Notes for remarks by
Mr. Charles Simpson
Board Member of the Transportation Safety Board of Canada
To the Air Line Pilots Association - Air Safety Forum
Washington, D.C., U.S.A.
August 21, 2003
Good morning. It's a great pleasure to be here, and speak on behalf of the Transportation Safety Board of Canada.
(Express regrets from the Chairman)
It's been said that leadership and learning are indispensable to each other.1 That's what makes this annual conference an exciting place to be. The annual ALPA Air Safety Forum brings together the best and brightest ... to share information and ideas ... all with the aim of building a safer future in aviation.
The TSB is also an exciting place to be. This year marked the conclusion of the Swissair Flight 111 investigation - the most complex and exhaustive investigation ever conducted by our organization. In fact, one of the most complex conducted by any organization.
It was a tragic air disaster, but some good has resulted from our investigation. In total, 23 Aviation Safety Recommendations were made.
I'm proud to say that many improved safety measures are now in effect, such as the upgrading of flammability standards of aircraft materials and in-flight firefighting procedures. And, of special interest to pilots, are the proposed rule changes affecting CVR and FVR independent power sources and recording times.
These positive outcomes are a great tribute to those who were involved, including the Accident Investigation Board of ALPA.
I want to take a moment to recognize ALPA's important contributions to the Swissair investigation, and to express our appreciation. By doing so, I'll introduce a central theme to the future of transportation safety: that being, the need for stakeholders to form closer working partnerships across the safety mosaic.
Your team played a substantial role - especially during the first, critical months of this investigation.
That's when the ALPA team helped sort through and categorize millions of pieces of the shattered aircraft. We eventually recovered 98 per cent of the aircraft from the ocean floor.
Many of the ALPA and IFALPA team who participated in this endeavour were honoured at this conference two years ago.
It was a tough job. But your contribution of expertise enabled us to identify failure modes, and validate facts that helped us direct the focus of the investigation.
Your insights allowed us to develop a better understanding of what the pilots must have faced on this tragic flight.
All of these contributions helped make it possible for us to conduct a detailed investigation ... one that uncovered a wide range of systems, operational and human factors that needed to be addressed to enhance aviation safety.
ALPA made an important investment. And I'm confident that your members, stakeholders and the travelling public will reap benefits from it for a long time to come. We're grateful for your contributions.
Your work on Swissair is a perfect example of what can be accomplished when teams work together to conduct an investigation. And it speaks to this central theme about the future of transportation safety.
Detailed investigations demand closer working partnerships among investigative bodies, and other stakeholders.
Simply put: it's the best way lead investigators can access the expertise and information required to answer the three toughest questions of every occurrence:
- what happened?
- why did it happen? and,
- how can we avoid it happening again?
We need more partnerships like the ones formed during the Swissair Flight 111 investigation.
That's because globalization has come of age. And that means transportation transcends international boundaries ... lessons learned in one jurisdiction must be lessons learned by all jurisdictions.
Other factors drive the need for greater cooperation.
Take some of the pragmatic changes occurring in the industry. There's an explosion of sophisticated investigative tools, given the rapid pace of technical advancements. But at the same time, there's a decrease in experienced investigators worldwide, given our aging workforce. The former development is welcomed, but its no substitute for the latter. The vacuum needs to be filled.
So, how do we meet this challenge?
To begin, we must commit to a greater focus on sharing information on studies and recommendations, accident data, as well as best practices in investigation techniques and methodologies. We must also support investigations onsite, when feasible, and promote a stronger safety culture worldwide.
Efforts are being made. For example, the TSB and ten other national investigative bodies - including the National Transportation Safety Board - have formed the International Transportation Safety Association. Together, we've acknowledged our mission to "improve transport safety in each member country by learning from the experiences of others."
There are other signs of greater cooperation. Aviation authorities in Canada, France, Iceland, Norway, Portugal and Thailand recently worked together on investigations, international standards, bilateral agreements and protocols.
The TSB, like many other organizations, has also transferred technology to investigation agencies, aircraft manufacturers, airline operators and professional associations ... all with the aim of improving aviation safety.
These are important steps forward -- although we still have a way to go.
There's a reluctance by some in the investigation business to cooperate with other stakeholders for fear that it might be seen as compromising their independence.
I understand their concern. The independence of accident investigation authorities must never be put at risk or be open to question. Their role remains to inform the public about what happened, why it happened and how it happened - in an impartial and unbiased way.
Still, I believe we can strike a balance between "independence" and "partnership". The key is to ensure that cooperative activities between international bodies, industry groups and regulators have more to do with sharing information than sharing responsibilities.
Let me explain.
The TSB, for example, encourages the involvement of knowledgeable observers who are capable of assisting us in the collection and validation of information and the identification of underlying factors that contribute to unsafe acts and unsafe conditions.
Having said that, our Board remains independent so that we can make our own findings and conclusions and put forward recommendations.
This structure ensures we can partner with organizations without compromising our independence.
Another important point needs to be made about closer working partnerships: their purpose must extend beyond any given investigation.
As I mentioned, our Swissair Flight 111 investigation produced 23 Aviation Safety Recommendations. In many regards, this can be considered a great success. But it's not a major step forward unless action is taken to eliminate - or at least mitigate - the deficiencies on which these recommendations were made.
There is definitely a willingness among all stakeholders such as international regulators, manufacturers, and airline operators to advance aviation safety. Without their dedication and determination to implement our recommendations, we would not succeed in advancing safety.
But there needs to be greater leadership ... follow through ... upon the completion of an investigation. And we cannot rely solely on others to fill the void.
As such, our partnerships must not only help to identify safety deficiencies, they must also advocate changes to advance our safety culture.
It's easier said than done.
That's because for many organizations, including the TSB, it requires a more active role in championing safety issues. In short, it requires us to expand our mandate as well as mindset.
I believe, in the future, it will not be enough to investigate accidents and produce recommendations ... we must also make sure the recommendations are implemented. To do less would be a disservice to the stakeholders we serve.
We must all measure ourselves by more than the volume of documents we produce, or information we share ... we must measure ourselves against the important advancements that we help to make ... to ensure the safest transportation system possible for every stakeholder ... from pilot to travelling public.
We know the benefits of working together on an investigation. Imagine the impact we could have, working alongside other stakeholders, to bring about change.
Together, let's find ways to champion causes ... influence industry stakeholders and regulators ... persuade policy makers.
Let's make sure our efforts make a difference.
Oliver Wendell Holmes once said: "The greatest thing in this world is not so much where we are, but in what direction we are moving."2
I would apply his philosophy to the global objective of safer transportation. The Swissair Flight 111 investigation provides a glimpse of things to come.
It underscores what we can do if we work together, and promises new ways in which we can enhance aviation safety.
We're moving in the right direction. In the coming years we must find ways to protect our independence and ensure it is never compromised. We must also find new ways to expand our role in the safety mosaic.
This century will require - from all of us - global coordination and solutions. That can only come from closer working partnerships ... that help to identify safety deficiencies and advocate change.
Again, thank you for the opportunity to address your conference, and my congratulations to ALPA for the leadership it has demonstrated in promoting aviation safety.
Together, let us forge stronger relationships with the shared objective to build a safer future in aviation.
1. John F. Kennedy
2. Oliver Wendell Holmes, 1809-1894, a celebrated author, poet, physician and professor of anatomy and physiology at Harvard.
- Date modified: