Opening Remarks to the Offshore Helicopter Safety Inquiry
Transportation Safety Board of Canada
October 28, 2009
Thank you Ms. Fagan.
I am very pleased to be in St. John's and to participate in your inquiry. It also gives me the opportunity to visit your community and to personally thank the many-many people who helped our investigators last March – in those early days when much needed to be done quickly.
I recognize this inquiry is very important to your community and to the families who lost loved ones as a result of the crash of Cougar Flight 491.
It's also very important to us at the TSB. No more so than to the team of investigators who arrived in St. John's in the days following the accident—and whose faces you've come to know.
Those same investigators are still hard at work in pursuit of the facts and the answers that we all need to ensure this tragedy does not repeat itself. This investigation is one of the Safety Board's top priorities. A very strong and capable team has been assigned to this work.
While the team focuses on their work, I am happy to be here to explain what to expect as TSB investigations unfold and discuss the role my organization plays in advancing transportation safety. We are not a regulator. We are an independent investigation body.
Over the last 20 years the Transportation Safety Board has built an international reputation as a leader in accident investigation.
To this end, our Annual Report reflects the volume of investigations and activities undertaken in the last year – to advance safety in marine, rail, pipeline and aviation.
Our Annual Report is Document 1.
I am sure a question on the minds of many is: How does this inquiry – your inquiry – differ from the TSB's investigation?
Right off the top – let me clearly distinguish your inquiry from the TSB investigation.
Offshore oil workers move back and forth by helicopter every day. You will look carefully at the role the Canada-Newfoundland and Labrador Offshore Petroleum Board (C-NLOPB) can play in ensuring workers get safely to and from the rigs. I maintain that the Offshore Petroleum Board can influence aviation safety indirectly through its regulation of petroleum producers.
It can also raise the safety bar through the imposition of license conditions and the setting of contract provisions – and this is a good thing.
By contrast, the TSB's role is to advance the safety of aviation and helicopter operations worldwide. We do this by investigating accidents whether in the offshore or elsewhere in the world. We seek to find out what happened and why it happened.
In accordance with our legislation, we take a systemic approach to all our investigations. We run the gamut of issues from the immediate causes of an accident, to the risks Canadians may encounter. And we do all of this to learn lessons to make the system safer.
At the end of the day, it is my belief this inquiry and the TSB investigation - each in their own way - will improve safety for the people of Newfoundland and Labrador.
Before I tell you about how we work, let me put the TSB's independent investigation of aviation accidents in perspective.– Let me give you a little context.
In 1990, the Government of Canada passed the Canadian Transportation Accident Investigation and Safety Board Act. That is a long title, and so we refer to it as the CTAISB Act.
This legislation contains a set of principles and gives the TSB its powers to investigate accidents and incidents.
When there is a transportation accident in rail, marine, aviation or pipeline, the legislation allows the TSB to occupy the field.
When the Safety Board is investigating no other federal government department, other than the Department of National Defence, can investigate for the purpose of determining the causes and contributing factors. Our Act and Regulations are Documents 2 and 3.
This "exclusivity" goes beyond Canada's borders. When we are investigating an aviation accident – in accordance with international agreements, no other country can investigate ... period.
An example close to home is our investigation of the Swissair 111 crash. The aircraft was manufactured and certified in the United Sates. It took off from New York bound for Switzerland.
The carrier and the crew were Swiss and the passengers came from many places in the world. The Canadian connection, if you will, was the waters off Nova Scotia or the crash site. This gave exclusive jurisdiction to the TSB.
Canada is one of about a dozen nations that, in keeping with international protocols, conduct independent accident investigations for the sole purpose of advancing safety.
Three fundamental principles form a solid foundation for this approach.
The first principle is to separate the investigation from the influence of regulators, airlines, manufacturers, and any other body with an interest. This is because all of our investigations look at these players and their roles.
Let me give you an example. The regulator – Transport Canada – sets safety standards for the industry. It licenses air carriers and crews and enforces the Canadian Aviation Regulations. In all of our investigations, we can and must look at the role of the regulator in overseeing the industry.
This means Transport Canada has a direct interest and, therefore, cannot objectively make findings on their own role.
The TSB, because of its independence, can follow the evidence wherever it may lead and say what we need to say.
The second principle is to separate the investigation from legal proceedings. Having served on the bench for many years Sir, you know well, that issues of criminal or civil liability rightly belong in Canada's courts. Whereas the TSB's sole purpose is to advance transportation safety and we do not lay blame.
Moreover, TSB investigators cannot be called into court and the Board's findings cannot be used in court or disciplinary proceedings.
The third principle is to conduct our investigations in accordance with agreed upon international practices and standards.
Canada follows the International Civil Aviation Organization's (ICAO) Annex 13 to the Convention on Civil Aviation. ICAO Annex 13 is Document 4.
