Opening Remarks for the Launch of the
Transportation Safety Board Watchlist
Wendy Tadros, Chair
Jonathan Seymour, Board Member
Kathy Fox, Board Member
16 March 2010
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Good morning ladies and gentlemen. On March 29 the Transportation Safety Board of Canada will celebrate its 20th year as a leader in transportation safety. This milestone gives us the opportunity to take stock not only of our safety accomplishments but, more importantly, of the challenges we think will mark the next 20 years in transportation safety.
Today the Transportation Safety Board launches its Watchlist. On the Watchlist are nine critical safety issues – issues that must be tackled to make Canada's transportation system safer. It will take a concerted effort by industry and government, to tackle these tough issues. The Transportation Safety Board's Watchlist is a blueprint leading the way forward.
I want to reassure Canadians that Canada has one of the safest transportation systems in the world. We have a strong foundation. Even so, our economy requires, and Canadians expect, that we, at the Transportation Safety Board, work to make it even safer.
Time and again, our investigators arrive at the scene of an accident and find the same old safety issues – issues that pose the greatest risk to Canadians. These are the issues on our Watchlist. We will deal with each one in some detail. In summary they are:
- Marine – fishing vessel safety and emergency preparedness on ferries
- Rail – passenger trains colliding with vehicles, the operation of longer, heavier trains
- Aviation – the risk of runway collisions, controlled flight into terrain, plus aircraft running off the end of runways and other landing accidents, and,
- More generally – Safety Management Systems, and data recorders.
Today we are calling for change. It is time for industry and Ottawa to step up and tackle these critical safety issues. For the Transportation Safety Board, there is no higher priority. To explain these nine critical issues, I am joined today by Mr. Jonathan Seymour and Ms. Kathy Fox, two of my colleagues on the Board with expertise in transportation. Mr. Seymour will take you through the Marine and Rail Issues on the Watchlist. Mr. Seymour...
Thank you Madam Chair.
First up is marine where we have two issues. Safety aboard fishing vessels is one of our top priorities at the Transportation Safety Board. Yes, fishing can be risky – Canadians know this, they've been doing it for generations. But death shouldn't be the cost of a life spent at sea. Too often – roughly once a month over the last five years – it has been.
Their families expect – and we insist – that more must be done. Every time the Board investigates, we make conclusions about causes and contributing factors, but the challenges we face run throughout Canada's fishing industry. Systemic problems need systemic solutions.
On fishing vessel safety, the Transportation Safety Board remains concerned about vessel modifications and their impact on stability; the use and availability of lifesaving equipment; regulatory oversight; the impact of fishery resource management plans and practices; and the lack of both a safety culture and a code of best practices.
Now both industry and government need to step up the pace and do more to promote safe operations and improve knowledge and training in this vital industry.
The Board's second marine issue involves the safety of Canada's ferries. Our ferries enjoy a good safety record. But the Transportation Safety Board is also mindful that tens of millions of passengers rely on them each year. There are over 100 passenger vessels above 500 gross tonnes operating in Canada, and roughly half of these can carry over 400 people at a time.
At the Board, we've learned the hard way that these vessels need to be better prepared for an emergency. If there is an accident, ferry operators need to know how many people are on board and, even better, where they are located on the ferry. And everyone is more likely to get off safely if crews have practiced realistic exercises.
Moving on to rail issues, at the Transportation Safety Board we see all too many crossing accidents at the thousands of railway crossings along Canada's busy corridors. Three hundred and eighty times in the last fifteen years – on average, once every two weeks – something has gone horribly wrong, and a passenger train and vehicle have collided.
Moreover, we've come to understand that the most common assumption – "driver error" – is seldom the only factor involved. In many instances, drivers simply do not have enough warning, or the angle of the track and the sightlines make it impossible to see an oncoming train in time. No matter what the risk, it can and must be reduced.
The Board is convinced that the railways and Transport Canada need to take the time to figure out which level crossings pose the greatest risk. Then they need to take those essential steps to bring the number of collisions down.
