Evidence of meeting #8 for Transport, Infrastructure and Communities in the 40th Parliament, 3rd Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was transport.
A recording is available from Parliament.
9:25 a.m.
Conservative
The Chair Conservative Merv Tweed
Welcome back.
Joining us today from the Transportation Safety Board of Canada we have Wendy Tadros, chairman; Mark Clitsome, director of investigations, air; and Jean Laporte, chief operating officer.
Thank you for joining us today. I know you have a presentation and then we'll go to questions. Please begin.
April 13th, 2010 / 9:25 a.m.
Wendy Tadros Chair, Transportation Safety Board of Canada
Mr. Chair and honourable members, I want to thank you for inviting the Transportation Safety Board of Canada to appear before your committee. I bring with me today solid experience: Mr. Jean Laporte, the TSB's chief operating officer; and Mr. Mark Clitsome, who is in charge of all the aviation investigations that we do at the Transportation Safety Board.
Twenty years ago Parliament created the Transportation Safety Board of Canada to conduct independent investigations, no matter whether the accident was on our waterways, pipelines, railways, or in our skies. The creation of the TSB was an investment in Canada's future; it was an investment in the infrastructure that is critical to our country's economic and social health.
This investment has paid dividends to Canadians by making us safer as we move ourselves and our goods across this country and around the world. For twenty years we have reported to Canadians and made it clear what needs to be done to make the system safer. And Canada now enjoys one of the safest transportation systems in the world.
Even so, Canadians expect that we at the Transportation Safety Board work to make it even safer. That is why we will continue to conduct independent, expert investigations. We will inform Canadians about what happened, why it happened, and we will suggest solutions to industry and government. When the board feels that not enough has been done to address the safety issues we have uncovered, we will speak up, as we did last month with our watchlist.
On March 16, the Transportation Safety Board of Canada launched its watchlist, and I'm going to take you on a very brief tour. On it are nine critical safety issues that must be tackled to make Canada's transportation system safer.
In Marine, there are two issues. The first is fishing vessel safety. Almost half of the marine accidents reported to the TSB are fishing vessel accidents. On average, one Canadian a month dies in a fishing vessel accident. The challenges we face are pervasive in the fishing industry; they range from vessel stability to safety culture.
The second marine issue involves Canada's ferries. Our ferries enjoy a good safety record, but we all need to be mindful that tens of millions of passengers rely on them each year. There are over 100 large passenger ferries, and roughly half of these can, and do, carry over 400 people on a regular basis.
At the board we've learned the hard way that these vessels need to be better prepared for an emergency. If there is an accident, ferry operators need to know how many people are on board. Everyone is more likely to get off safely if crews have practised realistic exercises.
In rail, the watchlist speaks to a collision every two weeks between a passenger train and a vehicle at one of Canada's 20,000 railway crossings. The board is calling on the railways and Transport Canada to take the time to figure out which level crossings pose the greatest risk and then do what is necessary to bring the number of collisions down.
The second rail issue is the operation of longer, heavier trains. In the last 15 years the weight and length of trains has increased by 25%. Marshalling is the order in which trains are put together. If you liken a long train to an accordion, pulling forces tend to separate the cars and pushing forces will compress them together. When lighter, more empty, cars are placed in the train without regard to these forces, the result can be a derailment.
Longer, heavier trains have to be marshalled and operated with safety as the imperative. We think that the rail industry understands the importance of this, but on the ground our investigators find that vigilance sometimes flags. While it is very early days, I can tell you that in our investigation of the recent derailment in Pickering, Ontario, we will be looking very carefully at marshalling and its impact on in-train forces.
Moving on to aviation, there are two watchlist issues related to safety at Canada's airports. The first issue concerns conflicts on the ground. While the likelihood of these conflicts is quite low, by focusing on improved procedures and enhanced collision warning systems, we think the risk at Canada's busy airports can and should be lowered even further. We are also concerned about the millions of aircraft that land at Canada's airports. Accidents can happen on the runway, or aircraft can run off the end. We learn hard lessons from all our safety investigations.
When an Air France aircraft ran off runway 24L in Toronto, we learned we had a problem, and this problem has continued. In a recent publication of the Flight Safety Foundation's AeroSafety World, Canada was shown to have more than twice the rate of runway overruns in wet conditions than the rest of the world. Building sufficient runway end safety areas, or the alternative, engineered material arresting systems, will be difficult and it will take political resolve to make the ends of Canada's runways safer.
