Branch Major Occurrence Investigation Checklist.

2. A coordinated review of Manual of Investigation Operations, Volume 1, Section 5 and the Air Branch Major Occurrence Investigation Checklist, Section 8 will be conducted to review the adequacy of the guidance on the management and monitoring of overtime during investigation operations, in particular from the occupational safety and health perspective.

3. Similar guidance will be included in the Manual of Investigation Operations, Volume 2, Part IV, Section 2.

4. Enhanced guidance will be published in the appropriate multimodal manuals.

5. All investigators will be made aware of the revised guidelines.
Persons Responsible Director General, Investigation Operations
Timeline 1. Completed by January 8, 2007

2. Completed by March 31, 2008

3. Completed by June 30, 2008

4. Completed by March 31, 2008

5. Completed by March 31, 2008

Recommendation 6 The Director General of Corporate Services should develop an overtime report that would be used by management to assess and oversee the use of overtime generally as well as during investigations.
Management Response Management agrees with the need for effective monitoring and management of overtime.
Actions Planned 1. Finance will consult managers and administrative officers to determine their information needs for the management of overtime and then determine the appropriate course of action to be taken.
Persons Responsible Director General, Corporate Services
Timeline 1. Completed by November 30, 2008

Recommendation 7 The Director of Investigation should review the minimum criteria for the selection of accommodation that will house a temporary Operations Centre during the field phase of an investigation. Such criteria should now include the availability of high speed internet and proper security features for the Operations room. Once documented, the criteria should be disseminated to those tasked with selecting accommodation and those tasked with ensuring the security of the Operations Centre during the field phase.
Management Response Existing documentation already covers the selection of appropriate accommodation.
Actions Planned 1. Although the existing documentation covers the requirements to obtain appropriate accommodation and tools to meet the requirements of the investigation at hand, the Air Branch Major Occurrence Investigation Checklist will be modified to emphasize security arrangements.
Persons Responsible Director, Air Investigations
Timeline 1. Completed by January 8, 2007

Recommendation 8 The Co-Chairs of the TSB National Occupational Safety and Health Policy Committee should ensure completion of the studies undertaken as part of the follow-up actions to the nine issues identified at the special joint committee meeting held subsequent to the Air France accident investigation.
Management Response Management agrees that follow-up should be completed on all nine issues identified.
Actions Planned 1. The Air Branch Major Occurrence Investigation Checklist has been amended to clearly separate the responsibilities for Site Manager, Site Safety Manager and Site Survey Group Chair. Included in this amendment are clear procedures for formalizing and documenting site handovers, site security and control; for conducting site safety surveys; and for ensuring OSH standards are followed.

2. These new procedures as well as other actions taken by the PPE Subcommittee are being evaluated by the National OSH Policy Committee.

3. Follow-up Action Plans will be formulated and implemented where required.
Persons Responsible Director General, Corporate Services
Timeline 1. Completed by January 8, 2007

2. Completed by March 31, 2008

3. Completed by December 31, 2008

Recommendation 9 The Director of Investigations should ensure that the corrective measures recommended by the National OSH Policy Committee are reflected in the MOIC and implemented during investigations.
Management Response Management agrees that the corrective measures should be implemented.
Actions Planned 1. An evaluation of the Recommended Measures was conducted and the Air Branch Major Occurrence Investigation Checklist has been amended to clearly separate the responsibilities for Site Manager, Site Safety Manager and Site Survey Group Chair. Included in this amendment are clear procedures for formalizing and documenting site handovers (Recommended Measure 3), site security and control (Recommended Measure 2), and for conducting site safety surveys, and for ensuring OSH standards are followed (Recommended Measure 5).
Persons Responsible Director, Air Investigations
Timeline 1. Completed by January 8, 2007

Recommendation 10 The three Directors of Investigation working with Human Resources should:

a) identify the skill sets required of administration officer who participate in a major accident investigation deployment and ensure that new administrative officers recruited possess the required skills;

b) formalize the training for administrative officers to include the tasks required from an administrative officer during a major investigation including how to cope with the pressure of the work during these periods; and

c) develop a list of administrative officers having the required skills and training required during a major investigation deployment and field phases.
Management Response Management agrees with the need to formally define work expectations, required competencies and training requirements for administrative officers who are expected to provide support services for major accident investigations.
Actions Planned 1. A list of administrative officers expected to support a major investigation has been established.

2. The existing work descriptions for administrative officers will be reviewed and work expectations will be clearly defined for administrative officers expected to support major investigation teams.

3. Familiarization training for all TSB administrative officers on the unique administration support factors for major occurrence investigations was conducted in October 2006. More detailed training will be developed and provided once the updated work descriptions are developed.
Persons Responsible Director General, Corporate Services
Directors of Investigations
Timeline 1. Completed by January 8, 2007

2. Completed by October 31, 2008

3. Completed by December 31, 2008

Recommendation 11 The Director of Investigation should review the MOIC to identify that one administrative officer is the Group Chairperson.
Management Response The Air Branch Major Occurrence Investigation Checklist, Section 8 clearly and unambiguously establishes the Investigation Team Administrative Officer as being in charge of the administration support to the investigation team. There are no changes required to the documentation.
Actions Planned 1. Appropriate training will be provided to administrative officers expected to support major investigations to ensure they are familiar with roles and responsibilities.
Persons Responsible Director, Air Investigations
Timeline 1. Completed by June 30, 2008

