The strength of working together
18 May 2016
Posted by Joe Hincke
Safety deficiencies must be uncovered, that’s the imperative here at the TSB. Our investigators and teams of specialists are continuously working to do just that, in addition to finding out what happened and why. But what about Board members? What is their role in the final output of an investigation report?
Who are we, and why are we here?
First, let me step back a bit and explain that members of the Board are appointed by the government, and a key criterion is their knowledge of either air, marine, rail or pipeline transportation. Take a quick look at our biographies on the TSB website and you will see that each of us holds a unique set of skills and a wealth of experience in one particular mode of transportation. As a result, when we work together, we can draw on substantial collective knowledge.
A central principle for any investigation is that it stand on the facts of the accident. Analysis of the facts must be objective and balanced, and support the report’s findings and any recommendations that are made. The complexity of the investigation determines how many Board members are involved in the development of the investigation report, but there are always at least three. If there are significant safety issues, and there’s a possibility of recommendations being made, then all Board members are usually involved from the outset of the report phase.
An important touchstone
During the report phase, the board members’ role is to review and approve the initial draft report. Because the Board has expertise in all four modes of transportation and reviews all the investigation reports, we have a broad view of the transportation industry and safety trends. As a result, we may ask that additional work be done before we approve the initial draft. For example, we may ask for more analysis on the effectiveness of a company’s safety management system (SMS), or the oversight of it, considering that SMS is on our Watchlist. Or we could request that investigators go back and do more work on a specific issue we’ve seen in other investigations.
When this first review is completed, a draft report is then sent to designated reviewers (DRs) on a confidential basis for their comments. A DR can be someone involved in the events, or companies or manufacturers whose products may be discussed in the report. They’re chosen for their potential to provide information that could enhance the completeness and accuracy of the report by correcting information or an omission, for example, or providing other information about the occurrence.
The investigator considers each of the DR’s comments individually and either amends the report or decides that no changes are needed. He or she creates a new version of the draft report, along with a separate document that shows how each comment was addressed, and submits it back to the Board for its review and approval. When the report is released to the public, each DR receives a document indicating how their comments were dealt with.
Avoiding the echo chamber
Why would we proceed this way? In the information world, there’s a phenomenon called the “echo chamber.” Basically, this is a scenario in which the same information is repeated in a closed system where differing views are obstructed—or even censored. This is the opposite of what we strive to achieve. Our process ensures procedural fairness, transparency, and openness, and provides an opportunity to improve the quality and accuracy of the report. We want to be sure that these investigations are balanced and fair, and that the facts and analysis support the findings and any safety messages—especially TSB recommendations—as the Canadian Transportation Accident Investigation and Safety Board Act requires.
From publication to the public sphere
Of course, our work as Board members extends well beyond reviewing reports. We use our voice to raise awareness of the issues we bring to light: safety deficiencies that have been identified, recently or not so recently, and that are still unresolved. We follow up on our recommendations until we reach a satisfactory response from the organizations concerned. And as much as the reports we review are dealing with accidents that happened in the past, the findings, causes and contributing factors we identify become the lens through which we look to the future—a safer future for all modes of transportation.
Joe Hincke joined the TSB after a long career in the Canadian Air Force. He was a pilot and flew the Sea King helicopter as well as serving in many varied post in Canada and abroad. He has degrees in Political and Economic Science as well as International Politics. In his spare time, Joe enjoys golf, travel and reading just about anything.
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