Canadian Accident Investigations Take Too Long, Survey Says

Air Safety Week, Oct 27, 2003

TSB: Approximately 4,000 transportation occurrences are reported to the TSB each year in accordance with reporting requirements. Practical considerations dictate that only a small proportion of these be investigated. But most reported occurrences by themselves offer little scope for adding to the board's knowledge of the underlying safety deficiencies. Decisions to investigate occurrences are based on this policy, which is available on the TSB's web site at: http://www.tsb.gc.ca/en/common/policies/occurrences.asp.> 6) ASW: Some respondents thought the TSB should more actively investigate issues, even in the absence of occurrence(s), to identify latent threats to safety. Do you have the resources for this, and if you did, should you?

TSB: To date, our safety issues investigations have been based on trends or issues arising from occurrences reported to us. All safety issues that come to our attention are assessed and a decision to investigate a particular issue is based on the criteria of our occurrence classification policy.

7) ASW: Occurrence reports were criticized for not being clear about the steps/actions needed to plug identified gaps/lapses in safety. How do you respond?

TSB: The TSB, as part of a thorough investigation process, makes public its findings as to causes and contributing factors. In addition, when warranted, safety recommendations are made directly to those change agents who are in the best position to make the required changes.

8) ASW: Numerous stakeholders lamented the lack of a usable, searchable accident/incident database.

TSB: A searchable web-based database has been developed by the TSB, and we are currently in the process of readying it for public use.

9) ASW: Complaints were raised that the TSB is not investigating accidents that occur outside Canada. The Air Transat A330 dead stick landing in the Azores comes to mind, which the Portuguese are investigating. What are the ground rules governing TSB investigations of Canadian-registered aircraft involved in accidents/incidents overseas?

TSB: The TSB is the government department responsible for ensuring that Canadian safety interests are represented in investigations conducted by foreign governments involving Canadian operators, aircraft, regulators and products. The responsibility is mandated by the provisions in the International Civil Aviation Organization's Annex 13.

The TSB has some involvement with approximately 100 foreign investigations per year, although our investigators only deploy to approximately eight international investigations per year.

Regarding the investigation into the Air Transat fuel-starvation event of August 23, 2001, the TSB contributed significantly to the investigation and now awaits the release of the final report by the government of Portugal.

10) ASW: Of recommendations that are generated, some stakeholders said that not all are linked to findings of safety deficiencies. Should they be?

TSB: Policy requires that all TSB recommendations be based directly on validated safety deficiencies.