Notes for remarks by
Mrs. Wendy A. Tadros
Board Member of the Transportation Safety Board of Canada
To the Empire Club of Canada - Our Collective Role in Transportation Safety
February 26, 2004
Thank you Mr. President for that kind introduction.
It's only fitting that I speak to you about our transportation system in a Hotel that owes its existence to a railway company.
The Royal York Hotel was the ninth property developed by Canadian Pacific Railway -- a company whose fortunes were closely tied to our nation's.
CP's first president, Sir William Van Horne, understood this symbiotic relationship. That's one reason he described his growth strategy in the following way:
"If we can't export the scenery," he'd say, "we'll import the tourists."
Sadly, Sir William did not live to see the Hotel's grand opening in 1929 - but it was, nevertheless, a fitting tribute to his career.
That's because the Royal York earned the immediate distinction as the tallest building in the British Empire.
To be sure, its 28 stories made a mark on the city's skyline - some would say an exclamation mark - that declared emphatically Toronto's presence in Canada and around the world.
Since then, this grand hotel has attracted more than 40 million guests ; and pumped millions of dollars into the local economy.
The hotel's origins touch upon a key theme in Canadian history: our transportation industry has played a vital role in our national prosperity.
But I'd argue its future contributions will be more critical.
Globalization demands it.
As the Throne Speech noted:
"Canada is a trading nation. And a 21st century economy is an economy open to the world. Canadian goods, services, capital, people, and knowledge must be able to reach international markets."
The public and private sectors are focused on a transportation system that ensures national prosperity in the new millennium.
Key initiatives include integrated transportation services with North America and the world; seamless intermodal links; innovative transportation technology; competitive rates and services, and so on.
But all these activities would fall - like a house of cards- if the industry could not fulfill its public duty of maintaining a safe and sound transportation system.
It's the prerequisite to participate in the global economy.
Everyone knows safety cannot be compromised. And it's a given that government "must maintain its role as a vigilant watchdog1."
But the private sector's role is often overlooked and undervalued in advancing safety.
And, ironically, it's the private sector that sometimes does not appreciate the contributions it can - and must - make in a world on the move.
This I think can be attributed, in part, to a misunderstanding of roles.
Our research shows that many industry players have high regards for the Transportation Safety Board of Canada. But some are concerned that we're not proactive enough in the prevention of accidents or promotion of safety issues2.
Let me be frank: government organizations, such as the TSB, cannot advance public safety alone. Nor, as I shall point out later, is this our intention.
We all have a role to play - and that includes Canada's private sector, which we call upon to address risk in an appropriate and realistic manner.
This approach works. Consider some stats:3
There were 541 marine accidents reported to the TSB in 2003 ... that's comparable to the 1998 - 2002 average of 537. But more importantly, fatalities reached a 29 year low of 18 ... down from 34 during the same five year period.
Furthermore, Canadian aircraft - other than ultralights - were involved in 297 accidents in 2003. This represents an 8 percent decline from the 1998 - 2002 average. There were also slightly fewer fatalities last year against the five year average ... 58 fatalities compared to 65.
These are good numbers. But our work is not done, as two recent tragedies attest.
On January 14th, a freight train derailed two intermodal container cars, as it approached a highway underpass near Whitby. One of the containers crushed a vehicle on the street below. Two people died.
Only a few days later, a small plane crashed in Lake Erie, killing 10 people.
The public has a right to know what happened with both accidents. And they will. But some want answers even before all the evidence is gathered or analysed.
I call this the "CNN effect" because the demand for new information can sometimes outpace the supply. When this happens speculation runs rampant.
As our Executive Director, David Kinsman, wrote in an opinion piece for 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 traveling public."
Still, the intense pressure is a sign of the times.
The public expects more. As one observer4 explains:
"Life is safer than it has ever been, but we are no longer prepared to accept any risk in anything we do,"
And if the public thinks the industry players - regulators, manufacturers, carriers, associations - are not responding to their safety concerns, I can assure you, they'll find other ways to influence practices and policies.
So what must our collective course be to ensure our ongoing prosperity as well as maintain public confidence in the transportation system?
I believe we must be guided by an open and honest dialogue…and a desire to advocate change.
Dialogue and advocacy: These are the two principles I'll discuss today. Let me, by way of introduction to the TSB, explain what these two principles mean to us.
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 if we're looking at the failure of a single part, we look beyond what physically happened - to all other factors at play.
This approach - recognized by safety experts around the world as the most meaningful - leads to a detailed understanding of the occurrence and thorough safety communications.
We don't assign blame. We focus on the safety deficiencies and bring them to light for regulators and industry to act upon.
I want to emphasize this last point. As soon as a deficiency is identified, we immediately inform industry players involved in the investigation. It's important to know that we don't wait for a final report to take action.
That's exactly what we did last year with regards to our investigation into the collapse of a wooden bridge in McBride, B.C.
As recent media reports state: The TSB informed the regulator and CN that it had not addressed all of the bridge's safety deficiencies. Our investigation continues.
More times than not our major investigations do produce recommendations. These too can be deemed a success if the industry takes swift action.
To be sure, the transportation industry is committed to the best system in the world. Everyone knows that accidents bear too many costs and strain too many resources.
But on occasion the industry and regulators have been slow to react to recommendations. And, in some cases, they have failed to implement them thoroughly.
This leads me to the first principle in advancing transportation safety. We need the commitment of the industry's leaders to support an ongoing dialogue with us and to advocate change.
The 1997 accident at Field Hill, in the Canadian Rockies stands out as a model of cooperation and success.
Let me provide you with a brief overview.
A westward train derailed 66 cars during an uncontrolled high-speed descent of "Field Hill."
