"Risk never sleeps"
Notes for an address by
Transportation Safety Board of Canada
at the Canadian Board of Marine Underwriters
Mont Tremblant, Quebec
May 26, 2005
Good morning, ladies and gentlemen. Thank you for being here today. It's always a pleasure to speak to, and share ideas with, industry stakeholders.
It's all the more special when the stakeholders represent a venerable institution such as the Canadian Board of Marine Underwriters.
As one of the oldest associations in Canada, your dedication to the industry is only surpassed by your expertise.
You've proven to be a valuable source of information on vital matters ranging from loss prevention to shipbuilding maintenance.
And I'm pleased to hear, as you enter your next century of service, that education and communication will be two key priorities.
This bodes well in an era of rapid change, when success, as one writer observed, rests on an organization's ability to "learn, unlearn, and relearn." [Alvin Toffler]
It's fortuitous that I speak to you about marine safety today. That's because on this very day … 40 years ago … the first treaty by the International Maritime Organization came into force.
The International Convention for the Safety of Life at Sea, or SOLAS, represented a considerable step forward in marine safety. Yet it was not the first - nor the last - time the international community worked towards this goal.
In fact, the origins of SOLAS date back to 1914, as an international response to the Titanic, which resulted in the loss of 1,500 lives.
To put this tragedy in perspective, it represented twice the annual number of fatalities for passenger ships at that time.
Times have changed for the better. So has SOLAS. There have been four other versions since 1914. The Convention has widened its scope and expanded its areas of interest. Yet it has never lost sight of its underlying purpose of advancing transportation safety.
But I'd argue its success has as much to do with the collective responsibility of shipping nations as with the creation of new regulations.
Put another way, a transportation safety culture is not sustained by a set of rules, but by people and parties who abide by these rules, and seek to improve them.
That's because risk never sleeps.
Consider some facts. Our most recent statistics show that, although there has been a gradual decline in the number of reported occurrences over the last 10 years, there was a 13 percent increase in marine accidents between 2002 and 2003, up from 485 to 547, but notably down to 480 again in 2004.
Accidents include vessel accidents and personal accidents aboard ship. We also note an average of 200 reported incidents per year (near collisions, machinery failures, etc.).
Although we can take some solace in the decline of the number of fatalities - 17 in 2003, representing a 29-year low, but back up to 28 in 2004, which is the average number for the last five-years - there remains a clear and present danger on the seas, especially so for smaller vessels.
My point is this: We all have an interest in the safe and secure passage of people and goods. Your members - perhaps above all else - can appreciate that it simply makes good business sense.
Over the next few minutes, I'm going to talk about the role my organization plays in advancing transportation safety.
It will be clear that we have different missions or mandates; our interests and activities may diverge; so too may some of our opinions and obligations.
But it will also be clear that we're in the same proverbial boat … that our success is reliant on a shared commitment and concern for promoting a strong safety culture.
To this end, we look to the Canadian Board of Marine Underwriters to play an increasingly prominent role in promoting a strong safety culture in the 21st century.
Transportation Safety Board of Canada
Let me now provide some background on the Transportation Safety Board of Canada.
We're an independent agency. That means we operate at arm's length from other government departments such as Transport Canada.
Our mandate is to advance transportation safety by conducting investigations into occurrences, such as the Lady Duck, an amphibious vehicle that sank in the Ottawa River, leaving four people drowned.
Or the Cap Rouge II, a fishing vessel that capsized off the coast of Vancouver Island in 2002, resulting in the loss of five lives.
Or the Cypriot bulk carrier Flare, which broke in two off Newfoundland, with the loss of 21 of 25 crew members. (Four were rescued in a very daring operation.)
In these and all investigations, our focus is straightforward. We examine what happened; why it happened; and how we can help ensure it never happens again.
I already mentioned there were 480 reported marine accidents in 2004. We respond to each of these occurrences, but only fully investigate those that represent the greatest potential to identify safety deficiencies.
When we find unsafe conditions, we act immediately by communicating with those who can take corrective measures.
We also identify unsafe conditions ... and make safety recommendations.
It's important to highlight a couple of key points about how we do our work:
From a legal perspective, information gathered by the TSB is to be used strictly for safety investigations, and it is not intended for the purpose of litigation.
That's a key premise, because the point is to get quickly to the facts of the case, find out what happened and make recommendations for improvements.
In the same vein, the confidentiality of evidence is protected because we're in the business of pursuing the greater public good, not pointing the finger of blame or demanding reparation.
Witness testimony, for example, is protected by law so that no individual is discouraged from giving complete and honest comments about what happened, and why, from their perspective.
Our investigative approach is comprehensive. We examine the individual parts of the whole transportation system, and look at how all elements and events relate to each other.
This means our safety recommendations consider the broader implications and the larger connections within the transportation system.
And finally, we take the time to get it right. The TSB will not cut corners, or rush complex processes. This would not enhance transportation safety, nor advance the interests of industry or Canadians. Having said that, when we uncover safety deficiencies, we will not wait until the report is completed to make recommendations or issue safety letters.
For some, the TSB may appear as a bit of a "stop and start" organization. We investigate an occurrence, we file a report and then we wait for the next call.
It's a bit of a simplistic view because the reality is that our investigators are in constant contact with the safety community. We know, for sure, that the Board makes a real difference in terms of setting the bar high for safety performance, particularly within federally regulated industries.