Recommendation 12 The Director of Investigation should review practices for sending the automated update to the policies and checklists to include investigators from other supporting groups such as engineers; human performance; macro analysis and publishing and languages services.
Management Response All investigation policies, standards and checklists are currently available in the TSB "Reference Centre" for the use of all personnel when they are at their normal workstations. In addition, the Administration Go-Kit also contains a disk with these documents.
Actions Planned 1. The computer hard drives of the investigators in the Human Performance Division and the Engineering Branch have been added to the Air Branch automatic distribution list.
Persons Responsible Director, Air Investigations
Timeline 1. Completed by January 8, 2007

Recommendation 13 The Director of Investigation and the Chief of Investigation Operations should aim at completing and disseminating the MOI Team List on a timely basis so that investigators can always be ready should a major accident occur.
Management Response TSB reviewed the purpose, content, and currency of the Air Branch, Major Occurrence Investigation Team list. The results of this review indicated that:

. For the positions, wherein the individuals would be required to conduct duties that are not normally part of their day-to-day responsibilities, specific names are required on the list to ensure that these individuals are adequately prepared for these additional responsibilities.

. For the positions, wherein the individuals would only be expected to perform their normal duties, the list contains either the TBD (to be determined) designation, the name of the TSB manager responsible for the technical expertise area, or the name of the point-of-contact for a particular support function.
Actions Planned 1. The purpose of and revision schedule for the Air Branch, Major Occurrence Investigation Team list has been documented in the Air Branch, Major Occurrence Investigation Checklist, Section 1 as well as on the team list.
Persons Responsible Director, Air Investigations
Timeline 1. Completed by January 8, 2007

Recommendation 14 Based on data collection requirements defined in TSB MOI Volume 2-4, Chapter 1, the Director of Investigation together with experienced IICs and Managers of Regional Operations should review the established procedures to ensure that group reports are produced on time and prior to the initial draft investigation report being completed. These procedures should then be included in the MOIC.
Management Response A review of the procedures related to the production and submission of Engineering Branch and Group Reports was conducted and the existing standards and guidelines were assessed to be adequate. Although it is desirable to have Group Reports and Engineering Branch Reports completed as soon as possible, due to extenuating circumstances, finishing all such reports before the IIC starts to write the initial draft report is not always possible. In such situations, the IIC has other documented options for acquiring the information necessary to complete the initial draft. Imposing a mandatory requirement such as recommended would result in significant delays in producing the initial draft report, in particular for major investigations.
Actions Planned No further actions are planned on this item.
Persons Responsible Director, Air Investigations
Director, Engineering
Timeline N/A

Recommendation 15a The Director of Investigation together with experienced IICs should:

a) review if a feedback process should not be carried out when less significant investigations are carried out;
Management Response A review was conducted of the procedures related to the conduct of investigations, specifically MOI Volume 2-4, Section 2. Although a specific requirement and procedures exist for wrap-up meetings, for large-team investigations, a documented formal process does not exist for smaller investigations for a number of reasons. As documented, it is the IIC's responsibility to manage the investigation including the responsibility for determining the cause(s) of problems, and resolving them. The managers of IICs also share in this responsibility. Experience has shown that this approach is effective and efficient for identifying and resolving problems encountered on smaller investigations. Many of the changes to our manual/procedures result from this approach. Notwithstanding, it is the DOI's decision, based on the IIC's, managers', and other's advice, whether a formal wrap-up meeting is required, and the DOI can call for such a meeting if special circumstances exist.
Actions Planned No further actions are planned on this item.
Persons Responsible Director, Air Investigations
Timeline N/A

Recommendation 15b The Director of Investigation together with experienced IICs should:

b) ensure that performance evaluation of each group chairperson takes place during the post field phase to be in compliance with the MOIC.
Management Response A review was conducted of the procedures related to the assessments of the performance of investigation team members, as contained in MOI Volume 2-4, Section 2 and the Air Branch Major Occurrence Investigation Checklist, Section 2. Although this section specifies that the IIC is to "Complete a performance evaluation report for each group chairperson", the intent of this evaluation was to provide the individual with the appropriate feedback, as well as to provide the individual's responsible manager with performance information for the annual appraisal. Notwithstanding, formal written appraisals would only be prepared when the individual worked for the IIC full time over an extended timeframe.
Actions Planned 1. The Air Branch Major Occurrence Investigation Checklist will be updated to provide more specific guidance as to when such evaluations are to be done and as to the options for fulfilling this requirement.
Persons Responsible Director, Air Investigations
Timeline 1. Completed by June 30, 2008

Recommendation 16 The DGIO and DOI should review all observations and recommendations to determine their applicability to other modes and take appropriate action as required.
Management Response The Director, Marine Investigations and the Director, Rail/Pipeline Investigations are participating in the work being done to address the audit recommendations. Consequently, they will be well informed and able to benefit from the lessons learned further to the audit.
Actions Planned 1. Multimodal standards and procedures will be developed / modified as required.

2. Marine and Rail/Pipeline checklists will be reviewed and updated as required.
Persons Responsible Director General, Investigation Operations
Director, Marine Investigations
Director, Rail/Pipeline Investigations
Timeline 1. Completed by December 31, 2008

2. Completed by December 31, 2008