Annual Report to Parliament 2007-2008

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Transportation Safety Board Annual Report to Parliament 2007-2008

Transportation Safety Board of Canada
Place du Centre
200 Promenade du Portage
4th Floor
Gatineau, Quebec K1A 1K8
(819) 994-3741
1-800-387-3557
communications@bst-tsb.gc.ca

© Minister of Public Works and Government Services
    Cat. No. TU1-2008
    ISBN 978-0-662-05508-2





ANNUAL REPORT TO PARLIAMENT 2007-2008


Place du Centre
200 Promenade du Portage
4th Floor
Gatineau, Quebec K1A 1K8

02 June 2008


The Honourable Rona Ambrose, P.C., M.P.
President of the Queen's Privy Council for Canada
House of Commons
Ottawa, Ontario K1A 0A6

Dear Minister:

In accordance with subsection 13(3) of the Canadian Transportation Accident Investigation and Safety Board Act, the Board is pleased to submit, through you, its annual report to Parliament for the period 01 April 2007 to 31 March 2008.

Yours sincerely,

Signature of Wendy A. Tadros Chair

Wendy A. Tadros
Chair


TABLE OF CONTENTS

The Chair's Message

Section 1: Overview

1.1 Members of the Board
1.2 Senior Management
1.3 Mission of the TSB
1.4 Independence

Section 2: Activities

2.1 Occurrences, Investigations and Safety Action
2.2 Communicating Transportation Safety to Canadians and the
Transportation Community
2.3 Marine Sector
2.3.1 Annual Statistics
2.3.2 Investigations
2.3.3 Safety Actions Taken
2.3.3.1 Marine Recommendations Issued in 2007-2008
2.3.3.2 Assessment of Responses to Marine Recommendations
   Issued in 2006-2007
2.3.3.3 Other Marine Safety Actions
2.4 Pipeline Sector
2.4.1 Annual Statistics
2.4.2 Investigations
2.4.3 Safety Actions Taken
2.5 Rail Sector
2.5.1 Annual Statistics
2.5.2 Investigations
2.5.3 Safety Actions Taken
2.5.3.1 Rail Recommendations Issued in 2007-2008
2.5.3.2 Assessment of Responses to Rail Recommendations Issued in 2006-2007
2.5.3.3 Other Rail Safety Actions
2.6 Air Sector
2.6.1 Annual Statistics
2.6.2 Investigations
2.6.3 Safety Actions Taken
2.6.3.1 Air Recommendations Issued in 2007-2008
2.6.3.2 Assessment of Responses to Air Recommendations
  Issued in 2006-2007
2.6.3.3 Other Air Safety Actions

Appendices

Appendix A - Reports Released by the TSB in 2007-2008 by Sector
Appendix B - Glossary

Figures

Figure 1 - Occurrences Reported to the TSB
Figure 2 - Investigations Started, in Process, and Completed
Figure 3 - Marine Occurrences and Fatalities
Figure 4 - Canadian-Flag Shipping Accident Rates
Figure 5 - Pipeline Occurrences
Figure 6 - Pipeline Accident Rates
Figure 7 - Rail Occurrences and Fatalities
Figure 8 - Main-Track Accident Rates
Figure 9 - Air Occurrences and Fatalities
Figure 10 - Canadian-Registered Aircraft Accident Rates

Tables

Table 1 - Safety Outputs by the TSB
Table 2 - Marine Productivity
Table 3 - Pipeline Productivity
Table 4 - Rail Productivity
Table 5 - Air Productivity


The Chair's Message

When a marine, pipeline, rail, or aviation accident befalls Canadians, the Transportation Safety Board of Canada (TSB) stands ready to conduct a full and independent investigation. That is why TSB investigators report again and again to the scenes of accidents, often under the most challenging of conditions, be those scouring ocean floors for wreckage, working with hazardous debris or walking miles of track to advance transportation safety.

When our work is done, we always tell Canadians what we learned. We report what caused the accident, what underlying safety issues there are and what needs to be done to improve the safety of our transportation system. At the TSB, we believe, in some measure, that our recommendations serve to save lives, preserve the environment and protect the property of Canadians.

To this end, the past year has been another busy year for the TSB. We have released a number of high-profile investigation reports including our investigations of derailments along the Cheakamus River in British Columbia and Lake Wabamun in Alberta, our investigations of the grounding of the BC Ferries Queen of Oak Bay and the sinking of the BC Ferries Queen of the North, and numerous investigations involving private and commercial aircraft such as the loss of a rudder from an Air Transat aircraft and the overrun of an Air France aircraft at the Toronto/Lester B. Pearson International Airport in Ontario. At the same time, we undertook a number of new investigations including a capsized fishing vessel, an oil pipeline rupture, main-track derailments and two hot air balloon crashes.

