All reported occurrences were assessed under the Board’s Occurrence Classification Policy to identify those with the greatest potential for advancing transportation safety. It is in these cases that a formal investigation is launched. However, whether we investigate or not, all information is entered into the TSB’s database to keep records, analyze trends, and validate safety issues.
In fiscal year 2014–2015, investigations were undertaken for 50 of the occurrences reported to the TSB. In that same period, 51 investigations were completed, compared with 69 in the previous year.3 The number of investigations in progress decreased slightly to 66 at the end of the fiscal year from 67 at the start. The average time to complete an investigation increased to 506 days in fiscal year 2014–2015 compared to the previous five-year average (495).
Figure 1: Reported occurrences
|Reported incidents (mandatory)||1333.00||1349.00||1270.00||1294.00||1736.00||1834.00|
The TSB has been successful in identifying safety issues and contributing to a reduction in the risks in the transportation system. Each Class 2 and Class 3 investigation led to a comprehensive report identifying causes and contributing factors, communicating lessons learned, and, when necessary, making recommendations aimed at reducing risks. Through the Occurrence Classification Policy and investigation methodology, our systematic approach ensured that TSB resources were invested to ensure the greatest safety payoff.
Figure 2: Investigations
|2009 - 2010||2010 - 2011||2011 - 2012||2012 - 2013||2013 - 2014||2014 - 2015|
In 2014–2015, in addition to investigation reports, the TSB issued a total of 50 safety communications.
In 2014–2015, in addition to investigation reports, the TSB issued a total of 50 safety communications,4 including two recommendations, 26 safety advisories, 20 safety information letters, and two safety concerns.
Table 1: Safety communications
|Sector||Recommendations||Safety advisories||Safety information letters||Safety concerns|
Knowledge is one key TSB deliverable. Our investigations uncover the causes and contributing factors that led to an accident. As the TSB identifies safety issues, it doesn’t wait until the end of an investigation to alert industry and government. Safety information is provided to stakeholders throughout the investigation, allowing them to take immediate action—a common practice for industry and government.
For example, regulators such as Transport Canada (TC) have issued emergency directives to the railway industry requiring inspections and replacements based on the TSB’s preliminary findings. In these situations, the TSB reports on the corrective actions already taken by industry and government. When an investigation identifies a serious or systemic safety issue, the Board will issue a recommendation, which warrants the highest levels of regulatory attention.
Under 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, or of the reasons for not taking action. The Board considers each response, assessing the extent to which the safety deficiency was addressed and provides its rating of the response and its reasoning soon after. The TSB continues to publish its yearly re-assessments of industry and government responses to its recommendations.
Since 1990, the Board has reviewed the responses to a total of 559 recommendations.
Board assessments of responses to recommendations
Since 1990, the Board has reviewed the responses to a total of 559 recommendations. Many of these recommendations have led to positive change. As of 31 March 2015, Board recommendations that achieved Fully Satisfactory status increased to 76% from 74% the year before, indicating that change agents have taken action that will substantially reduce the safety deficiency. Another 5% were assessed as Satisfactory Intent, indicating that change agents have taken action or plan to take action that, when fully implemented, will substantially reduce the safety deficiency.
In 13% of cases, a rating of Satisfactory in Part was issued, which means change agents have taken or plan to take action that will only partially address the deficiency. The remaining 6% of responses received a rating of Unsatisfactory, as change agents have not, and do not plan to, take action that will address the deficiency. The Board has been unable to assess the response to one recommendation due to a lack of new information from TC.
Our goal is a safer transportation system for everyone. To help get there, we want 80% of our recommendations assessed as Fully Satisfactory by March 2017. So far, there has been progress in every mode, but not nearly enough in aviation, where too many safety issues remain outstanding.
Table 2: Board assessments of responses to recommendations, 1990–2015
|Number of recommendations||147||20||139||253||559||100|
|Satisfactory in Part||8||0||9||57||74||13.2|
|Unable to Assess||0||0||0||1||1||0.2|
|Not Yet Assessed||0||0||0||0||0||0|
Figure 3: Ratings of assessed responses, 1990–2015
|Fully Satisfactory 76%||Satisfactory Intent 4.7%||Satisfactory in Part 13.2%||Unsatisfactory 5.9%||Unable to Assess 0.2%|