This Annex sets out the protocols for determining which State will conduct the investigation, the roles and responsibilities of other States in an investigation and how the investigation is to be conducted.
Above all it states clearly that the sole objective of the investigation shall be the prevention of accidents.
The application of these three important principles:
- The independence of the investigation;
- The separation from legal proceedings; and
- The adherence to international agreements,
help ensure public confidence in the TSB and the work we do to advance aviation safety.
This process, this approach, has proven very successful.
As I mentioned before, it has put the TSB at the forefront of accident investigations worldwide. But a process is nothing without a dedicated workforce to put it into action.
I hope you will take away with you a sense of my pride in the work of the 235 men and women who make up the TSB. These people are specialists in investigations, engineering, metallurgy, analysis, human factors, communications and human resources ... to name just a few. They are focused and dedicated to our mission.
They are engaged every day in making transportation safer than it was the day before, not only for Canadians, but for people around the world. They are the ones who, after careful science and thorough analysis, nail the causes and contributing factors leading to accidents.
And they provide the Board with the information it needs to make its recommendations – recommendations that can be credited with changing the way aircraft are operated and maintained AND with improving the way they are designed, built and certified.
Now I would like to show you our corporate video. This was created in-house at our Engineering Laboratory. It will provide an overview of how we work day-to-day. I will add a few details after the video. Just in passing, I can tell you that it is also available in French and we have copies for anyone wishing one after today's session. The video is Document 5.
Slide 5 – Play video (English)
There are three phases to a TSB investigation.
These are described in some detail in our pamphlet entitled "Investigation Process". This is Document 6.
The first phase is the Field Phase. An Investigator-in-Charge or IIC is appointed and an investigation team is assembled.
The makeup of the team is based on the circumstances of the occurrence and investigation needs, and may consist of operations, equipment, maintenance, engineering, scientific and human performance specialists. The number of investigators sent to an occurrence site varies from one or two, for a relatively straightforward investigation, to 10 or more for a major investigation.
The field phase can last from one day to several months. During this phase, team members will:
- secure the occurrence site;
- examine the equipment, vehicle or wreckage on site;
- interview witnesses, company and government personnel;
- collect pertinent information;
- select and remove specific wreckage for further examination;
- review documentation; and
- identify potential unsafe acts and unsafe conditions.
The second phase of the investigation is the post-field phase. Significant investigation activity takes place after the TSB team departs the occurrence site.
The post-field phase can take many months, depending on the size and complexity of the investigation. During the post-field phase, the TSB typically:
- Examines all relevant company, vehicle, government and other records;
- Examines selected wreckage in the laboratory and tests selected components and systems;
- Analyzes records and data;
- Creates simulations and reconstructs events;
- Conducts further interviews;
- Determines the sequence of events; and
- Identifies safety deficiencies by looking at occurrences in Canada and worldwide.
At the end of the post-field phase, the IIC produces an initial draft investigation report that is reviewed by other TSB experts and is ultimately approved by the Director of Investigations.
During the first two phases of the investigation, a built-in independence separates the work of the investigators from the Board.
The Board is not involved in the work and exercises no control or influence over the direction of the investigation. This leaves investigators free to ask any question and follow all leads.
So for instance in the investigation of Cougar 491, while the Board has been kept apprised of the conduct of the investigation, they have not been involved in any of the investigative or communications developments.
The third phase is the report production phase. In this phase, the Board steps up to review the draft investigation report, which may be approved, amended or returned for further staff work. Once the draft report is approved, the TSB legislation requires this report to be sent to designated reviewers on a confidential basis.
The designated reviewers are persons and corporations whose performance or products are being remarked on in the report. They are most qualified to comment on the accuracy. For this reason, they are given the opportunity to dispute, correct or contradict information they believe is incorrect or unfairly prejudicial to their interests.
This process is intended to both ensure procedural fairness and the accuracy of the Board's final report. The Board considers all comments and will amend the report if it is convinced that a change is warranted. Once the Board approves the final report, it is released to the public.
Many cooperate with the TSB during an investigation. We work with all levels of government, transportation companies, equipment manufacturers, and individuals such as survivors, witnesses, next-of-kin and operators.
We also work with coroners, police, fire departments and search-and-rescue teams. This cooperation is essential to a successful investigation.
When fatalities occur, the police, coroner, or the transportation company will advise the next-of-kin. Along the way, the TSB keeps survivors and next-of-kin informed and may request interviews with them to assist in the investigation.
TSB investigators conduct interviews with anyone who may be able to assist them with their investigation. The statements in the interviews are protected under our Act and individuals are never named in Board reports.
The Board may grant observer status to anyone who, in its opinion, can contribute to the investigation. In this regard, representatives from transportation companies, equipment manufacturers and regulatory agencies often attend investigations under the supervision of an investigator and in accordance with the conditions imposed by the Investigator-in-Charge.