No matter the occurrence, the TSB acts quickly to ensure that lessons learned are made public and passed on to those persons and agencies best positioned to take effective action and make changes. This year, the TSB made public its concern over cannabis use on board the BC Ferries Queen of the North. More recently, the Board made interim recommendations dealing with the regulation and operation of commercial hot air balloons. The recommendations are based on findings from an ongoing investigation and demonstrate that the cause of safety is quickly served once a TSB investigation begins.

By definition, the TSB is a learning organization. We learn not only about accidents and safety, we also learn about organizational growth and development, about improving our processes and about becoming more efficient. This year, I challenged the management team at the TSB to find ways of improving on the uptake of our recommendations and I am happy to report that work is well underway on this initiative.

I am confident that the TSB will continue to play a strong role to ensure that Canadians will always enjoy one of the safest transportation systems in the world.

Signature of Wendy A. Tadros Chair

Wendy A. Tadros
Chair

Section 1: Overview

1.1 Members of the Board

Wendy A. Tadros  

Chair Wendy A. Tadros
Transportation and legal experience includes Director of Legal Services for the National Transportation Agency of Canada; Inquiry Coordinator for "The Road to Accessibility: An Inquiry into Canadian Motor Coach Services"; and counsel to the Canadian Transport Commission before the Commission of Inquiry into the Hinton Train Collision.


Kathy Fox  

Member Kathy Fox
Transportation safety and air traffic services experience includes air traffic controller, commercial pilot, flight instructor, various management positions at Transport Canada, and Vice President of Operations at NAV CANADA. In 1999, received the Transport Canada Aviation Safety Award. In November 2004, was inducted into the Quebec Air and Space Hall of Fame.


Jonathan Seymour  

Member Jonathan Seymour
Transportation policy and marine management experience includes Executive Director of International Maritime Centre-Vancouver; chartering, commercial and general manager for several shipping companies; marine policy advisor to the British Columbia government; and policy and economic consultant.


James P. Walsh  

Member James P. Walsh*
Was the Member of the House of Assembly in Newfoundland and Labrador for the district of Conception Bay East-Bell Island from 1989 to 2003. Served as Minister of Works, Services and Transportation, and also served as Minister of Tourism and Culture, Parliamentary Secretary to the Minister of Finance and Treasury Board, and Parliamentary Secretary responsible for the Newfoundland and Labrador Housing Corporation. Also served as Caucus Chairman and Vice-Chair of the Public Accounts Committee. In 2003, received the distinction of Honorary Life Member of the Transportation Association of Canada.

* Member Walsh is currently on administrative leave.


R. Henry Wright  

Member R. Henry Wright
Management and consulting experience includes auditor for the Ontario Ministry of Community and Social Services; senior management administrator of several non-profit organizations; and consultant in government and public relations.

1.2 Senior Management

Executive Director G. McDonald
General Counsel A. Harding
Director General, Corporate Services J. L. Laporte
Director General, Investigation Operations T. Burtch
Director, Marine Investigations Y. Myers
Director, Rail/Pipeline Investigations I. Naish
Director, Air Investigations N. Stoss/M. Clitsome
A/Director, Engineering J. Foot/T. Givins/D. Rocheleau

1.3 Mission of the TSB

We conduct independent safety investigations and communicate risks in the transportation system.

1.4 Independence

To encourage public confidence in transportation accident investigation, the investigating agency must be, and be seen to be, objective, independent and free from any conflicts of interest. The key feature of the TSB is its independence. It reports to Parliament through the President of the Queen's Privy Council for Canada and is separate from other government agencies and departments. Its independence enables it to be objective in arriving at its conclusions and recommendations. The TSB's continuing independence and credibility rest on its competence, openness, integrity and the fairness of its processes.

Section 2: Activities

2.1 Occurrences, Investigations and Safety Action

In 2007, a total of 2119 accidents and 1390 incidents were reported in accordance with the TSB's regulations for mandatory reporting of occurrences.1 The number of accidents in 2007 decreased by 2 per cent from the 2161 accidents reported in 2006 and by 5 per cent from the 2002-2006 annual average of 2223 accidents. The number of reported incidents increased to 1390 in 2007 from 1325 in 2006, but decreased from the 2002-2006 average of 1392. There were also 886 voluntary incident reports. Fatalities totalled 155 in 2007, down 13 from the 2006 total and 26 from the 2002-2006 average.

Figure 1: Occurrences Reported to the TSB

Figure 1 - Occurences Reported to the TSB
[D]f1

All reported occurrences were examined in accordance with the Board's Occurrence Classification Policy to identify those with the greatest potential for advancing transportation safety. Information was entered into the TSB database for historical record, trend analysis and safety deficiency validation purposes.

In fiscal year 2007-2008, investigations were undertaken for 68 of the occurrences reported to the TSB. In that same period, 82 investigations were completed, compared to 57 in the previous year.2 The number of investigations in process decreased to 106 at the end of the fiscal year from 120 at the start. Average time to complete an investigation increased to 631 days in fiscal year 2007-2008 from 573 days in the previous year.

Figure 2: Investigations Started, in Process, and Completed

Figure 2 - Investigations Started, in Process, and Completed
[D]f2

Overall, the TSB has been successful in identifying safety deficiencies and in reducing risks in the transportation system. TSB investigations result in reports identifying safety deficiencies and, where appropriate, containing recommendations to reduce risks. Over this past year, in all cases where the TSB undertook an investigation, safety deficiencies or contributing factors were identified and communicated. These results reflect careful application of the TSB's Occurrence Classification Policy in deciding whether to investigate, and a thorough implementation of the investigation methodology. This systematic approach ensures that TSB investigation resources are invested in areas with the greatest potential safety payoffs.

In 2007-2008, in addition to investigation reports, the TSB issued a total of 85 safety outputs: 18 recommendations, 41 safety advisories and 26 safety information letters (see Table 1 for a breakdown by sector).

Table 1: Safety Outputs by the TSB

Sector Recommendations3 Safety Advisories Safety Information Letters
Marine 3 12 4
Pipeline 0 0 0
Rail 4 16 13
Air 11 13 9
TOTAL 18 41 26
Note: In 2007-2008, a total of 14 marine safety concerns, 6 rail safety concerns and 1 air safety concern were identified.

Safety information is also provided informally to key stakeholders throughout the investigation process, permitting them to take immediate safety actions where appropriate. It is common practice for industry and government to take safety actions during the course of TSB investigations. Such safety actions range widely in scope and importance. Operators will often take immediate remedial action after discussion with TSB investigators (for example, to clear the sight-lines at a railway crossing by trimming bushes and vegetation). Regulators such as Transport Canada and the Federal Aviation Administration in the United States regularly issue mandatory directives requiring inspections and/or component replacement based on the TSB's preliminary findings. In such situations, rather than issuing recommendations, the TSB can then report on the corrective actions already taken by industry and government agencies.

In accordance with the Canadian Transportation Accident Investigation and Safety Board Act, a federal minister who is notified of a TSB recommendation must, within 90 days, advise the Board in writing of any action taken or proposed to be taken in response, or the reasons for not taking action. The Board considers each response, assessing the extent to which the related safety deficiency was addressed. When a recommendation generates responses from within and outside Canada, the Board's assessment is based primarily on the Canadian response. This year, the TSB continued to publish on its website its assessment of industry and government organization responses to its recommendations made after 01 January 2005.

2.2 

Communicating Transportation Safety to Canadians and the Transportation Community

Communicating lessons learned is a cornerstone of TSB practice. Our efforts are maximized when cutting-edge work is made public and acted upon. To that end, the TSB undertakes a number of activities to ensure the uptake of recommendations and safety action on all of its safety communications. In large part, these activities consist of publishing investigation reports, publicizing recommendations and safety concerns and sustaining safety messages using a variety of means and venues including conferences, publications, news events and the internet.

As in past years, TSB staff and Board members have sought out and participated in conferences and symposia pertinent to transportation safety. This has allowed the TSB to extend the reach of its safety messages and to make the case for safety action to a broader audience. The TSB Outreach Program is beginning to gain momentum. This year, Board members, senior managers and staff attended 21 outreach events to present information and provide insight on transportation safety and the role of the TSB.

In 2007-2008, the TSB published 82 investigation reports, as well as annual and monthly statistical reports. During that period, 1409  ew subscribers joined the TSB website for a total of 3474 subscribers. The TSB Macro-Analysis Division responded to 341 requests for complex transportation occurrence database information.

The TSB strives to satisfy both the public and the media's expectation for up-to-date factual information. This year, the TSB added webcasting to its tool belt. Two high-profile final reports were released as webcasts and reached audiences in Europe and the United States. In total, the TSB held 4 news conferences, 4 media availabilities, issued 12 news releases and responded to 694 media calls, not including those inquiries handled at an accident site or at a report release news conference.

The TSB also uses its website to increase awareness of safety issues and other transportation safety information. The TSB website received an average of more than 91 223 daily hits and 5937 daily visits. The majority of visitors are Canadians. However, the website continues to attract visits from all around the world.

Of special significance over the reporting period was Canada's chairing of the International Transportation Safety Association and our hosting of its Annual Meeting in Ottawa. The Annual Meeting brought together representatives from Australia, Europe, Asia, and North America. It provided an opportunity for countries to share information and lessons learned in an open forum. The meeting was a great success.

In all, the 2007-2008 fiscal year was a very active year in which the TSB continued to increase its reach and stretch the envelope in its communications activities.

2.3 Marine Sector

2.3.1 Annual Statistics

In all, 453 marine accidents were reported to the TSB in 2007, a 4 per cent decrease from the 2006 total of 472 and an 9 per cent decrease from the 2002-2006 average of 497. Marine fatalities totalled 14 in 2007, down from the 2006 total of 18 and the 2002-2006 average of 22.

Shipping accidents, which comprised 87 per cent of marine accidents, reached a 30-year low of 393 in 2007, down from 422 in 2006 and from the five-year average of 447. Nearly half of all vessels involved in shipping accidents were fishing vessels. Accidents to persons aboard ship, which include falls, electrocution, and other types of injuries requiring hospitalization, totalled 60 in 2007, a 20 per cent increase from the 2006 total of 50 and a 22 per cent increase from the five-year average of 49.

Marine activity for Canadian commercial non-fishing vessels over 15 gross tons (excluding passenger vessels and cruise ships) increased by 2 per cent from the 2002-2006 average, yielding a 3 per cent decrease in the accident rate to 3.3 accidents per 1000 movements from the five-year average of 3.4. Marine activity for foreign commercial non-fishing vessels increased by 2 per cent from the 2002-2006 average while the accident rate decreased by 6 per cent decrease to 1.5 accidents per 1000 movements, down from the five-year average of 1.6.

In 2007, shipping accidents resulted in 3 fatalities, down from 12 in 2006 and the five-year average of 15. Accidents aboard ship resulted in 11 fatalities, up 5 from the 2006 total and up 4 from the five-year average.

Twenty-eight vessels were reported lost in 2007, down from the 2006 total of 34 and the five-year average of 30.

In 2007, 222 marine incidents were reported to the TSB in accordance with the mandatory reporting requirements. This represents a 3 per cent increase from the 2006 total of 216 and a 2 per cent increase from the five-year average of 218.

Figure 3: Marine Occurrences and Fatalities

Figure 3 - Marine Occurrences and Fatalities
[D]f3

One indicator of marine safety in Canada is the Canadian-flag shipping accident rate. The 2007 accident rate has remained the same as 2006 at 3.3 accidents per 1000 movements.

Figure 4: Canadian-Flag Shipping Accident Rates

Figure 4 - Canadian-Flag Shipping Accident Rates
[D]f4

2.3.2 Investigations

In 2007-2008, 6 marine investigations were started and 19 investigations were completed. The number of investigations completed more than doubled compared to last year. This is due to a reduction of new investigations started and concentration of the Marine Branch efforts on the significant report backlog. The average duration of completed investigations increased to 936 days compared to 801 days the year before. This increase is attributable to concentrated efforts to complete older investigations and focus on completion of the complex Queen of the North report, which was the largest marine investigation in TSB history.

Table 2: Marine Productivity

  2003-2004 2004-2005 2005-2006 2006-2007 2007-2008
Investigations Started 14 16 17 8 6
Investigations Completed 18 21 12 8 19
Average Duration of Completed Investigations (Number of Days) 953 881 651 801 936
Recommendations 7 4 6 0 3
Safety Advisories 6 9 5 8 12
Safety Information Letters 11 8 8 8 4
Note: Results can fluctuate significantly from year to year due to a number of factors such as staff turnover, the complexity of investigations and the investigation of major occurrences.

2.3.3 Safety Actions Taken

Three marine safety recommendations were issued in 2007-2008.

In 2007-2008, there were no reassessments of responses to recommendations issued in previous years.

2.3.3.1 Marine Recommendations Issued in 2007-2008

Striking and Subsequent Sinking, Passenger and Vehicle Ferry Queen of the North, Gil Island, Wright Sound, British Columbia, 22 March 2006

Report No. M06W0052
RECOMMENDATION M08-01

The Department of Transport, in conjunction with the Canadian Ferry Operators Association and the Canadian Coast Guard, develop, through a risk-based approach, a framework that ferry operators can use to develop effective passenger accounting for each vessel and route.
RESPONSE Awaiting response
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending
RECOMMENDATION M08-02

The Department of Transport establish criteria, including the requirement for realistic exercises, against which operators of passenger vessels can evaluate the preparedness of their crews to effectively manage passengers during an emergency.
RESPONSE Awaiting response
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending
RECOMMENDATION M08-03

The Department of Transport extend the requirement for the carriage of voyage data recorders/simplified voyage data recorders to large passenger vessels over 500 gross tonnage and all other commercial vessels on an equivalent basis to those trading internationally.
RESPONSE Awaiting response
BOARD ASSESSMENT OF RESPONSE To be reported next fiscal year
BOARD ASSESSMENT RATING Pending

2.3.3.2 

Assessment of Responses to Marine Recommendations Issued in 2006-2007


Because no marine recommendations were issued in 2006-2007, no assessment of responses was done this year.


