Canadian Accident Investigations Take Too Long, Survey Says

Air Safety Week, Oct 27, 2003

11) ASW: With the "revolving door" of people moving from Transport Canada to TSB, some respondents questioned the independence of the TSB. Address briefly the independence issue.

TSB: The TSB is an independent agency that reports directly to Parliament through the president of the Privy Council. The TSB does not report to the Minister of Transport. While staff do move between government departments, this enriches the capabilities of government organizations and in no way compromises the independence of the TSB.

12) ASW: It was suggested that the TSB schedule public hearings to bring out key issues and to advance safety. Does the TSB's enabling charter allow for such public hearings and what is the TSB's position on convening them?

TSB: Section 21 of the TSB Act provides for public inquiries. They would be conducted in accordance with our occurrence classification policy, which identifies a number of considerations, including: (a) whether an inquiry would uncover facts that might not otherwise be made known; or (b) whether an inquiry would result in quicker remedial action.

To date, the TSB has not deemed it necessary to use the vehicle of a public inquiry to meet its mandate.

Stakeholders' Perceptions of the TSB

Perceived strengths:

* Professionalism of staff.

* Transparency of the investigative process.

* Independence from the regulatory body, Transport Canada.

Perceived weaknesses:

* Inordinate length of time to complete accident investigations.

* TSB takes its independence too far, isolating itself from industry.

* Shortcomings, gaps in accident/incident database categorized by aircraft, engine type & causal factors.

* Unclear investigative criteria (incidents not involving loss of life or significant damage not investigated, yet these may have significant safety implications).

* Inadequate resources (TSB only tends to fully investigate "spectacular" accidents like Swissair).

* Recommendations not always linked to findings.

* Some evidence (from recommendations) that the TSB operates on an unrealistic assessment of risk tolerance (e.g., zero) vs. regulators and the industry's acceptance of a reasonable level of risk.

* Poor marketing of work products and services.

* Need for more work on macro safety studies that transcend the particulars of individual accidents.

Source: Sage

A Sampling of TSB Investigations

Accident Date: 14-Jun-02
Circumstances: Air Canada A330 tail strike on takeoff at Frankfurt/Main
Report Approved: 29-Apr-03
Elapsed Time: 10 mos.

Accident Date: 6-Jun-02
Circumstances: Cessna 182 Skylane VFR flight into adverse weather, collision
with terrain, Needle Peak, BC
Report Approved: 12-Mar-03
Elapsed Time: 9 mos.

Accident Date: 14-Jun-01
Circumstances: Bombardier CL-600 false ILS localizer capture, Victoria Int'l.
Airport, BC
Report Approved: Aug. 13, 2002
Elapsed Time: 14 mos.

Accident Date: 22-May-01
Circumstances: First Air B737 hard landing at Yellowknife
Report Approved: 19-Jun-02
Elapsed Time: 13 mos.

Accident Date: Jan. 24, 2001
Circumstances: Lufthansa B747-400 collision with icing truck at Toronto
Report Approved: 3-Jul-02
Elapsed Time: 18 mos.

Accident Date: 12-Jun-00
Circumstances: WestJet B737 cabin depressurization, 120 NM of Kelowna, BC
Report Approved: Dec. 4, 2001
Elapsed Time: 17 mos.

Accident Date: Sept. 2, 1998
Circumstances: Swissair MD-11 crash at Halifax, in-flight fire
Report Approved: 27-Mar-03
Elapsed Time: 55 mos.

Accident Date: 18-May-98
Circumstances: Kelner Airways PC-12 engine failure/forced landing at
Clarenville, Newfoundland
Report Approved: Feb. 4, 2000
Elapsed Time: 21 mos.

Accident Date: 18-Jun-98
Circumstances: Propair Metroliner II, wheel well fire, separation of wing in
flight in attempted landing at Mirabel
Report Approved: 28-May-02
Elapsed Time: 47 mos.

Accident Date: Dec. 16, 1997
Circumstances: Air Canada CL-600 loss of control on go-around at Fredericton
Report Approved: 15-Apr-99
Elapsed Time: 17 mos.

Source: TSB