Evidence of meeting #9 for Transport, Infrastructure and Communities in the 39th Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was investigation.

On the agenda

MPs speaking

Also speaking

Wendy A Tadros  Acting Chairman, Transportation Safety Board of Canada
David Kinsman  Executive Director, Transportation Safety Board of Canada
Nick Stoss  Acting Director General, Investigation Operations, Transportation Safety Board of Canada
Clerk of the Committee  Mr. Georges Etoka

11:10 a.m.

Conservative

The Chair Conservative Merv Tweed

Good morning, everyone, and welcome to the Standing Committee on Transport, Infrastructure and Communities.

Today we're studying safety solutions on all modes of transportation and security.

Just to advise the committee, we have about a four-minute video presentation, but we're having some technology concerns with it. So I've asked that we start, and hopefully by the end of the meeting we'll be able to view the DVD.

With us today is Wendy Tadros, Nick Stoss, and David Kinsman. I would ask them to start, and then we'll have questions to follow.

11:10 a.m.

Wendy A Tadros Acting Chairman, Transportation Safety Board of Canada

Thank you, Mr. Chairman and honourable members, and thank you for your indulgence while we try to get our technical difficulties squared away.

Good morning to all. Bonjour.

I appreciate the opportunity to appear before your committee to discuss the important work of the Transportation Safety Board of Canada. I want to talk to you about the way in which we work to advance safety in all modes of transportation for the benefit of all of our communities. Specifically, I want to talk to you about how we work to bring about change through the safety solutions we offer government and industry.

I bring with me today a wealth of experience: Mr. David Kinsman, our executive director; and Mr. Nick Stoss, our acting director of investigations operations. The three of us will try our very best to help you and Canadians to understand the vital role played by the Transportation Safety Board of Canada.

The TSB is an independent organization the sole mandate of which is to promote transportation safety by conducting investigations into maritime, pipeline, rail and airline accidents.

Our role will always be to inform the public about what happened, why it happened, and to suggest solutions. The TSB is not a regulator or a court; that means we don't make laws, nor do we find guilt or assign blame.

If they get the video up and running, we'll show it at the end, if that's all right. The video will tell you a little bit about who we are, but I also want to explain how we work and how we contribute to solutions for transportation safety.

Approximately 4,000 transportation accidents and incidents are reported to the TSB each year. These occurrences are wide-ranging, from accidents involving small aircraft to engine-room fires on ships, and from pipeline ruptures to train derailments. Some have resulted in major loss of life, and others only in very small damage.

When we are notified of an occurrence, we collect the available information, often deploying an investigation team to the site. And Canadians have come to identify us with the big TSB letters, les lettres BST, on the shirts and jackets worn by our investigators.

After the initial assessment, we decide if a full investigation is warranted. This decision hinges on whether there is significant potential for reducing future risks to persons, property, or the environment and, consequently, whether there is a high probability that transportation safety will be advanced. Once an investigation is under way, if we find unsafe conditions, we do not wait for our final report to make these known; we act immediately by communicating with those who can make transportation safer.

Along the way there are a number of tools we use to communicate risks. We may do this through interim safety recommendations, as we did most recently in the Ryan's Commander and Morningstar Air Express investigations, or we may choose to send out safety advisories, safety information letters, or safety communiqués.

When all is said and done, our role is to advise the public, regulators, and industry about what happened, and why it happened, in an impartial and unbiased way. Ultimately, we do this by making all our reports and all our recommendations public.

Just to provide you with a little bit of a snapshot. In 2005-2006 the TSB made 75 investigation reports public, issuing 12 safety recommendations, 21 safety advisories, and 22 safety information letters. Many of these communications have already led to concrete solutions by industry and regulators to mitigate risks, and thereby improve safety.

Our big payoff comes when everyone agrees during the course of an investigation about what needs to be done. Safety deficiencies are addressed quickly, and rather than making recommendations, we report the progress in our final report.

Recent safety actions resulting from our work include improvements made by CP Rail to their rail traffic control system as a result of our Whitby investigation, and measures to address risks to passengers and crew that came to light during the Joseph and Clara Smallwood investigation.

Sometimes, interim recommendations are the best course of action, and they too are effective. In the course of our Pelee Island investigation, the board concluded that pilots needed better tools to assess weight. We recommended that actual passenger weights be used for small aircraft, and that standard weights for all aircraft be increased to reflect current realities.

