TSB Watchlist: a blueprint for change
John Clarkson, Member
Transportation Safety Board of Canada
Halifax, Nova Scotia, 27 June 2013
Check against delivery.
Slide 1: Title page
Slide 2: Outline
- About the TSB
- Watchlist issues
- Key factors in marine safety
Slide 3: About the TSB
The TSB is an independent government body that reports to Parliament through the President of the Queen’s Privy Council for Canada. Maintaining our independence is crucial, so we can fulfill our mandate without interference from any external source. The structure and mandate of the TSB is based on the Canadian Transportation Accident Investigation Safety Board Act and Regulations. We have no powers of enforcement; we do not assign fault, nor do we determine civil or criminal liability.
There are a total of 5 Members of the Board, including the Chair, along with approximately 230 employees. We have 9 offices nationwide, from Dartmouth to Vancouver, as well as 1 lab.
Slide 4: Our mission
It is vital that we communicate our mission and mandate in order for stakeholders and change agents to fully understand and appreciate our role and responsibilities both in Canada and internationally through various conventions. Our mission is to advance transportation safety in the marine, pipeline, rail, and air modes of transportation that are under federal jurisdiction by:
- conducting independent investigations;
- identifying safety deficiencies;
- identifying causes and contributing factors;
- making recommendations; and
- making our reports public.
Slide 5: Integrated Safety Investigation Methodology (ISIM)
The backbone of our investigative processes is a system known as Integrated Safety Investigation Methodology, or ISIM. It is a scientific approach that is built on best practices and safety.
Slide 6: ISIM Process
This is a diagram of how the ISIM process works. Following assessment of an occurrence, we collect data and then build a sequence of events. This is a working model of how we feel a given accident scenario unfolded. We then identify those elements of the narrative that are "safety significant," and begin a drill-down process to determine what happened. By regularly asking "why" at each stage, we can determine the critical safety issues, identify risks, and begin to look at risk control options. These then culminate in findings and, possibly, safety communications, so that those who need to know are informed of what we learn.
Slide 7: Watchlist 2012
Based on an analysis of hundreds of TSB reports, safety concerns, and recommendations the TSB maintains a Watchlist of transportation safety issues that pose the greatest risk to Canadians. In each case, the TSB has found that actions taken to date are inadequate, and that industry and regulators need to take additional concrete measures to eliminate the risk.
In the case of marine transportation, the current Watchlist identifies " Safety Management Systems" and "Loss of Life on Fishing Vessels". However, Safety Management Systems are also an issue in the Aviation mode.
Slide 8: Safety Management Systems
The issue of SMS has been identified as a major concern, because it is not currently required for smaller coastal marine operations and their vessels.
However, SMS has been shown in all transportation industries to have a significant positive effect on safety—provided it is properly applied.
At the TSB , we want Transport Canada to require all commercial vessels to have SMS, and we want every SMS to be certified and audited.
In the United States, the National Transportation Safety Board (NTSB) has also indicated (on its equivalent of the Watchlist) a call for Safety management Systems on all U.S. commercial vessels.
Slide 9: Marine SMS (continued)
The general outline and structure of a robust SMS has been well established in all transportation modes, and in the marine sphere it is currently centered around the International Safety Management (ISM) Code as Chapter IX of the Safety of Life at Sea Convention (SOLAS)
While the ISM Code does not apply in general to domestic shipping, it does outline the basics of safety management practice. However, many other forms of SMS are available and offer equal levels of safety—particularly as the SMS currently applied through the ISM Code may not be the most applicable to some coastal operations.
Slide 10: SMS (continued)
In order to be successful, here are some key points to remember about SMS.
SMS integrates safety into all daily activities.
It is a systematic, explicit, and comprehensive process for managing safety risks … it becomes part of that organization’s culture, and [part] of the way people go about their work."
SMS involves investigating safety concerns to identify systemic deficiencies.
Labour climate may require building (or rebuilding) trust in management.
Slide 11: SMS in regulation (Canada)
Currently Transport Canada does not require SMS on all commercial vessels in Canada. Here are the basic points of the proposed Safety Management Regulations with regard to SMS in Canada. This has been put forward at the National Marine Advisory Council (CMAC) meetings in Ottawa in November 2012. There was no further discussion on the proposed SMS regulation at the May 2013 CMAC.
In short, the proposed regulations would require an SMS for:
- a Canadian vessel subject to Chapter IX of SOLAS;
- a Canadian vessel of 500 GRT and upward;
- a Canadian vessel certified to carry more than 50 passengers; and
- a vessel more than 24m in length and less than 500 GRT (not subject to audit and certification requirements).
Slide 12: SMS in regulation (United States)
Some nations have already developed SMS schemes in regulation that are not based on the ISM Code but which nonetheless apply the same principles. One such nation is the United States, which has now incorporated in regulation an SMS requirement very similar to the pilot DSM scheme in Canada. The outline on the next two slides is taken directly from U.S. text.
The U.S. towboat industry equivalent to the CMC, the American Waterways Operator (AWO), worked closely with the United States Coast Guard to develop this regulatory format, which has now been incorporated in U.S. regulation.
Slides 13: Factors in establishing an SMS (U.S)
Here is an overview of the factors deemed relevant to establishing an SMS in the domestic U.S. towboat industry. The U.S. Coast Guard is relying on approved third parties to verify compliance with the new regulations, which is a similar process to delegated authorities in Canada.