Another aviation issue the TSB focused on is called controlled flight into terrain. In Canada between 2000 and 2009 an unsuspecting crew flew a perfectly good aircraft into the ground 129 times. Let me try to put that figure in perspective for you. This represents just 5% of aviation accidents, but nearly 25% of all fatalities. The answer to this problem is technology; it's to fit smaller aircraft with terrain awareness warning systems, and we must get on with it.
The last two watchlist issues are common to marine, rail, and aviation. The first one I want to talk about is data. Recently the TSB participated in an International Civil Aviation Organization safety meeting in Montreal, where the world grappled with the challenge of recovering the recorders from Air France flight 447. To do our job, the Transportation Safety Board of Canada needs objective data from onboard recorders--an airplane's black box, a locomotive's event recorder, or a ship's voyage data recorder. The patchwork of requirements we have in Canada is no longer acceptable. We need to ensure that when there is an accident the safety board will always have secure, retrievable data.
The last issue on the watchlist that I want to discuss with you is safety management systems. This is an issue in marine, rail, and aviation, but because I know you are now studying aviation safety, I will focus on SMS in the aviation world. I also want to talk about business aircraft and the lessons learned from our Fox Harbour investigation.
The Transportation Safety Board has consistently emphasized the advantages of safety management systems. I want to be really clear about that. These systems are a powerful, internationally recognized management tool to help organizations find trouble before trouble finds them. At the board we think SMS is the right way to go, but to make these systems work there needs to be a firm and consistent commitment from companies, and oversight from the regulator is critical.
Safety management systems have been fully implemented by Canada's 35 large carriers--those are the CAR 705 carriers, which transport most passengers in Canada. It should be noted that our large carriers have a very good safety record. The challenge to come, in our view, will be with the rest of the aviation industry--Canada's air taxis, helicopter operations, commuter airlines, and flight training schools. For smaller companies, whether they operate commercial or business aircraft, Transport Canada will need to closely monitor the industry to ensure all are on board and there is a smooth transition to SMS. This is something we will be paying special attention to in our investigation.
Then there is the unique case of business aircraft. Let me stress that it is a unique case. Let me put the issue in context and tell you about our Fox Harbour investigation.
About a decade ago, Transport Canada and the Canadian Business Aviation Association began to transfer responsibility for certification and auditing to the CBAA. This transfer of responsibilities was premised on the CBAA maintaining a number of conditions. I won't go into all of those conditions, but I specifically want to talk about the condition on safety management systems.
The intent was for the CBAA to require each business aircraft operator to have a functioning safety management system. When a Global Express aircraft touched down short of the runway in Fox Harbour, Nova Scotia, the TSB's investigation took an in-depth look at the transfer of responsibilities and at the implementation and functioning of the SMS in the business aviation community. What we found was that while commercial operators were required to implement SMS in stages, on a fixed timeline, business operators were free to implement SMS on their own terms with no fixed timeline.
This meant many, including the operator in Fox Harbour, did not have a fully functioning SMS. This operator, for instance, did not properly assess the risk of introducing a larger aircraft to its fleet, in accordance with sound safety management principles. That is why the board recommended that the CBAA set SMS implementation milestones for its certificate holders and that Transport Canada ensure that the CBAA put in place an effective quality assurance program to audit certificate holders.
On March 16 of this year, Transport Canada went one step further and decided to take back the certification and oversight of business aviation. This change will come into effect on April 1, 2011. I must say, the TSB is pleased with this outcome.
As is our practice, we will continue to monitor the response to this and all board recommendations and we will be reporting on whether progress has been made. When efforts come up short, as they did with the nine issues on our watchlist, the TSB will report to Canadians and challenge industry and government to step up and make transportation safer.
The early reactions by the regulator and industry to the watchlist have been positive. On the vast majority of issues we are in agreement about the safety issue, but they are on the watchlist because progress has been far too slow and the problems we identified over and over in our investigations have not been fixed. Sometimes I think this is because industry consultations drag on and that is part of the regulatory process, and sometimes it's because the regulatory process itself is not nimble enough to deal with critical safety issues.
Let me leave you with this thought. Perhaps we should have a faster, more streamlined way of dealing with regulatory changes that are necessary for the safety of Canadians.
Thank you. Merci de votre attention.
Now we would be pleased to answer your questions.
9:35 a.m.
Liberal
Joe Volpe Liberal Eglinton—Lawrence, ON
Thank you, Mr. Chair.
