Notes for an address by
Mr. Terry Burtch
Director General of the Transportation Safety Board of Canada
To the International Airline Passengers Association (IAPA) - Annual Conference
April 28, 2004
Good morning and thank you for coming.
As many of you know, today's conference coincides with National Mourning Day, a day to remember workers killed or injured on the job.
One of the best ways to commemorate those workers is to share our collective insight and expertise on occupational health and safety.
This conference provides us with an excellent opportunity to do just that.
The theme for this year's meeting provides a good introduction to my own remarks today.
Knowledge In Motion is all about tapping into vital information - from a wide variety of sources - to advance safety in the workplace.
This approach is the hallmark of IAPA's success since its inception some eight decades ago.
My remarks will explore how the Transportation Safety Board of Canada takes on a similar approach.
And if there is one message I want to impress upon you today, it's this: transportation safety increasingly relies on the cooperative efforts of stakeholders.
That's because it's the best way investigators can access the expertise and information needed to conduct a thorough investigation - one that delivers meaningful results in advancing safety transportation.
This spirit of cooperation is more pressing today than ever before.
Transportation transcends international boundaries... and lessons learned in one jurisdiction must be lessons learned by all jurisdictions.
Take aviation for example.
We're experiencing a massive increase in air traffic.
More than 1.6 billion people use the world's airlines for business and pleasure. This is expected to grow to 2.3 billion people by 2010.1
We've enjoyed many benefits since the Wright Brothers' first flight some 100 years ago.
Yet we've also paid a tragic price for progress. More than 46,000 people have lost their lives during this century of flight.2
We cannot repeat history. And we won't - if we continue to build closer working relationships among all stakeholders.
To this end, we must understand and embrace our respective roles to ensure the safe passage of people and goods in Canada and around the world. And be sensitive to the key elements that support seamless and streamlined investigations.
I want to outline the role we play at the TSB in doing just that, and in turn, highlight the way in which we can work together to advance workplace safety.
Let me begin with a brief overview of our role at the TSB.
The TSB is an independent body that investigates accidents with the purpose of advancing safety and to report publicly on our investigations.
Our focus is straightforward: We examine what happened; why it happened; and how we can help ensure it never happens again.
The TSB takes a systemic approach to all our investigations. That means we examine the individual parts of the whole incident, and we look at how all elements and events relate to each other.
This approach leads to a detailed understanding of an accident and thorough safety communications.
It's important for everyone to understand that we don't assign blame. We focus on the safety deficiencies and bring them to light for regulators and industry to act upon.
Furthermore, we won't find answers in haste, despite the pressure we may receive to do so.
As our Executive Director, David Kinsman, wrote in the London Free Press: "we understand the natural inclination to rush to judgment. But... the TSB will not cut corners, or rush complex processes. This would not enhance safety, nor advance the interests of Canada's travelling public."
Now let me turn to specific role during an investigation.
As many of you know, investigations are complex undertakings. Just consider the Georgian Express Flight 126, which led to the death of the pilot and 9 passengers off the shore of Pelee Island in Lake Erie earlier this year.
The TSB arrived within 24 hours of the accident. Our investigator-in-charge brought a team of 9 TSB specialists. Other specialist advisers/responders to the occurrence included the NTSB, the FAA, Cessna and Pratt & Whitney Canada.
We immediately began working alongside a multitude of agencies-the Coast Guard, coroner, police and Transport Canada-all of whom were carrying out their own responsibilities.
Undertakings during the initial stage of the TSB investigation included wreckage recovery and examination, a review of records and interviews with witnesses.
The second stage is an analysis of all information gathered to date. This often leads us to the TSB's engineering lab in Ottawa, where amongst other activities, experts examine wreckage and test selected components and systems, read and analyze recorders and other data, and create simulations and reconstruct events.
The third and final stage involves the drafting of a report, which is sent in confidence to the parties involved for their review to ensure the report's accuracy and procedural fairness. Once the Board approves the final report, it is released to the public.
We believe our success with this and all investigations relies on our ability to work with a variety of stakeholders throughout the entire investigation.
And the fact is everyone benefits from this cooperative approach.
For instance, the TSB keeps relevant parties informed of any safety deficiencies as soon as they're identified.
This allows regulators and the transportation industry to act upon discovered deficiencies as soon as they have been validated, and often before a final report is published.
Ongoing dialogue pays off.
We've seen a gradual decline in accidents across all modes over the past decade. More importantly fatalities are decreasing and in some cases are at historic lows.
We believe this downward trend is linked to sharing information with stakeholders.
Let me illustrate this point with an example from our marine division. A few years ago, a Great Lake Bulk Carrier hit a bridge in the seaway which resulted in a fire.
The subsequent investigation determined that there was a lack of awareness of the firefighting techniques to be used by shore fire fighters. During the investigative process, seaway officials, fire fighting crews and municipal and federal officials along with TSB investigators shared information that resulted in the development of a local emergency plan and training program.
This program goes along way in addressing a safety deficiency.
In the best cases, transportation safety is advanced before the final report is published.
Let me turn to another example - one of the best known cases in Canada and around the world.
The crash of Swissair Flight 111 into the waters southwest of Peggy's Cove, Nova Scotia resulted in the loss of the 229 passengers and crew members. Determining the facts about this terrible tragedy was a lengthy and complex process.
Time was needed to sift through and examine millions of pieces of shattered aircraft recovered from the ocean floor; as well as the 250 kilometres of electrical wiring - much of it no longer than an index finger.
We also needed to conduct an extensive array of flight and laboratory tests and analyze the series of events that led to the plane's demise as well as work alongside a wide range of dedicated and determined stakeholders... international regulators, airline operators, manufacturers, unions ..
All together, the investigation spanned five years.
