The TSB then and now
7 April 2016
Posted by Johanne Ostiguy
When it was first created in 1990, the TSB's approach was one of “quiet professionalism”. While the investigators and specialists conducted thorough investigations, leaving no stone unturned to uncover the root cause of transportation incidents and accidents, their work attracted little attention. Even the Board's recommendations were issued without much fanfare. Most reports were sent to the regulators, stakeholder organizations and the people involved (or their next-of-kin), but were not widely distributed (bear in mind that reports had to be printed back then). Only reports on high-profile occurrences were printed and publicized through the distribution of a news release. As is still the case today, some of the most significant occurrence reports were released at media events.
That is the time when my public service career started at the TSB, when the organization was still in its infancy. Upon joining the Communications team, my role was to edit aviation occurrence reports. Shortly thereafter, I assisted with the editing and translation of the TSB Manual of Investigation Operations for the Marine Branch. By virtue of working closely with the team lead for this project and with Marine investigators, I was soon recruited as bilingual editor for that mode.
Turning up the volume
About four years after the creation of the TSB, in an effort to reach a broader audience with our safety messages, a new magazine, Reflexions, came to life, and I was glad to take up the challenge of being involved in the production process. This modal quarterly publication (i.e., 12 issues a year, 4 per mode — Aviation, Marine, and Rail/Pipeline — on a rotating basis) consisted of summaries of the occurrence reports that offered the best opportunities for lessons to be learned from our investigations. Paper copies were mailed out to organizations in the transportation industry for distribution within their ranks; individuals could also subscribe to our mailing list.
This magazine, which was published more or less regularly from 1993 to 2005, did achieve its primary goal of reaching many people working in the field and increasing their awareness of unsafe and dangerous practices. However, the summary information it contained was not aimed at encouraging regulators and industry stakeholders to take measures to address the safety deficiencies identified by TSB investigators. Also, the public was largely unaware of the existence of Reflexions and, to a lesser extent, of the TSB's mandate and activities.
Eventually, I left the TSB to pursue other opportunities outside the public service and in other government departments. When I returned to the TSB in 2013 after a 12-year absence, I was struck by the change of approach – gone were the days of “quiet” professionalism.
Making our voice heard
All Class 2, 3 and 4 investigation reports are now posted on our website and a news release highlighting the Board's findings and related safety action is published in all cases. We issue notices when a TSB team of investigators deploys to an occurrence site or when the TSB launches an investigation. The TSB website has an active investigation page (AIP) for all ongoing investigations. We are active on social media, with our YouTube channel, and our Flickr account, where we regularly post photos of occurrences; and we now have well over 15 000 followers on Twitter. Furthermore, the responses of the regulators and other organizations to Board recommendations are assessed, and the results are published on an annual basis.
In addition, every two years, the Board publishes a Watchlist of the issues posing the greatest risk to Canada's transportation system. All of these activities contribute to greater transparency, better accessibility to our safety messages for the media, and to improved availability of our investigation reports for the Canadian public. In turn, this increased visibility helps focus the attention of regulators and industry on the safety deficiencies that need to be addressed.
Some things never change
We might be aware of how technology has improved the TSB's capacity to recover and analyze data and hence to conduct its investigations. However, we may not realize to what extent technology, the Web in particular, has enabled us to share safety information quickly and efficiently with stakeholders and the public. (Note to self: Keep that in mind next time I'm frustrated by my computer not responding quickly enough.) Of the many things that have not changed over the TSB's 25 years of existence, however, is the professionalism of the staff, the determination of investigators to get to the underlying systemic issues that led to accidents in order to improve transportation safety, and the widespread team spirit that contributes to our world-class investigations. It's great to be working among such dedicated people again, contributing to making our safety messages heard far and wide.
Johanne Ostiguy worked at the TSB first as an editor then as Head, Editorial Services, between 1990 and 2002. After more than a decade away working in the private sector and in other government departments, Johanne came back to the TSB in 2013 to support the Lac-Mégantic investigation team during the report-writing phase, and has been a member of the Publishing Services unit since that report was released. Johanne loves to visit her two children who live overseas (in Scotland and in Germany) when time allows. Otherwise, she can be found touring Frank Lloyd Wright houses or poring over books with his designs.
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