Ms. Tadros, Mr. Clitsome and Mr. Laporte, thank you for your address.
Madam Tadros, you seem to be positive about the first reaction of regulators and industry, but the fact of the matter is that you keep reporting the same thing over and over again—not in the same details, but the issues are still there. What does government not have in its quiver of arrows that's required in order to resolve the problems that you identify?
9:40 a.m.
Chair, Transportation Safety Board of Canada
I think government has all the tools they need to make the changes to address these important safety issues, but I think sometimes it's a question of priorities. It's our hope that these nine critical safety issues will rise to the top of the priority list.
9:40 a.m.
Liberal
Joe Volpe Liberal Eglinton—Lawrence, ON
Ms. Tadros, that shocks me, because in all of the cases you talked about accidents. That's injury and fatality. If there's another priority that's higher for this government, would you please point it out for us?
9:40 a.m.
Chair, Transportation Safety Board of Canada
It's not my role to point out the priorities of the government. My role is to tell you and to tell the Canadian people what are the nine critical safety issues that we need to have addressed right away, and that's what we've done with the watchlist. So from the perspective of the Transportation Safety Board, these are the priorities in the transportation world in Canada today.
9:40 a.m.
Liberal
Joe Volpe Liberal Eglinton—Lawrence, ON
On your watchlist, you indicate the priorities of the issues that require urgencies, and reaction or response is fine, but action is better. Your watchlist tells us that there has been no action. Yet one of the things you ask for is more complete data. Is that data requirement going to improve your reporting? Or is it going to improve the government's political will to do anything about what you report?
9:40 a.m.
Chair, Transportation Safety Board of Canada
I think it's a combination of things. When we see an investigation where we have all of the data recorders and the cockpit voice recorders, then I call tell you that's a more thorough and a more scientific investigation. We are able to go further with that investigation than in one where we don't have the recorders. Too often the recorders are not on--not on the vessel, for instance--or on trains they are burned in a fire, or on aircraft sometimes they are lost.
I think if we have the data we need to demonstrate that there is a safety issue and then we're able to make a more compelling argument for change. So that's why we are calling for better recorders.
9:40 a.m.
Liberal
Joe Volpe Liberal Eglinton—Lawrence, ON
What I hear when you tell me those things, Madam Tadros, is that you are unconvinced that government--this government, because that's the one we're talking about now--is capable of listening to the evidence.
For example, when a plane gets off the runway--you said there were 129 incidents--when there are fatalities from planes that come down, when you talk about train derailments that happen excessively, with greater frequency, and there are injuries and fatalities associated with them, when you talk about the number of marine accidents with vessels on a monthly basis, I don't know how much more evidence one would require than seeing a corpse or a mangled body as an indication that there is a problem. And pardon me for being so blunt. I'm hearing you tell me that government is always responding, that this government is always responding with the issue that perhaps it is a human error, i.e., the fault of the operator. Otherwise, what purpose will the other evidence provide you?
9:40 a.m.
Chair, Transportation Safety Board of Canada
I don't think that's what I said, with respect.
9:40 a.m.
Liberal
Joe Volpe Liberal Eglinton—Lawrence, ON
I'm not accusing you. I'm saying that this is what I'm hearing when you're telling me these things.
9:40 a.m.
Chair, Transportation Safety Board of Canada
I'll just make a quick correction, because we at the Transportation Safety Board do not talk about the fault of the operator.
When there's an interface between man and machine, we try to figure out why an individual did what they did so that we can understand the whole context of the accident. But I don't really think that's the point. I think the point is action in terms of the lessons that we've learned from our investigations.
If you look at the uptake on the recommendations, we rate the response to 67% of our recommendations as fully satisfactory. For most of the remainder, there's agreement with the regulator that this is a safety issue and that this needs to be done. What happens is, from there to implementation it takes far too long.
9:45 a.m.
Liberal
Joe Volpe Liberal Eglinton—Lawrence, ON
So what I'm hearing, then, again, is if the Minister of Transport is unwilling or unable to satisfy the gap between your recommendation and the satisfaction that would eliminate the need for your recommendation, somebody is being negligent, and when there's injury or fatality, that negligence borders on the criminal. That's what I'm hearing, and that has to be what the purpose of your recommendations to the public would be. Somebody has to do something.