In January 2005 Transport Canada began a review of the way in which weight is determined for small aircraft. They also adjusted standard weights, making travel on all aircraft safer. And in the Morningstar Air Express investigation, we made two interim recommendations on the winter operation of Cessna 208 aircraft. Significant safety action has been taken both here and in the U.S., and we have come a long way toward making winter flights in Cessna 208s safer all over the world.

In the marine world, our recommendation made during the investigation into the capsizing of the Ryan's Commander has resulted in positive interim measures to ensure stability of fishing vessels.

This being said, the TSB does not impose changes on the transportation industry and regulators; solutions to transportation safety are a shared responsibility amongst players, and our job is to make a convincing case for change. When our recommendations go unheeded, I think we need to find a stronger voice to influence those who can make transportation safer.

Over the past year, in an effort to make the case for change and to find our voice, we have invested in two key initiatives. The first is to issue more investigation updates so that the public, the regulator, and the industry will know more, earlier on, about our investigations. This is a bit of a balancing act, because we're trying to provide factual information that has been proven without prejudging the final outcome of the investigation.

The second important initiative has to do with tracking the action taken. We are actively monitoring responses to our recommendations, and clearly communicating our assessment of those responses to those who can improve safety. And we are posting those responses and our assessments on our website at www.tsb.gc.ca.

It is my hope that our independence, steadfast processes, and the technical accuracy of all our work have fostered public trust in the Transportation Safety Board. The more our work is understood by parliamentarians and Canadians, the more everyone will have greater insight, the next time we are in the news, into what we do and how we work to ensure a strong and safe transportation system.

I think at this point the video is ready, so we're going to show you the short video that we have.

[Video Presentation ]

I also have the same video in French if you would like us to play it.

I'm glad we were able to get that up and running, because I think it really is quite good.

I hope the video and my remarks have given you a taste of the very complex but important work the TSB does, and that you will pass on this information to your constituents and encourage them to visit our website.

If any of you are interested, we would be more than pleased to welcome the members of this committee to visit our engineering laboratory. Our laboratory is the cornerstone of much of the work we do, work that is internationally recognized. A tour of the facility provides a real visual understanding of the leading-edge scientific work done by TSB investigators.

In closing, let me assure you that everybody at the board is fully committed to improving transportation safety.

We firmly believe that we have improved and will continue to improve transportation safety in Canada and abroad.

Thank you.

Now we would be pleased to answer any of your questions.

11:25 a.m.

Conservative

The Chair Conservative Merv Tweed

Thank you very much, and we certainly appreciate your getting the video working for us.

Questions?

Mr. Hubbard.

11:25 a.m.

Liberal

Charles Hubbard Liberal Miramichi, NB

Thank you, Mr. Chair.

It's certainly very good to know we have an active group working toward improving safety in various modes of transportation.

The name of the organization.... In most industries safety is an ongoing process that tries to avoid accidents, but it appears the Transportation Safety Board would only have a job if there were accidents. Is that correct? Without accidents, there is no work? Could you explain what you do when you don't have accidents?

11:30 a.m.

Acting Chairman, Transportation Safety Board of Canada

Wendy A Tadros

We have never faced that situation.

11:30 a.m.

Liberal

Charles Hubbard Liberal Miramichi, NB

You've never faced that situation? But to follow up on that question, the main concern is to avoid accidents. Could you give some response in terms of industry and the various parts of industry, how they are working with you as partners to avoid accidents?

I think of the Cessna 208. That wasn't the first report where there were problems with that plane. There had been similar difficulties on the west coast with that before, and your report was a major factor in limiting the capabilities of the Cessna 208.

In your review of that safety situation, were you aware before that accident in the west where the pilot took off with some icing--I don't know what the load was, but I think it was within limits--were you aware there was a problem with that plane before the accident happened with the Morningstar delivery of parcels?

11:30 a.m.

Acting Chairman, Transportation Safety Board of Canada

Wendy A Tadros

Let me back up and start with the beginning of your question.

The mandate Parliament has given us is to investigate accidents. So when there is an accident and we think there is something we can learn, those are the accidents we investigate. We try to find out what happened and why it happened and then we look at the underlying safety deficiencies. When we look at the underlying safety deficiencies, that allows us to determine whether there are problems in the system. If we determine there are problems we communicate those.