2.3.3.3 Other Marine Safety Actions

With the coming into force of the Canada Shipping Act, 2001, on 01 July 2007, Transport Canada's new Marine Personnel Regulations took effect. Under the requirements of the Pleasure Craft Operator Card, compulsory training is required for operators of small commercial vessels supporting logging operations (TSB occurrence M07W0031).

A ship classification society issued a Memo to Surveyor for three sister ships to ensure that International Safety Management Code (ISM Code) audits verify that the master, senior officers and relevant crew members are familiar with the procedures for continually scrutinizing the vessel's side plating for cracks because these vessels may be prone to brittle fractures when operating in cold waters (TSB investigation report M02L0021).

The National Search and Rescue Secretariat, in conjunction with other agencies such as Transport Canada and the Canadian Coast Guard, sent out 10 000 reminders to vessel owners informing them of their responsibility to ensure that their emergency position indicating radio beacons (EPIRBs) are registered. A maintenance plan was also developed to ensure that the data collected in the Beacon Registry continue to be updated on a regular basis (TSB occurrence M07W0072).

Transport Canada issued Ship Safety Bulletin 06/2007 entitled Information on Persons on Board, Counting, Recording, and Special Needs. The bulletin recommends that passenger vessel owners and masters have readily available information on all persons on board that will be of assistance during emergency situations and search and rescue operations (TSB investigation report M06W0052).

Transport Canada issued Ship Safety Bulletin 07/2007 entitled Inflatable Liferafts and Rescue Platforms, Stowage and Proper Access. The bulletin urges owners and operators to stow liferafts in such a manner as to float free automatically if the vessel sinks. It also urges owners and operators that, even if liferafts are carried voluntarily, these should float free (TSB investigation report M05W0141).

BC Ferries developed a new Policy and Commitment to Employee Wellness and Substance Abuse. The policy includes a provision for mandatory testing for alcohol, drugs, and medications where "reasonable cause" exists. Information sessions regarding substance abuse were provided to northern route employees (TSB investigation report M06W0052).

2.4 Pipeline Sector

2.4.1 Annual Statistics

In 2007, 64 pipeline accidents were reported to the TSB, down from the 2006 total of 9 and down from the 2002-2006 average of 17. Estimated pipeline activity was unchanged from the previous year. The last fatal pipeline accident in the portion of the industry under federal jurisdiction occurred in 1988, and the last accident involving serious injury occurred in 2006.

In 2007, 64 pipeline incidents were reported to the TSB in accordance with the mandatory reporting requirements, unchanged from 64 in 2006 and up from the five-year average of 58. In all, 84 per cent of those incidents involved uncontained or uncontrolled release of small quantities of gas, oil and high-vapour-pressure products.

Figure 5: Pipeline Occurrences

Figure 5 - Pipeline Occurrences
[D]f5

One indicator of pipeline transportation safety in Canada is the pipeline accident rate.4 This rate decreased to 0.5 pipeline accidents per exajoule in 2007, down from 0.7 in 2006 and down from the 2002-2006 average of 1.0.

Figure 6: Pipeline Accident Rates

Figure 6 - Pipeline Accident Rates
[D]f6

2.4.2 Investigations

In 2007-2008, two pipeline investigations were started and two investigations were completed. The average duration of completed investigations has increased to 489 days, compared to 407 days in 2006-2007.

Table 3: Pipeline Productivity

  2003-2004 2004-2005 2005-2006 2006-2007 2007-2008
Investigations Started 0 0 2 1 2
Investigations Completed 0 2 1 1 2
Average Duration of Completed Investigations (Number of Days) 0 1081 922 407 489
Recommendations 0 0 0 0 0
Safety Advisories 0 0 0 0 0
Safety Information Letters 0 0 0 1 0
Note: Results can fluctuate significantly from year to year due to a number of factors such as staff turnover, the complexity of investigations and the investigation of major occurrences.

2.4.3 Safety Actions Taken

No pipeline safety recommendations were issued in 2007-2008.

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