I'm looking for a recommendation that tells me what the next step is. I've been in government, so this isn't a partisan issue. Safety and security shouldn't be partisan issues. If your recommendations on an ongoing basis tell us that people are at risk as a result of what's in the air, on a track, on a road, or in the water, then surely somebody has to assume the responsibility. What I'm hearing you tell me is that the minister's not assuming his responsibility.
9:45 a.m.
Chair, Transportation Safety Board of Canada
The initial feedback we have from Transport Canada has been very positive, so it is my hope that there will be a positive reaction to each and every one of the issues on the watchlist.
I think part of the problem is the regulatory system. When we go out and do an investigation, it can take up to a year. It's incredibly detailed, scientific, expert work. That work is then given to the regulator and to industry. In aviation, for instance, if there is agreement, and Transport Canada has done a risk assessment following our investigation, it goes to an industry-government committee called CARAC. That can take years and years. When there is an agreement coming out at the end of that, you have the regulatory process, which can also take years and years. For instance, in rail, there have been proposals to create new grade-crossing regulations. They have been in the works for more than 20 years. We have the issue in aviation of CFIT accidents, for which the answer is technology. We first identified this issue in 1995, and work started on regulatory changes in 2003. We're now in 2010.
It really is my belief that there needs to be a streamlined process for those regulatory changes that the government has agreed need to be made. If they affect safety, there needs to be a streamlined process.
9:45 a.m.
Conservative
9:45 a.m.
Bloc
Mario Laframboise Bloc Argenteuil—Papineau—Mirabel, QC
Thank you, Mr. Chairman.
I'm trying to get a clear understanding of how to proceed because this is a real maze of regulations. You think it's taking too much time. Let's take pilot fatigue as an example. There was a story on the subject on the CBC. Today you're making a report and suggesting priorities for all transport sectors. The pilot fatigue issue isn't in your report today. Why?
9:45 a.m.
Chair, Transportation Safety Board of Canada
There are a number of issues in transportation safety. There are many issues. We took all the issues we had looked at over the last 20 years and decided which were the most pervasive and which presented the highest risk. While we watch and always look at the issue of pilot fatigue in each of our investigations, it didn't arise as the central cause in any of our investigations.
Do you want to add anything?
9:45 a.m.
Mark Clitsome Director of Investigations, Air, Transportation Safety Board of Canada
We've conducted a number of investigations over the years in cases in which pilot fatigue has been a contributing factor. We've made no recommendations on that fact, because up to this point it's not the regulations that have been a problem. When we identify an investigation of pilot fatigue, we look at whether the pilot was fatigued inside of the regulations or outside of the regulations.
As of now, the regulations are sufficient for pilot fatigue.
9:50 a.m.
Bloc
Mario Laframboise Bloc Argenteuil—Papineau—Mirabel, QC
According to the CBC, 12 aircraft accidents have occurred in the past 10 years for which the Transportation Safety Board of Canada, your office, has determined that fatigue was one of the causes. Is that true?
9:50 a.m.
Director of Investigations, Air, Transportation Safety Board of Canada
It contributed.
9:50 a.m.
Bloc
Mario Laframboise Bloc Argenteuil—Papineau—Mirabel, QC
Fatigue contributed to it.
I think there's a problem. Perhaps you didn't read it, but when Mr. Grégoire appeared before our committee and we discussed fatigue, he told us that had never been a recommendation by the Transportation Safety Board of Canada. He said that, even though a report had been submitted to Transport Canada in 2001 requesting that it examine the matter of pilots' biological clocks and fatigue and stating that this was important, the Transportation Safety Board of Canada never made an actual recommendation. Was Mr. Grégoire right in saying that?
9:50 a.m.
Director of Investigations, Air, Transportation Safety Board of Canada
That was correct.
9:50 a.m.
Bloc
Mario Laframboise Bloc Argenteuil—Papineau—Mirabel, QC
I sit on this committee to try to protect the lives and health of citizens when they use a means of transportation. You say that fatigue contributed to a dozen accidents over the past 10 years, but that isn't important enough for you to make a recommendation to Transport Canada.
9:50 a.m.
Director of Investigations, Air, Transportation Safety Board of Canada
The result of the investigations on pilot fatigue has to do with pilots who are fatigued outside of the regulations. For example, there is a maximum number of hours a pilot can fly in a day, in a month, and a year. There is a minimum requirement for pilots to have a certain amount of rest in a day between flights. The investigations that we've conducted indicated that these pilots were exceeding those maximums and that's why they were fatigued.