Opening Remarks to the House of Commons
Standing Committee on Transport, Infrastructure
and Communities
Wendy Tadros

Transportation Safety Board of Canada
Ottawa, Ontario
13 April 2010

Check against delivery

Mr. Chairman, Honourable Members. I want to thank you for inviting the Transportation Safety Board of Canada to appear before your Committee.

I bring with me today solid experience. To my right is Mr. Jean Laporte, the TSB's Chief Operating Officer. To my left is Mr. Mark Clitsome – Mr. Clitsome is in charge of all of the aviation investigations we conduct at the TSB.

Twenty years ago, Parliament created the Transportation Safety Board of Canada – to conduct independent investigations no matter whether the accident was on our waterways, along our pipelines or railways or in our skies. The creation of the TSB was an investment in Canada's future. It was an investment in the infrastructure critical to our country's economic and social health.

This investment has paid dividends to Canadians by making us safer as we move ourselves and our goods across this country and around the world.

For twenty years, we have reported to Canadians and made clear what needs to be done to make the system safer. And Canada now enjoys one of the safest transportation systems in the world.

Even so, Canadians expect that we at the Transportation Safety Board work to make it even safer.

That is why we will continue to conduct independent, expert investigations. And we will inform Canadians about what happened, why it happened and suggest solutions to industry and government.

And when the Board feels that not enough has been done to address the safety issues we have uncovered, we will speak up as we did last month with our Watchlist.

On March 16, the Transportation Safety Board of Canada launched its Watchlist. I'm going to take you on a very brief tour of the Watchlist. On it are nine critical safety issues that must be tackled to make Canada's transportation system safer.

In Marine there are two issues. The first is fishing vessel safety. Almost half of the marine accidents reported to the TSB are fishing vessel accidents and on average one Canadian a month dies in a fishing vessel accident.

The challenges we face are pervasive in the fishing industry and they range from vessel stability to safety culture.

The second marine issue involves Canada's ferries. Our ferries enjoy a good safety record. But we all need to be mindful that tens of millions of passengers rely on them each year. There are over 100 large passenger vessels and roughly half of these can and do carry over 400 people.

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 everyone is more likely to get off safely if crews have practiced realistic exercises.

In Rail, the Watchlist speaks to a collision every two weeks between a passenger train and a vehicle at one of Canada's 20 000 railway crossings.

The Board is calling on the railways and Transport Canada to take the time to figure out which level crossings pose the greatest risk – then to do what is necessary to bring the number of collisions down.

The second rail issue is the operation of longer, heavier trains. In the last 15 years, the weight and length of trains has increased by 25%. "Marshalling" is the order in which trains are put together. 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. Longer, heavier trains have to be marshalled and operated with safety as the imperative.

We think that the rail industry understands the importance of this, but on the ground, we find that vigilance sometimes flags. While it is early days, I can tell you that, in our investigation of the recent derailment in Pickering, Ontario, we will be looking very carefully at marshalling and its impact on in-train forces.

Moving on to aviation, there are two Watchlist issues related to safety at Canada's airports. The first issue concerns conflicts on the ground. While the likelihood of these conflicts is low, by focussing on improved procedures and enhanced collision warning systems, we think the risk at Canada's busy airports can and should be lowered even further.

We are also concerned about the millions of aircraft that land at Canada's airports. Accidents can happen on the runway or aircraft can run off the end. We learn hard lessons from all our safety investigations.

When an Air France aircraft ran off runway 24L in Toronto, we learned that we had a problem in Canada. And this problem has continued. In a recent publication of the Flight Safety Foundation’s AeroSafetyWorld, Canada was shown to have more than twice the rate of runway overruns in wet conditions than the rest of the world.

Building sufficient Runway End Safety Areas or the alternative Engineered Material Arresting Systems will be difficult and it will take political resolve to make the ends of Canada’s runways safer.

