Figure 4: Ratings of assessed responses to Watchlist recommendations, 1990–2015
|Fully Satisfactory 67%||Satisfactory Intent 8%||Satisfactory in Part 13%||Unsatisfactory 12%|
The following is a summary of some successes and some of the issues that persist on the Watchlist, and where more needs to be done.
Loss of life on fishing vessels
Although fish harvesters have long known that their job carries risks, one disturbing statistic stands out: approximately once a month across Canada, someone is killed in the commercial fishing industry. This figure has remained unchanged for too long, but the TSB is convinced things don’t have to be this way. In fact, in the three years since the TSB released its groundbreaking 2012 report into fishing safety in Canada, a dialogue has taken place. Whether they’re on the wharf or at association meetings, many fishermen are making safety issues top of mind. However, while industry response has been encouraging, growing awareness has not yet translated into a reduction in the number of serious accidents.
Nor has growing awareness translated into regulatory action, as TC has yet to finalize its promised fishing vessel safety regulations. In 2008, TC indicated that pre-publication of the proposed regulations was expected in the fall/winter of 2009-2010, but it has been repeatedly postponed. While the regulations are expected to play an important part in improving safety in Canada’s fisheries, the delays are unreasonable. The risk to fishermen, meanwhile, remains. For this reason, six of the Marine Branch’s active Watchlist recommendations now languish at the TSB’s lowest level of assessment: Unsatisfactory.
Railway crossing safety
Much of the improvement in safety this year stemmed from the implementation of new grade crossing regulations (GCR), which came into force on 17 December 2014. This is a major step. Given that all grade crossings must meet the safety requirements of the GCR within the next five years, the Board foresees a substantial reduction in risk. However, there must also be ongoing consultation with provincial authorities and further public driver education on the dangers at railway crossings.
Transportation of flammable liquids by rail
This is a new issue on the TSB’s Watchlist. Put simply, the increase in the transportation of flammable liquids, such as crude oil, by rail across North America has created emerging risks that need to be effectively mitigated. Although TC now requires emergency response assistance plans whenever large volumes of liquid hydrocarbons are being transported, other associated risks must also be addressed. These include better route planning and analysis, ongoing risk assessments, and the longstanding issue of the vulnerability of Class 111 tank cars—a flaw that the TSB pointed out years before the devastating tragedy in Lac-Mégantic, Quebec.
Following railway signal indications
Since 2004, there has been an average of 30 occurrences per year where a train crew did not respond appropriately to a signal indication displayed in the field. When this type of occurrence results in a train collision or derailment, it may present a significant risk to the public and the environment. Additional physical safety defences must be implemented to ensure that railway signal indications governing operating speed or operating limits are consistently recognized and followed.
On-board video and voice recorders
With no requirement for on-board video and voice recorders on locomotives, key information to advance railway safety may not always be available to accident investigators. This has occurred in a number of recent investigations, with TSB findings, recommendations and other safety communications identifying human factors as an underlying safety issue. Many of these investigations would have benefitted from a recording of crew communications and interactions immediately prior to an accident. What’s needed is for the railway industry to ensure that communications and interactions in locomotive cabs are recorded. The TSB is committed to working with the regulator and the railway industry to explore ways of making progress on this issue.
Approach-and-landing accidents continue to occur at Canadian airports. That’s why we’re calling on TC and aviation operators to take action to reduce unstable approaches. The TSB has also urged the regulator to move ahead with regulatory changes to guide airports to develop tailored solutions to lengthen runway end safety areas (RESAs) or implement other engineered systems to stop planes that overrun. These efforts continue to be delayed.
Risk of collisions on runways
There remains an ongoing risk of aircraft colliding with vehicles or other aircraft on the ground at Canadian airports, a situation industry calls an “incursion.”
Given the millions of take-offs and landings each year, incursions are relatively rare, but their consequences could be catastrophic. Since the TSB first placed this issue on its Watchlist in 2010, the number of these occurrences has remained at approximately one a day or more. Despite the Board’s concern, TC has not done enough to encourage industry to improve procedures and adopt enhanced collision-warning systems.
Safety management and oversight
Some transportation companies are not effectively managing their safety risks, and TC oversight and intervention have not always proven effective at changing companies’ unsafe operating practices. In the aviation mode, TC’s requirement for safety management systems (SMS) does not extend to smaller carriers such as air taxis and commuter airlines, or to other types of operations such as helicopter operators and flight-training schools—even though these are responsible for over 90% of all commercial aviation accidents and fatalities. In the marine mode, the TSB continues to push for the introduction of formal safety management processes on smaller commercial vessels, and TC must oversee those processes. In the rail mode, meanwhile, two problems have been observed: a failure to identify companies’ ineffective processes, and an imbalance between auditing processes and traditional inspections.
Moving forward, the implementation of three elements is key in all modes: a clear regulatory framework requiring companies to implement some form of safety management process; SMS that are effective in identifying hazards and mitigating risks; and balanced regulatory oversight and audits by TC.