During this time the TSB issued 14 of the total 23 safety recommendations, many of which were being acted upon by the time the final report was published.
That's why we can confidently say that airline safety has already been enhanced through the collective efforts of transportation stakeholders.
Now, to this point I've discussed our role in advancing safety, and how we all benefit from sharing information with other groups involved in transportation safety.
I want to turn to two challenges related to this cooperative approach. One is perceived, the other is real.
Let's first talk about the perceived challenge.
I mentioned earlier that the TSB is an independent body.
Some stakeholders may perceive our independence is at risk if we cooperate with those directly involved in an incident.
I understand their concern. The independence of accident investigation authorities must not be put at risk or perceived as such. Our role remains to report findings to the public in an impartial and unbiased way, with the sole aim of advancing transportation safety.
Without this independence the TSB could not expect any party involved in an incident to provide us with full disclosure.
But does that mean we cannot dialogue with industry and regulators? Not at all. The key is to share information, not responsibilities.
The fundamental factor in the TSB's cooperative approach is that the TSB and "observers" share a common interest, that being advancing safety.
In my opinion, the more pressing challenge relates to the key element that underpins cooperation, that being good communications.
In our experience there are three factors that can influence good communications during an investigation. They relate to roles and responsibilities; information sharing; and personal conflict.
I've already spoken about our role and responsibility.
It's important for each investigative team to have an understanding or acknowledgment of each party's mandate and purpose on site. That way we can see "eye-to-eye" on how an investigation should be carried out.
This is especially critical if the incident has led to loss of life, is complex in scope and fueled intense public scrutiny.
In such cases, cooler heads must prevail.
That's why the TSB has established formal working relations with local authorities, coroners and other stakeholders.
These Memoranda of Understanding (MoU's) identify and dictate protocol, as well as outline respective roles and responsibilities.
For instance, our investigators recognize the legal mandates of the provincial coroners overlap with our own when a fatal incident occurs.
It's for this reason why an agreement was struck between the two parties to address key issues around control of site prior to the removal of human remains; possession of the human remains and wreckage; and ongoing access to the site.
These and other guidelines enable us to streamline efforts during the critical moments following such an occurrence.
In my experience, there have been occasions when individuals have been unaware of our agreements with their respective organizations. This has led to inefficiencies in the investigation process. So, I encourage you to find out if your organization has an arrangement with the TSB.
A related issue to roles and responsibilities is information sharing.
You've heard me talk about our commitment to share information with other groups, particularly as it relates to safety deficiencies. In fact, much of what we do is guided by open and honest communications.
It's not uncommon, for instance, for the TSB to invite a person with a direct interest in an investigation to observe the process. Of course they must be professional individuals who can provide a positive and meaningful contribution to the investigation.
However, there are times when the TSB has certain limitations in the information it can share with other organizations and individuals.
For instance, we do not allow other organizations to join us as we conduct witness interviews. Moreover witness statements are privileged and cannot be shared with other organizations.
By no means do we prevent other organizations to speak with witnesses. And we certainly regularly provide investigation updates to appropriate organizations.
Having said that, we understand how our inability to share this kind of specific information may look. And we recognize it may draw out the investigation process by duplicating efforts.
Yet the law of the land demands it. Remember that our mandate is solely to advance transportation safety. We don't assign blame or point fingers.
It would be difficult to extract all relevant information if witnesses thought our motivations were otherwise. That's also why, for the most part, we're not compelled to act as witnesses in any civil or criminal hearing.
To be sure, appropriate authorities would be notified if we believed a criminal act caused an accident, but in all other cases the witness information gathered is confidential.
Most organizations appreciate our position once they understand our role and responsibility.
And there's a lot still to gain from sharing information on studies and recommendations, accident data, and best practices in investigation techniques and methodologies.
The key is to be aware of and respect each organization's purpose onsite.
Problems can still arise, many of which focus on personalities rather than investigative protocols.
This leads me to my third and final point on supporting good communications during an investigation: personal conflicts.
Personal conflicts are rare and unique occasions. For the most part, our experience is that all organizations on site share the same spirit of cooperation and professionalism, and the common interest of advancing transportation safety.
This is not a tactic on our part to apply intense pressure on those who we have differences with; rather, it's a way to move the issue off-site. That way front line workers can focus on the job at hand, and take direction from their superiors once the issue has been resolved.
We do our best to preempt these scenarios with a variety of internal programs designed to enhance interpersonal skills and better understand the respective role of other investigative bodies.
We also participate in other courses offered by first responders. Most importantly the TSB values the feedback from stakeholders. We encourage your organizations to let us know when we have worked well together and when we haven't.
If an issue arises on site, and it can't be resolved in the field, we tend to enlist the help of our senior management.
The TSB is committed to a cooperative approach to investigations. And we'll continue to seek out new ways to work with others to expand our collective interest in protecting the public's right to the safest transportation system.
For instance, the Marine Investigations program has become increasingly involved in providing safety information based upon our investigations to persons or groups involved in improving safety.
On both coasts, TSB marine investigators participate in meetings with fish harvesters as well as regulators and other marine interests where multi agency programs have been developed to increase awareness of fishing safety. Also, marine investigation branch persons participate in similar meetings and forums relating to the safe operation of passenger vessels, response to emergency situations, and commercial vessel operation.
This kind of approach is critical for a world on the move.
That's why we will all require better coordination and solutions. These can only come from closer working partnerships... helping to identify safety deficiencies and the changes needed to address them.
This begins by a better understanding of our respective roles in advancing safety. Also, we must be sensitive to the key elements that support seamless and streamlined investigations.
On this day - a day to reconfirm our commitment to occupational health and safety - let's begin to forge stronger relationships with the shared objective to build a safer future in transportation.
- Date modified: