Gatineau, Quebec, 3 May 2012—Highlighting outstanding safety concerns with the transportation system, the Transportation Safety Board of Canada (TSB) today released its annual reassessments of responses to Board recommendations. There were some advances, but challenges still remain.
“When investigations uncover serious safety deficiencies, we make recommendations so that future accidents may be avoided,” explained Wendy Tadros, Chair of the TSB. “That is why we look to regulators and industry for the effective and timely implementation of our recommendations.”
Safety in Canada’s rail industry saw positive movement in 2011 12, with four recommendations attaining the Board’s highest rating of “fully satisfactory.” Safety at railway crossings, however, continues to pose significant risks, as recommendations targeting the adoption of the Grade Crossing Regulations, signage for low ground clearance vehicles, vehicle collision defenses in the high speed corridor and emergency contact signage remain unresolved. Despite recent action taken by Transport Canada (TC) to review the issue of locomotive voice recorders, the Board is concerned that in the absence of this technology, data critical to our investigations will not be captured.
In the marine sector, safety has improved slightly. Following a number of regulatory changes by TC impacting voyage data recorders and emergency preparedness on passenger ferries, the TSB has reassessed TC’s responses to two recommendations as fully satisfactory. With eleven recommendations pertaining to small passenger and small fishing vessels still outstanding—some dating as far back as 1992—the safety of these vessels remains a top concern for the Board.
In contrast to the rail and marine sectors, only one air recommendation achieved a “fully satisfactory” assessment, leaving thirty two active recommendations with significant room for improvement. Since 2000, the Board has made five recommendations aimed at enhancing crew resource management, which have just recently received TC’s priority status. TC has also submitted several proposed amendments to the Canadian Aviation Regulation Advisory Council. While little action has been taken since, the Board is pleased by TC’s pilot project, which will fast-track four recommendations made in 2011.
“Every year we take stock of whether improvements have been made and what still needs to be done to address important safety issues,” added Tadros. “This year there is some progress, and that is encouraging, but in many areas we still see safety risks, risks that will persist until concrete action is taken.”
The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
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Marine Recommendations Reassessments
Safety in Canada’s marine sector has improved slightly, but complex and lengthy regulatory processes continue to hinder progress. Of the 19 outstanding marine recommendations assessed in 2012, two progressed to “fully satisfactory”, two regressed and 13 remained unchanged. The remaining two recommendations were assessed for the first time in 2012.
Fully Satisfactory Recommendations
In 2000, the Board recommended that Transport Canada (TC) require small passenger vessels to provide pre-departure briefings, be equipped with deployable liferaft and accessible lifesaving equipment, and have the means to immediately alert others during emergency situations (recommendation no. M01‑03). Since then, TC has amended several regulations and shared safety guidance with small passenger vessel owners.
The Board also identified a need for large passenger vessels to carry voyage data recorders (M08‑03). TC has amended the Voyage Data Recorder Regulations so that as of January 2012 they will address this requirement, and it has tasked its inspectors to monitor and enforce compliance through regular inspections.
Regressed Recommendations
The Board has identified a number of issues involving fishing vessels. The design and construction of fishing vessels operating in ice (M08‑04) pose significant concern. While TC’s proposed amendments to the Fishing Vessel Safety Regulations will reduce risks, more than 6,000 registered fishing vessels will be exempt from construction improvements, leaving them exposed to safety deficiencies.
Unchanged Recommendations
Other safety deficiencies involving passenger and fishing vessels have been highlighted by the Board. Dating back as far as 1992, Board recommendations have targeted anti-exposure work suits (M92‑07), stowage and launching of liferaft (M93‑03), stability booklet information (M94‑33), periodic liferaft inspections (M97‑01), emergency position indicating radio beacons (M00‑09) and fire-extinguishing systems (M05‑05). Although TC has proposed amendments to four safety and fishing vessel regulations, the underlying safety deficiencies will not be addressed until implementation is achieved.
The Board has also expressed concern regarding the fishing industry’s overall safety culture (M03-02), best practices (M03‑07) and use of hatch covers (M00-06), issues that continue to be met with limited progress. Additionally, the Board has recommended that TC collaborate with Canadian and international partners to address emergency preparedness (M03‑03), liferaft testing (M05‑03) and the transfer of maintenance and failure records to new vessel owners (M09‑01).
Unchanged / Unable To Assess
The Board was unable to reassess one recommendation (M04‑01), which targets the requirement for small passenger vessels operators to have safety management systems, because the information TC provided was unclear.
Reassessments
Rail Recommendations Reassessments
Transportation safety in Canada’s rail sector continues to see positive movement. Of the 16 outstanding rail recommendations reassessed in 2012, four progressed to “fully satisfactory” and 11 remained unchanged.
Fully Satisfactory Recommendations
In 2001, the Board recommended that Transport Canada (TC) and the Railway Association of Canada ensure that maintenance standards and practices address the level of risks in heavy tonnage “other than main tracks” (R01-04). To ensure railway personnel consistently and accurately assess track conditions, TC approved the new Track Safety Rules, which come into effect on May 25, 2012.