With respect to the Cessna 208, yes, there were some previous accidents, but we learned much more on the Pelee Island accident than we ever knew before, and on the Morningstar we learned even more, because on the Morningstar investigation we believed we had an aircraft that took off clean and encountered icing conditions. That allowed us to learn an awful lot more about the performance of the aircraft in those conditions, and that is why we made interim recommendations on the Morningstar.

11:30 a.m.

Liberal

Charles Hubbard Liberal Miramichi, NB

Just to clarify, it seems there's a void here. You are looking at the accident after it happened, but who was out there trying to prevent the accident from happening?

I see people here from the railway group. We have reports that the New Brunswick East Coast Railway are not maintaining their railbed. They've reduced the speed limit on the trains between Miramichi and Bathurst because of the declining railbed. We know there's going to be an accident. The speed has been reduced to about 60 kilometres an hour, when it could be up to 90 or 100 kilometres an hour.

Do you feel that the industry is really active in making sure accidents don't happen before you're called upon to investigate either a derailment or some problem with the railbed that would cause the closure of that line?

11:30 a.m.

Acting Chairman, Transportation Safety Board of Canada

Wendy A Tadros

I think inspecting the railways or other industries and putting safety regulations in place is within the purview of the Minister of Transport. We investigate, and everything we learn that we think could be of benefit to those communities or the regulator is communicated.

11:30 a.m.

Liberal

Charles Hubbard Liberal Miramichi, NB

There was nearly a 10% increase in railway accidents in 2004. We can go back to the years before that and look at the Burgess, for example, in British Columbia, the problems with derailments, and some of the misadventures there. Do you feel that the companies and Transport Canada are active enough in trying to prevent those types of accidents?

On page 7 you say, “When our recommendations go unheeded, I think we need to find a stronger voice...”. What do you mean by that? Who should the voice be to influence those--it must be Transport Canada--who can make transportation safer?

11:30 a.m.

Acting Chairman, Transportation Safety Board of Canada

Wendy A Tadros

Let me go back to the beginning of your question on the increase in rail accidents.

We have to be careful about the data we receive and the statistics. In 2004-05 the number of derailments was up substantially, but in the first quarter of this year it was down substantially. So before drawing any conclusions, I think you have to look at the whole trend and treat those statistics with caution.

From our perspective, we investigate each accident, each occurrence, to try to determine the underlying factors. If there are factors in common, we can do a safety issues investigation. But on the rail, derailments were up in 2004-05 and that caused some public concern, but again in the first quarter of this year they were down. So those are things we watch carefully.

The second part of your question was about our voice. We make all of our recommendations public. The Minister of Transport has 90 days in which to answer what he will do about not only our recommendations, but the findings on cause and contributing factors that we outline in our reports.

We also have very good and strong communications with the industries we investigate. So more often than not there is positive action. Every once in a while we like to tweak it a little bit.

11:35 a.m.

Conservative

The Chair Conservative Merv Tweed

Mr. Laframboise.

11:35 a.m.

Bloc

Mario Laframboise Bloc Argenteuil—Papineau—Mirabel, QC

Ms. Tadros, I'd like to focus on your comments respecting the rail industry. You've tried to temper somewhat the statistics on rail accidents that occurred in 2004 and 2005. You claim that the number of accidents decreased in the first quarter of 2006, but that statement is hardly reassuring to the public. It's clear to Canadians that the number of accidents has increased in recent years.

What steps are you taking in an effort to improve the condition of the rails and thereby reduce the number of rail accidents? I'd like an answer to that question because I get the impression that you focussing on individual cases and that you're not so concerned about the overall picture. We are. It's all well and good to analyse every single accident that occurs, but the number of such incidents is on the rise. We expect a number of recommendations from you to reverse this trend.

Does the TSB make general recommendations about the state of the rail industry in Canada? Would you like your mandate to include responsibility for formulating policy guidelines or general recommendations? Perhaps you do not have the authority to do that, but we would like you to have that authority.

11:35 a.m.

Acting Chairman, Transportation Safety Board of Canada

Wendy A Tadros

On your question about our mandate, we have a full mandate to make any recommendations that we see fit. So if we are able to demonstrate, through one or a number of investigations, that there's an underlying safety deficiency, we do not hesitate to make a recommendation that the deficiency be addressed.