Slide 14: Role of governance / oversight
In order to have a successful SMS, there needs to be a clear regulatory requirement that is practical in nature and which creates a level playing field for the industry. The role of governance and oversight must be supported by ALL levels of marine operations, from the boardroom floor down.
Again, an SMS is only as good as the "buy-in," and requires full acceptance by all parts of an organization—including management and labour—together with the regulators and their mandate under audit and inspection.
Slide 15: Safety Issues Investigation: Fishing Safety in Canada
In 2009, the TSB launched a safety issues investigation into fishing safety in Canada. Our goal was to gain a better understanding of all the factors involved in fishing safety, and to determine why the same kind of accidents kept on happening. And what I mean by that is simple: Why is it that the likelihood of someone dying today is the same as 20 years ago? Why is it that, on average, one fisherman a month is killed in fishing related activity?
To find out the answers to those questions, we talked to people from coast to coast, conducting interviews, surveys, and town-hall meetings.
Slide 16: SII: Findings
What we learned was that there are 10 key safety issues at the heart of it all. And while it may seem counter-intuitive, when it comes to solutions, addressing these issues one-by-one doesn’t work. Stability, training, resource management, safe work practices—they’re all interdependent, and any solutions need to be that way too. Real and lasting improvement in fishing safety can only come when the fishing community tackles safety issues in a coordinated way. Across Canada, there are some strong regional initiatives, but other fishing communities need to follow suit. The key is cooperation, because no single group or government can fully address all the challenges. The TSB strongly urges leaders in the fishing community to take focused and concerted action in all regions of the country. In other words, we’d like to see more regional governance structures, aimed at helping to foster a safety culture.
Slide 17: SII: 10 key safety issues
These are the 10 issues our report identifies:
- fisheries resource management;
- lifesaving appliances;
- regulatory approach to safety;
- safety information;
- cost of safety;
- fishing industry statistics; and
- safe work practices.
Slide 18: SII: Safety action required
The fishing community faces a number of challenges, including:
- recognizing the interconnected nature of safety issues;
- coordinating solutions to issues;
- creating regional governance structures;
- promoting safe work practices as routine;
- fostering a safety culture; and
- placing a greater emphasis on training.
Slide 19: Human Factors
Here are some key factors when describing a successful organizational culture and safety culture. The organization must have shared values and beliefs that interact with an organization’s operations to produce behavioral norms that govern risk-taking. For this to occur, these shared values, beliefs, and practices must be demonstrated and passed down to all employees.
The "just culture" part of this recognizes that individuals should not be held accountable for systems failings over which they have no control. Having said this, a just culture does not tolerate the disregard of rules, reckless behavior, or gross misconduct. An organization must have the ability to determine the levels of risk proportion to safety and regulatory requirements that still allows them to carry on business. It is impossible to have so many checks and balances that an organization cannot function or participate in the transportation industry. In order to achieve success the labour / management climate may require building or rebuilding the levels of trust required.
Slide 20: Fatigue
Fatigue has been recognized as a key contributor in many transportation occurrences. At one time, fatigue was discounted as a potential cause or contributing factor in accidents. Today, however, backed by scientifically accepted evidence and better investigation analysis, fatigue is no longer so overlooked. In fact, we know that fatigue often plays a major role. As a result, many international transportation organizations are tackling the causes and creating action plans to combat, or at least mitigate, fatigue as much as possible.
Slide 21: Voyage Data Recorders
The Voyage Data Recorder (VDR) is a mandatory piece of equipment, and it is the responsibility of a vessel’s owner and crew to ensure that it is fully functional at all times. There have to be clear instructions and processes—either through SMS or otherwise—that guide owners and crew in the operation of VDRs. A ship owner not keeping the VDR in a functional state would place him or her in direct violation of the flag administration requirements and SOLAS carriage requirements. Having said that, it is evident to the TSB (and many other international marine safety investigative bodies), that VDR requirements are not being followed.
Slide 22: Loss of basic principles
I do not think it will come as a surprise to anyone that the transportation industry is raising a new generation of marine officers—and aviation pilots—who do not apply or have the same knowledge of base principles as the previous generation. We see this in many accidents, where a high reliance on technology has left a void when it comes to reacting to emergencies once equipment fails. This has resulted in a need to look at how basic principles are taught, trained for, and practiced. Examples of a high degree of reliance on technology are the current navigational procedures for modern cruise ships and the flight operations of modern passenger aircraft.
Slide 23: Conclusions
Having a robust SMS has been proven repeatedly to be an effective way to manage and reduce risk; however, in order to be successful the system must still be followed.
One of the key factors in an SMS’s success is the "culture" of an industry—whether it is a major marine, pipeline, rail or aviation organization. In nearly all cases, the culture of the organization had to adapt to bring about the safety culture required to meet the needs of the organization. This is not always easy, and it requires commitment and perseverance, from both labour and management.
In addition, the flag administration must have the ability to create and deliver effective regulations that meet international and domestic needs. This can be challenging, depending on government resources, the organization, and the method employed for consultation.
Valid and continuous training and education are also vital—whether from the perspective of the regulator or the company—in order to give employees the ability to operate safely and efficiently.
Slide 24: Questions?
Slide 25: Canada wordmark
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