Following a 2004 derailment in Whitby, Ontario, the Board recommended that TC work with the Railway Association of Canada to implement rail traffic control protocols and training that will recognize periods of high workload and make safety paramount (R06-01). In collaboration with industry stakeholders, TC has evaluated the approaches at both Canadian National (CN) and Canadian Pacific and concluded that the industry has developed satisfactory processes for predicting and recognizing periods of high workload as experienced by rail traffic controllers.
In Canada, the railway industry did not track wheel sets or the date they were removed from original cars. Due to incomplete product recalls, the Board recommended that TC ensure that railways adopt procedures and technologies to track all wheel sets (R08-02). Railways have since begun using ID tags and an electronic system to track wheel sets, which will substantially reduce or eliminate the underlying safety deficiency.
In 2009, the Board noted CN’s inefficient use of safety management systems and recommended that it take effective action to identify and mitigate risks to safety, and that TC require CN to do so (R09‑03). This recommendation led CN to improve its risk assessment practices and safety culture, resulting in a decrease in non-main track derailments, employee injuries and crossing accidents. TC has also revised its guidelines on safety management systems and developed additional tools to help railways improve their safety management systems.
Unchanged Recommendations
Occurrences at railway crossings continue to pose safety risks. In 2009, the Board made recommendations for improving the visibility of emergency contact signage (R09‑02), implementing standards for low ground clearance advance warning signs (R09‑04) and assessing the effectiveness of vehicle collision defenses along the Quebec-Windsor corridor (R09‑01). While TC is working toward making progress on the Grade Crossing Regulations and advance warning highway signs, it is not yet known when or if proposed regulations and signs will be implemented. TC has deferred railway crossing safety assessments of the Quebec-Windsor corridor to rail companies.
Following a 1999 occurrence, the Board identified a need for locomotive data recorders to include on‑board voice recording systems (R03-02). In March 2012, TC referred the issue to the Advisory Council on Railway Safety, which is expected to make a recommendation within a year. In 2000, the Board also signaled a concern regarding the widespread practice of crew members not calling signals effectively and made a recommendation for implementation of additional backup safety defences (R00‑04). This safety deficiency has yet to be addressed and continues to pose a threat to the public, as evidenced by several recent occurrences, including occurrence numbers R12T0038, R11Q0011, R10V0038, R09V0230 and R11E0063. [1]
Over the past 11 years, the Board has made several other recommendations, including those on grade crossing regulations (R01‑05), ground hazard research (R07‑03), non-pressurized tank car construction standards (R07‑04) and tank car stub sill failures (R10‑01). While TC has made some progress towards addressing these files, regulatory delays continue to allow some of these safety deficiencies to persist.
Reassessments
Air Recommendations Reassessments
Limited progress has been made in Canada’s aviation sector to address outstanding safety deficiencies. Regulatory delays continue to allow unsafe conditions to persist. Of the 33 outstanding air recommendations assessed in 2012, one progressed to “fully satisfactory”, two regressed and 27 were unchanged. The remaining three recommendations saw slight improvements in 2012.
Fully Satisfactory Recommendations
Following a 1992 occurrence in Red Lake, Ontario, the Board recommended that Bombardier amend two Twin Otter manuals to include safety limitation warnings (recommendation no. A94‑17). To ensure the safe operation of this aircraft, an advisory circular and an updated manual were published. The Board now considers the risks associated with the safety deficiency to be sufficiently mitigated.
Regressed Recommendations
In 2003, the Board underlined the importance of cockpit image recorders and recommended that regulatory authorities require aircraft be fitted with such systems (A03‑08). Due to technical and social issues, Transport Canada (TC) will not pursue Canadian measures until international solutions have been adopted. The Board has therefore downgraded its assessment from “satisfactory intent” to “unsatisfactory”.
Unchanged Recommendations
Between 2000 and 2009, the Board made a number of recommendations concerning crew resource management, including pilot decision making training standards (A00‑06), approaches into convective weather (A07‑01), pilot landing decisions in deteriorating weather (A07‑03), landing distance considerations (A07-05) and crew resource management training (A09‑02). TC has since elevated these five recommendations to its list of regulatory priorities and is scheduled to submit proposals for consultation in spring 2012.
TC has made some progress towards addressing outstanding safety deficiencies by drafting several notices of proposed amendments, which it has or will soon present to the Canadian Aviation Regulation Advisory Council. These safety deficiencies include quick access recorder data (A03‑07), runway end safety area requirements (A07‑06), propulsion system reliability (A07‑08), flight recorder duration and power supply (A99‑02 and A99‑03). TC has also published proposed amendments that seek to address ground proximity warning systems (A95‑10) and is finalizing the draft of a new Canadian Aviation Regulations subpart that will address two oversight-related recommendations (A09‑05 and A09‑06).
TC is piloting an accelerated rulemaking process that seeks to fast-track changes required to reduce the risk posed by four safety deficiencies identified in 2011: safe ditching and successful evacuation (A11‑03), emergency underwater breathing apparatuses (A11‑04), emergency egress for seaplanes (A11‑05) and personal flotation devices (A11‑06).
Due to limited new information from TC, the Board maintained its previous assessment of four recommendations concerning take-off performance monitoring systems (A06‑07), carry-on baggage (A07‑07), bounced landing training (A09‑01) and visual glide slope indicator training (A09‑04).
Reassessments