On the statistics, I did say that they bounce all over the place. You have to really stand back and take a careful look at the underlying factors at play. We are investigating a number of derailments this year, and thus far there doesn't seem to be any one pervasive factor. There are always a number of contributing factors. So we work objectively and methodically to determine what happened and why so that we can figure out if there are any systemic issues that need to be addressed. If we do find those systemic issues, we make recommendations.

11:35 a.m.

Bloc

Mario Laframboise Bloc Argenteuil—Papineau—Mirabel, QC

So then, you're telling me that since 2003, 2004 and 2005, there haven't been enough rail accidents to compel you to make a recommendation about the state of the industry in general.

11:40 a.m.

Acting Chairman, Transportation Safety Board of Canada

Wendy A Tadros

No, that's not exactly what I'm saying. I'm saying that before you make a recommendation you have to demonstrate, through proper investigation methods and using the tools available to us, what exactly is the problem and what are the issues that need to be addressed. We need to do that through solid scientific methods. If we do find that there are matters in common, that's what we do.

11:40 a.m.

Bloc

Mario Laframboise Bloc Argenteuil—Papineau—Mirabel, QC

Consequently, there are not enough common denominators at this time to make a recommendation with respect to the rail industry. Earlier, for instance, you stated that the TSB had made a recommendation concerning the fatigue experienced by airline employees. Therefore, you likely had enough evidence on file to make such a recommendation. However, you claim that with respect to the rail industry, you don't have enough evidence yet to make a recommendation about the quality of the rail network.

11:40 a.m.

Acting Chairman, Transportation Safety Board of Canada

Wendy A Tadros

We have enough information to make comments on the specific accidents, and in a number of the ongoing investigations we have safety communications on a number of issues. But if you're asking me whether there's one kind of Eureka thing that we think is going on, the answer is no. We investigate each accident fully to determine what happened and why.

11:40 a.m.

Bloc

Mario Laframboise Bloc Argenteuil—Papineau—Mirabel, QC

My next question pertains to your budget the amount of which is negotiated directly with the government. Do you operate with a fixed annual budget, or does it fluctuate, based on your requirements?

11:40 a.m.

Acting Chairman, Transportation Safety Board of Canada

Wendy A Tadros

It's really both. For 2006-07, the operating budget of the Transportation Safety Board is about $25 million. We have a staff of about 240, and about 75% of our budget is for salaries. We also have a provision that when we have a very large investigation, such as the investigation involving Swiss Air 111—and we have a number that are ongoing at the moment—we can go to Treasury Board to request and demonstrate and make a case for additional funds.

11:40 a.m.

Bloc

Mario Laframboise Bloc Argenteuil—Papineau—Mirabel, QC

Are investigations always carried out by the same staff members? Do you hire people to work on contract or do you consult with other departments to acquire the services of experts? Do you have the in-house expertise you need?

11:40 a.m.

Acting Chairman, Transportation Safety Board of Canada

Wendy A Tadros

We generally have most of the specialists we need. You can't predict when accidents are going to happen, so there are fluctuating needs. We also contract with experts in Canada and have relationships with other investigating bodies around the world. We sometimes contract with the National Research Council and people who have very specialized expertise, but the bulk of our expertise is in-house in those 240 people.

11:40 a.m.

Bloc

Mario Laframboise Bloc Argenteuil—Papineau—Mirabel, QC

Can you tell me approximately what percentage of your budget is spent on outside experts?

11:40 a.m.

Acting Chairman, Transportation Safety Board of Canada

Wendy A Tadros

I will ask Mr. Kinsman to respond.

I'm not sure there's an exact--

11:40 a.m.

David Kinsman Executive Director, Transportation Safety Board of Canada

We'd have to do some research in order to come up with the exact figures. However, I would have to say that it's a small percentage of our budget. As Ms. Tadros indicated, most of our investigators have the necessary skills and expertise to start and complete an investigation. Occasionally, in light of the current technology in use in the four transportation sectors, we may not be certain that our expertise is the best. In such instances, we call upon the services of outside experts. As for the percentage of our annual budget spent on outside experts, it's really quite small. In most cases, I think it's substantially below $200,000.