Another trend the Board is tracking is the steady increase in the weight and length of trains. Since 1995, these have increased over 25 per cent, and, as our economy gears up to meet future demand, we expect them to become even bigger. "Marshalling" is the order in which freight cars are put together to make a train – and longer, heavier trains have to be marshalled and operated with safety as the imperative.
If you liken a long train to an accordion, pulling forces tend to separate cars and pushing forces will compress them together. When lighter empty cars are placed in the train without regard to these forces, the result can be a derailment.
Canada's rail industry shares the Board's concern, but we continue to see accidents – at least a dozen in the last decade. That is why railways need to make sure that these risks to safety are always managed.
Thank you Jonathan.
I would like now to turn to Ms. Kathy Fox who will take you through the next four issues on the Transportation Safety Board's Watchlist. She will talk to you about the issues we see in aviation and about Safety Management Systems and what needs to be done on this front in the Marine, Rail and Aviation worlds. Ms. Fox.
Thank you Madam Chair.
Let me talk first about the critical issues in aviation safety. The likelihood of a collision on runways at Canada's airports is low. However, should two aircraft collide, or an aircraft collide with a vehicle – the consequences could be catastrophic. That is why this issue is on our Watchlist.
Airports are complex environments where aircraft and ground vehicles must coexist in a confined area. Too often, over three thousand eight hundred times since 1999, there have been conflicts, or "runway incursions". By focussing on improved procedures and enhanced collision warning systems, we think the risk of these incursions at Canada's busy airports can be lowered.
Moving to another area, in low visibility or at night, pilots may lose track of exactly where they are in relation to the ground or water. The risk is greatest for smaller planes venturing into remote wilderness or into mountainous terrain as they do not have ground proximity warning systems.
In Canada, between 2000 and 2009, an unsuspecting crew flew a perfectly good plane into the ground one hundred and twenty-nine times. These cases account for just 5 per cent of accidents but nearly 25 per cent of all fatalities! In our Watchlist, we urge wider adoption of ground proximity warning systems for smaller Canadian aircraft.
Landing is one of the most critical phases of flight and every year millions of aircraft land at Canadian airports. This leads us to our next Watchlist issue. Accidents can happen on the runway or aircraft can fail to stop in time and run off the end. Many of these accidents happen in bad weather – where it is crucial that pilots receive timely information about runway conditions.
Aircraft running off the end of runways is a problem worldwide. The latest figures from the Flight Safety Foundation reveal that almost thirty percent of aircraft accidents between 995 and 2008 were runway overruns. And at home, we have the vivid reminder of the Air France aircraft at Toronto's Pearson Airport in 2005.
When this happens – and it will happen again – the TSB needs to know that passengers will be safe. Sometimes all that is required is to lengthen the safety areas at the end of runways. Where geography will not allow it, solutions may be found in engineered systems and structures designed to quickly and safely stop an airplane.
The Watchlist contains two issues common to the Marine, Rail and Aviation industries. The first is Safety Management Systems a powerful, internationally recognized management tool to help organizations find trouble before trouble finds them. They help companies foresee what might go wrong so they can take pre-emptive action.
The Transportation Safety Board has emphasized the advantages of Safety Management Systems. However, in some of our investigations, we have found there is a lack of regulatory oversight or that key industry segments are not required to have a systematic approach to managing safety.
We are pleased that Transport Canada is committed to improving effective safety management systems.
Let me paint a picture for you in Marine, Rail and Aviation and tell you what must be done on this important front. Since July 2002, all vessels over five hundred gross tonnes that sail in international waters have had to implement a Safety Management System.
However, domestic vessels are not required to have these systems. The Transportation Safety Board thinks that this distinction makes no sense. That is why we are calling for the mandatory adoption of Safety Management Systems for all commercial shipping.