We now know the crew was unable to control the speed after the train was set in motion on the steep descending grade- with a depleted air brake system and a dynamic brake that was not engaged.
A variety of factors such as a series of inappropriate train handling decisions and certain railway operating procedures contributed to the accident.
Over the course of the investigation, senior management of the railway took an active interest in the factors at play; and made important policy and procedural changes to mitigate the risk of it happening again.
Working with the TSB, these executives initiated safety enhancements to improve their operations, training and locomotive design. As a result, our final report had no recommendations, nor expressed any safety concerns.
We need this case to be the norm - not the exception.
That's because detailed investigations - by their very nature - demand ongoing dialogue between investigators and industry.Simply put: it's the best way lead investigators can access the expertise and information they require to do their job.
To this end, we must commit to a greater focus on sharing information on studies and recommendations, accident data, as well as best practices in investigation techniques and methodologies.
The TSB encourages a company's involvement in the development of our reports. And we believe ongoing dialogue is an important part of the process.
That means if a company is involved directly or indirectly in an accident, we welcome its input ... it's OUR way of testing the theories in the draft and ensuring we have the facts straight before making them public.
Let me remind you that our role will always be to inform the public about what happened and why it happened - in an impartial and unbiased way.
Still, we believe our ongoing dialogue will not interfere with our independence. The key is to ensure that cooperative activities with industry groups have more to do with sharing information than sharing responsibilities.
Dialogue is the first of two principles to fulfill our collective responsibility in advancing transportation safety. The second is advocacy. Its aim is to ensure our efforts take effect.
The successful completion of the Swissair Flight 111 investigation is a case in point.
Its crash into the waters off Peggy's Cove resulted in the loss of the 229 lives. Determining the facts about this terrible tragedy was a lengthy and complex process - more than 4 years to complete.
One year ago, we reported that a fire started in a hidden area above the cockpit ceiling. The fire started from an electrical wire arcing event, that ignited flammable material on thermal acoustic insulation blankets.
The fire then spread across the surface of the insulation blankets, where other flammable materials ignited.
As a result, the fire intensified, leading to the deterioration of the cockpit environment, the loss of some of the aircraft's systems, and the eventual loss of the aircraft.
Make no mistake, Swissair was a terrible tragedy. But positive outcomes have been realized. Boeing, Swissair, Transport Canada, the FAA, the NTSB and the Airline Pilots Association, all committed to change.
Twenty-three recommendations came from this investigation with the first of 14 interim recommendations issued six months after the accident.
This can be considered a success by anyone's definition.
To be sure, airline safety has been enhanced. Important upgrades, for example, have been made to flammability standards for aircraft materials.
But more work needs to be done. It will take many years for the airline industry to eliminate all flammable materials on aircraft.
We're okay with that - it's realistic to factor in economic realities, and to allow time for technological advances.
But there are other more immediate steps one can take to mitigate the risk of fire onboard. We would like to see the industry adopt an integrated, comprehensive firefighting strategy for crews.
Operators believe the industry is capable of developing such a plan, but have been hesitant to initiate change on their own.
As a result, little progress has been made in this area, despite the important findings uncovered during our investigation.
It now falls to regulatory bodies such as Transport Canada and the Federal Aviation Administration in the U.S. to institute mandatory policies on firefighting in order for meaningful change to come about.
I want to be clear: the Swissair stakeholders have done a great deal to advance safety through our investigation.
But advocacy is easier said than done. Two reasons come to mind.
First, it requires organizations to champion safety issues in a more proactive way.
We're not dreaming the impossible dream. I've met with industry leaders who are very active in addressing safety issues. One railway company - Burlington Northern Sante Fe - is a case in point.
This company working with the NTSB in the U.S., tracked all outstanding safety recommendations and set about implementing them. Today, they are able to report, they've taken action on all of those concerns.
The second reason why some organizations have not embraced their advocacy role is because they still view safety as a cost - not an investment.
Ultimately, it's up to industry leaders to figure this one out. I can only encourage them to think hard about the cost/benefits of preventative measures stemming from our investigations.
We know the benefits of working together on an investigation. Imagine the impact we could have, working alongside the industry in every investigation, to bring about change.
Earlier on I spoke about the investment made by one railway company in this Hotel. Coincidentally, the same year of its launch, an executive from another railway company addressed the Empire Club.
Sir Henry Thornton paid tribute to all those who had made Canadian National a powerful industry player.
Thornton said and I quote:
"If the Railway has achieved any material degree of success it has been due to that co-operative spirit, that freedom with which advice is offered, and that unity of effort..."
Co-operative spirit. Unity of effort. These phrases can also be applied to the enviable track record Canada has earned in transportation safety.
As our experiences with Field Hill and Swissair attest, our success is based on our combined efforts to establish meaningful dialogue and advocate change.
We need to build upon these efforts. The global economy demands it and Canadians deserve nothing less.
Transportation transcends international boundaries … and lessons learned in one jurisdiction must be lessons learned by all jurisdictions.
That's why the TSB works closely with ten other national investigative bodies - including the National Transportation Safety Board - to "improve transport safety in each member country by learning from the experiences of others5."
Its clear: Our industry's expertise is needed to promote a safe and sound transportation system in Canada, and around the world.
By doing so, we'll honour our industry's legacy - by contributing to our country's future prosperity.
1. Paul Tellier, as CEO of CNR, 2000
2. TSB Stakeholder Review, February 28, 2003, page 5
4. Alice Thompson, Daily Telegraph quoted in Know the Risk Learning from Errors and Accidents: Safety and Risk in Today's Technology
5. Refers to the International Transportation Safety Association
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