Another aviation issue the TSB focussed on is called "Controlled Flight into Terrain." In Canada, between 2000 and 2009, an unsuspecting crew flew a perfectly good plane into the ground one hundred and twenty-nine times. This represents just 5% of aviation accidents overall but nearly 25% of all fatalities. The answer to this problem is to fit smaller aircraft with Terrain Awareness Warning Systems. And we must get on with it.

The last two Watchlist issues are common to Marine, Rail and Aviation. The first one I want to talk about is data. Recently, the TSB participated in an International Civil Aviation Organization safety meeting where the world grappled with the challenge of recovering the recorders from Air France Flight 447.

To do our job, the Transportation Safety Board of Canada needs objective data from onboard recorders – an airplane's black box, a locomotive's event recorder, or a ship's voyage data recorder. The fact is the patchwork of requirements we have in Canada is no longer acceptable. We need to ensure that, when there is an accident, the Safety Board will always have secure, retrievable data.

The last issue on the Watchlist that I want to discuss with you is Safety Management Systems. This is an issue in marine, rail and aviation. But because I know that you are now studying aviation safety, I will focus on SMS in the aviation world. I also want to talk about business aircraft and the lessons learned from our Fox Harbour investigation.

The Transportation Safety Board has consistently emphasized the advantages of Safety Management Systems.

These systems are a powerful, internationally recognized management tool to help organizations find trouble before trouble finds them. We think SMS is the right way to go. But to make them work, there needs to be a firm and consistent commitment from companies and oversight from the regulator is critical. Safety Management Systems have been fully implemented by Canada's 35 large carriers (CAR 705) which transport most fare paying passengers. And it should be noted that our large carriers have a good safety record.

The challenge to come will be the rest of the aviation industry – Canada's air taxis, helicopter operations, commuter airlines and flight training schools. For smaller operators, whether they operate commercial or business aircraft, Transport Canada will need to closely monitor the industry to ensure that all are on board and that there is a smooth transition to SMS. This is something we will be paying special attention to in our investigations.

And then there is the unique case of business aircraft. Let me put the issue in context and tell you about our Fox Harbour investigation and its aftermath.

About a decade ago, Transport Canada and the Canadian Business Aviation Association began to transfer responsibility for certification and auditing to the CBAA. This transfer of responsibilities was premised on the CBAA maintaining a number of conditions.

I want to talk specifically about the condition on Safety Management Systems. The intent was for the CBAA to require each business aircraft operator to have a functioning Safety Management System.

When a Global Express aircraft touched down short of the runway in Fox Harbour, Nova Scotia, the TSB's investigation took an in-depth look at the transfer of responsibility and at the implementation and functioning of SMS in the business aircraft community.

What we found was that, while commercial operators were required to implement SMS in stages on a fixed timeline, business operators were free to implement SMS on their own terms with no fixed timeframe. This meant that many, including the operator in Fox Harbour, did not have a fully functioning SMS. This operator, for instance, did not properly assess the risk of introducing a larger aircraft to its fleet – in accordance with sound safety management principles.

That is why the Board recommended that the CBAA set SMS implementation milestones for its certificate holders and that Transport Canada ensure that the CBAA put in place an effective quality assurance program for auditing certificate holders.

On March 16, 2010, Transport Canada went one step further and decided to take back the certification and oversight functions of business aviation.

This change will come into effect on April 1, 2011. I must say that the TSB is pleased with this outcome.

As is our practice, we will continue to monitor the response to this and all Board recommendations and we will be reporting on whether progress has been made.

When efforts come up short as they did with the 9 issues on our Watchlist, the TSB will report to Canadians and challenge industry and government to step up and make transportation safer.

The early reactions by the regulator and industry to the Watchlist have been positive. On the vast majority of issues, we are in agreement about the safety issues, but they are on the Watchlist because progress has been far too slow and the problems we identified have not been fixed. Sometimes, this is because industry consultations drag on. Sometimes, it is because the regulatory process is not nimble enough to deal with critical safety issues. Let me leave you with this thought. Perhaps we should have a faster way of dealing with regulatory changes that are necessary for the safety of Canadians.

Thank you. Now we would be pleased to answer your questions.

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