In the rail industry, a systematic approach to rail safety has been required since 2001. While it has been implemented in theory, it has not always permeated to front line operations. Risk assessments are not always being done when operations are changed and audits don't always pick up the risks. We urge Transport Canada to step up – to ensure Canada's railways walk the talk when it comes to managing safety.
In the aviation industry, we note with satisfaction that Canada leads the world in requiring its commercial carriers to have a Safety Management System. By and large, Safety Management Systems appear to be working well with our large carriers. The challenge to come will be the rest of the aviation industry – Canada's air taxis, helicopter operations, commuter airlines and flight training schools.
Transport Canada will need to closely monitor the industry to ensure all are on board and that there is a smooth transition. The Transportation Safety Board believes that Canadians should and will reap the benefits that effective safety management can bring.
The Board will be watching this issue very closely. Madam Chair.
Thank you Kathy.
The last issue on our Watchlist is about the tools the TSB needs to deliver, for the benefit of Canadians. As Churchill once said, "...give us the tools and we will finish the job."
The tool we most need is objective data to provide a clear picture of what happened. Following any accident, investigators have a long list of questions, starting with "what happened," and "why." A prime source for information are the onboard recorders – an airplane's black box, a locomotive's event recorder, or a ship's voyage data recorder.
These contain engine and equipment settings, navigation details, voice recordings, and computer data to quickly pinpoint what happened.
In Canada, we have a real patchwork of requirements. In some industries, there simply are no recorders. In others, data is recorded but not voice. Some recorders are required to be crash and fire resistant and others are not.
Without secure, retrievable data, the search for hard evidence becomes more difficult.
I'd like to describe the patchwork. In the Marine mode, only ships on international voyages are required to be fitted with Voyage Data Recorders. While we note with satisfaction that some domestic operators have voluntarily outfitted their large ferries, we think they should all do this – so the Transportation Safety Board will always have the tools to do its job.
All too often, lost data impedes our rail investigations. New crashworthy recorders are slowly being phased in as older locomotives reach the end of their service life. However, let's be clear, locomotives last 20-30 years. This means replacement of all recorders may be decades away. We call on the rail industry to step up the pace and modernize event recorders in their fleets.
The aviation industry has enjoyed the benefits of voice and data recordings for approximately 50 years. However, critical information is still sometimes lost. The Transportation Safety Board has made repeated recommendations to extend all cockpit voice recordings to two hours from the current 30 minutes.
While there has been some industry movement, a final regulatory change in Canada has yet to be made. Global efforts are required to build better recorders, to enhance the quality and duration of their recordings, and to ensure they keep recording when the power supply fails. As we embark on the next 20 years, this issue is fundamental to advancing transportation safety. I think you'll agree that this patchwork makes little sense. That's why this issue concludes our Watchlist.
At the outset of this presentation, I told you that this year marks our 20th anniversary. For twenty years...when the phone has rung, the Transportation Safety Board of Canada has answered.
No matter whether the accident was – on our waterways, along our pipelines or railways or in our skies – we have responded. We have reported our findings to Canadians and have made clear what needs to be done to make the system safer.
The creation of the TSB was an investment in Canada's future, an investment in the infrastructure critical to our country's economic and social health. This investment has paid dividends to Canadians by making all of us safer as we move ourselves and our goods across this country and around the world. Canadians can be proud of the TSB's innovative work – work that has made Canada a global leader.
I am proud of each and every one of these investigations. Now as we enter our third decade, we look back on 20 years of success – much of which has been instrumental in changing operating practices, equipment, and the laws that underpin the transportation industry.
In closing, at the Transportation Safety Board of Canada, we are pleased with how the lessons learned from the thousands of accidents we have investigated, have made transportation safer. However, the Board knows from hard experience that if a persistent problem is not addressed, there will be another accident.
Airlines, ferries, railways – we're talking about tens of millions of trips annually. We need to tackle the nine tough issues on our Watchlist NOW to make the system safer. Our Watchlist provides a blueprint for a safer transportation system – that's our goal.
I thank you for your time.
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