Canadian Accident Investigations Take Too Long, Survey Says

Air Safety Week, Oct 27, 2003

Vital safety messages, recommendations diluted with passage of time

The Transportation Safety Board (TSB) of Canada has been sharply criticized for taking too long to complete major accident investigations, according to a survey of officials in that country's transportation industry.

"With only a few exceptions, everyone complained about the length of time between an investigation and the availability of the occurrence report," said a summary of the responses from industry "stakeholders" in Canada.

The TSB was perceived as carrying out its mandate, but taking so long that some respondents deemed the timeliness of its work products "to be totally unacceptable."

Canadian-based Sage Research Corp. conducted the survey and covered all modes of transportation in which the TSB is involved: air, marine, rail and pipeline.

To be sure, some accidents are more complicated than others, not only to unravel, but also because of the numerous and often interrelated safety issues involved. The fatal 1998 crash of Swissair Flight 111 stands as a case in point. The $56 million investigation took more than four and a half years to complete, consuming on average more than $1 million per month (see ASW, April 7). A sampling of 10 TSB accident investigations covering a range of causes and a variety of aircraft types shows an average time-to-completion of about 22 months.

The Sage report may be a window into a worldwide problem. Virtually all accident investigation bodies are marginally resourced, with lean staffing levels the prevailing norm. A 1999 Rand Corp. study of the U.S. National Transportation Safety Board (NTSB) reads in many respects like a parallel product of the Sage Survey of the situation in Canada (see ASW, Dec. 13, 1999). Respondents to the Sage survey perceived many strengths and weaknesses in the TSB's operation, but lack of timeliness led the list of perceived weaknesses.

As of October 22, the TSB has 71 ongoing aviation accident investigations, of which 28 are more than a year old. This workload is being carried by 56 TSB aviation accident investigators. That number reflects two recent hires to beef up the staff and to help reduce the backlog of active investigations.

The TSB was invited to respond to a number of key issues raised in the 98-page Sage report. Those responses follow:

1)ASW: Did the TSB commission this independent assessment and, if so, why?

TSB: Yes. The objective of the project was to develop a comprehensive understanding of our stakeholders' needs related to our products and services. The study confirmed that stakeholders do appreciate the contribution TSB makes and the value of receiving our reports.

2) ASW: One of the universal complaints from the stakeholder survey was the perceived excessively long time between the accident and final report. Swissair 111 took more than four years to complete. In the U.S., National Transportation Safety Board Chairman Ellen Engleman has set as a goal that major accident investigations should be completed in two years (see ASW, Sept. 15). How might the time to complete some of these investigations be accelerated? Is there an intrinsic tension between pushing to completion at a sacrifice in depth? Recall the aphorism, "If you want it bad, you get it bad."

TSB: We are committed to producing complete and professional reports on transportation occurrences in a timely manner. Having said that, we will take the time needed to ensure a thorough and meaningful final report. However, our primary interest is getting the safety message out as quickly as possible to those who can best act on the information. By way of example, during the course of the Swissair 111 investigation, 14 recommendations were issued by the TSB, six of these in the first year of the investigation and prior to the publication of the final report.

With respect to improving the timeliness of our investigation reports, the TSB has been reviewing its processes to identify opportunities for streamlining. To achieve that, we have introduced training in areas such as investigation management and communicating safety deficiencies. We are exploring other options for getting our safety messages out.

3) ASW: Stakeholders complained that the TSB has stopped working on safety studies and providing safety workshops.

TSB: We are undertaking a complete review of the role of safety issues investigations.

The TSB continues to offer training to other agencies in such subjects as safety investigations and the investigation of human factors, as time and circumstances permit.

4) ASW: The TSB was criticized for not marketing its products and services more effectively. How do you respond?

TSB: This is important and valuable feedback. The TSB is committed to increasing the level of awareness of our products and services. As well, the TSB is working to enhance the availability of safety information through the Internet.

5) ASW: Some stakeholders said the TSB focuses on large, regulated carriers and accidents involving loss of life and substantial damage, to the detriment of investigating cases where no lives were lost or significant damage occurred, but which have significant safety implications. How do you prioritize your resources?