But we're keen to have our work contribute to a stronger sense of the "safety continuum" in Canada. That's because the world is far too complex for short-term, band-aid solutions.
And ultimately, we know that our findings bear no return if stakeholders fail to act upon the issues that we identify or any recommendations that we propose.
It's for this reason that we need to strengthen links between stakeholders to ensure our safety culture can be improved.
Nowhere is this more critical than in marine transportation. That's why we look to the CBMU to enhance its leadership role in this regard.
Why? Simply put, your organization has a vested interest in safety: fewer accidents mean fewer claims.
To this end, your own efforts can be enhanced if we work together as change agents for safety.
What does this entail?
For one thing, it means a greater focus on our part to share information on studies and recommendations, accident data, as well as best practices in investigation techniques and methodologies.
For another, it means an expanded role for your organization to ensure your members' clients remain current with the shipping and operational practices of their vessel types.
It is not enough to be satisfied with legal compliance. Indeed, we believe that organizations need to embrace the spirit of international conventions and national legislation, and place safety at the centre of everything they do.
I'll suggest some practical ways that this can be done, focusing on the safety issues of small passenger and fishing vessels.
Consider some facts: 57 people died in 166 shipping accidents involving small passenger vessels between 1975 and 2002. There were only 5 fatalities from more than 1,080 shipping accidents involving all other passenger vessels during the same period.
Our investigation report - issued in 2004 - of the sinking of the Lady Duck helped explain why such risk is prevalent. It showed that small passenger vessel operators may not be aware of the risks associated with the operation of their vessels or possess the competence to manage those risks.
That's why we called on Transport Canada for a system tailored to the needs of operators of small passenger vessels.
We understand that new regulations will come into force in 2006. And we support the department's efforts. But following a review of the regulator's reform plans, we believe certain shortcomings will still exist.
For instance, regulatory compliance for small passenger vessels relies on self-inspection by owners/operators who may not be fully conversant with all safety requirements.
Until such time as the regulatory framework can be easily understood, the implementation of a self-inspection regime will be problematic, and risks to passengers will continue.
Your organization's ongoing efforts to educate members could, for example, provide applicable, easy-to-understand solutions to address this issue.
Programs, for instance, could help provide information on the safe management and operation, as well as proper maintenance, of vessels to your members' clients.
Valuable information could be delivered through web-based courses and cross-Canada seminars, and through coordinating and sharing intelligence with safety organizations, such as the TSB.
The Lady Duck investigation also highlighted that certain small commercial vessels are not required to incorporate sufficient inherent buoyancy to prevent sinking.
As a result, there are no provisions on certain vessels for the timely and unimpeded evacuation of passengers in the event of an emergency.
Again, we've asked Transport Canada to address this matter.
But in the meantime, your organization could draw this issue to the attention of your members' clients, and encourage them to learn more about sufficient inherent buoyancy and other design features that will permit safe and timely evacuation of passengers and crew in the event of an emergency.
Let me now turn to one more example of how your organization can act as a change agent for safety on behalf of the fishing industry.
We know fishing can be a risky business. In the past decade, 493 Canadian fishing vessels have been lost, and 76 fishers have perished.
Yet such figures rarely hit home with those most at risk: the fishers themselves.
Our investigation report - issued in 2003 - of the Cap Rouge II capsizing underscored how the lack of a strong safety culture puts fishing vessels at risk. This was reflected, in part, by the absence of emergency drills, as well as the lack of awareness of shipboard practices that affect vessel stability.
To this end, we have called on Transport Canada, in collaboration with the fishing community, to reduce unsafe practices by means of a code of best practices for small fishing vessels, including loading and stability, and that its adoption be embraced through effective education and awareness programs.
Your organization could assist in this process by encouraging industry input and promoting the code once it has been introduced.
Risk never sleeps
As I mentioned earlier, risk never sleeps. Nor does it discriminate.
Large bulk carriers and small passenger boats alike are susceptible to it, at sea or in harbour.
That's because accidents are complex in nature. They're usually the result of a combination of contributing factors.
The tragic sinking of the True North II five years ago in Georgian Bay, with the loss of two grade-seven schoolchildren, is a perfect example.
Our investigation found the vessel's watertight integrity was compromised, life-saving equipment was not readily available, and there was only one crew member on duty, when two were required.
As our Chairman said at the time, "No one thing alone would have caused the accident, but all of them together created a disaster. Small factors, which in and of themselves would appear insignificant, combined to produce fatal results."
That's why we need to be vigilant in our efforts to promote a safety culture.
This will not be achieved by a set of rules, but by groups of people who embrace these rules, and seek to improve upon them.
We're calling on your organization to be one of those groups: To explore ways in which you can leverage resources and exert influence in order to advance safety.
To this end, we ask the CBMU to:
- stay current with TSB investigations, our key findings and safety recommendations;
- encourage others to do the same;
- maintain an open dialogue with like-minded organizations, including the TSB;
- engage them in enhancing your own efforts; and
- promote safety through your existing programs.
Risk never sleeps. So we can never rest when it comes to promoting a safety culture.
Your organization has a vested interest and an important role to play in this regard.
Like the sea that's always changing, our industry is always evolving. All of us must adapt … to learn, unlearn, and relearn … so that safety is at the centre of everything we do.
In this light, your organization is uniquely qualified and well positioned to take on a leadership role. We look forward to your efforts and ongoing contributions.
I hope you have an excellent conference. Thank you.
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