International agreements entitle other countries to designate accredited representatives to Canada's investigations. The TSB also sends its people to investigations in other countries. These representatives bring technical expertise to investigations.
I want to give you more detail about when and why we investigate and the methodology we use.
Every investigation starts with the notification of an occurrence. With over 4000 occurrences reported to the TSB every year, the initial information must be assessed against our Occurrence Classification Policy to determine how much investigating to do.
One of the things we look at very carefully is whether the available evidence is enough for the Board to determine the causes and contributing factors. The other consideration is whether new safety deficiencies would likely be uncovered. If there is real potential to advance safety, we launch an investigation. The TSB's Occurrence Classification Policy is Document 7.
The TSB has developed a methodology that we call, the Integrated Safety Investigation Methodology or ISIM. Other industries, like the nuclear industry, use similar approaches. This type of methodology is also used in accident investigation in other countries. I have made these slides and the ISIM training manual available to you as Documents 8 and 9.
ISIM is an analysis tool. The purpose is to examine each accident for safety significant events – to identify unsafe acts or unsafe conditions.
We then search for the underlying factors that made the unsafe acts or conditions possible.
At this stage, it is really about asking a whole lot of "whys" which prompt us to drill down and uncover new facts.
Next, we assess the nature and extent of risks to safety.
This includes an analysis of the risk controls or safety defences in place. Inadequacies in safety defences are found in every accident. Either the means of controlling risk didn't exist, or they didn't function as intended.
There are two categories of defences: physical and administrative.
Physical defences include, for example, alarms and warning lights in the cockpit, runway lighting and air traffic control radar. And administrative defences include standards, regulations, operating procedures, supervision, training, and the like.
Let me give you a slice of a hypothetical investigation. A commuter aircraft carrying 11 passengers crashes on landing. On examination, it is clear that the pilot did not select the landing gear down – this is an unsafe act. The pilot did not react to the alarm – warning that the landing gear was not in the down and locked position. This is an unsafe condition.
In trying to determine why, investigators find that the alarm functioned properly. Upon further analysis, the investigators learn that the pilot had only slept 5 of the past 36 hours and was significantly fatigued. In this scenario, fatigue is the underlying factor. Investigators will look carefully at the reasons for the pilot's fatigue to determine the level of risk.
They want to know, is this isolated or does it represent a risk in the aviation industry.
They will then look at whether defences were in place and, if so, whether they were adequate.
These would include administrative defences like duty time regulations, company policies and training, pilot scheduling and company means of identifying hazards. Where these defences are not adequate, we consider there is a safety deficiency. Each safety deficiency is assessed qualitatively for risk.
Risk control options are then assessed.
That sounds like a lot of process – and it is. We have to be methodical.
But we are also mindful of the need for speed where safety is concerned. This means, if we uncover risks affecting safety, we don't wait for the final report. We report on them right away.
It may be by way of interim safety recommendations as we did in the Ryan's Commander investigation. Or we may choose to send out safety advisories or safety information letters to the regulator and industry.
Where helicopters are concerned, over the past 10 years the TSB has issued many safety information letters and safety advisories in the course of ongoing investigations.
I am providing these to you for your consideration. These are Document 10.
And, a little more than a week into the Cougar 491 investigation, the TSB revealed the failure of the damaged titanium studs on the main gearbox filter bowl assembly. This led the manufacturer to immediately replace studs on these aircraft worldwide.
But it didn't stop there. Fast on the heels of that came a Federal Aviation Administration (FAA) Emergency Airworthiness Directive aimed at reducing the risk of a similar failure. These actions have led to reduced risk for Sikorsky S92 operators early and while the investigation is ongoing.
The big safety payoff occurs 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 on progress in our final report.
This being said, the TSB does not impose changes on the transportation industry or regulators. Solutions to safety are a shared responsibility amongst many players, and our job is to make a convincing case for change.
I spoke in the opening about the indirect ways this inquiry can influence the safety of helicopters operating in the offshore.
I know you will look carefully at our public report on this accident. There you will find the Board's final word and its definitive findings as to the causes and contributing factors that led to the accident.
I would draw your attention to Section 4, which, as in all TSB reports, will contain the Board's opinion on what needs to be done to advance safety.
Most TSB recommendations are made to regulators like Canada's Department of Transport and the Federal Aviation Administration in the United States. The reason for this is if we find a safety deficiency, the fix should apply to the entire industry – worldwide.
But changes to laws take time and many of our recommendations have not been fully implemented. Meanwhile, nothing stops the offshore industry or the C-NLOPB from taking action to reach a higher standard.
For example, many in the oil and gas industry require sub-contractors to maintain ISO standards or have Integrity Management Systems. The regulator, the C-NLOPB in Newfoundland and Labrador could require similar things. You could think about advising them on the setting of licensing conditions for petroleum producers.
Or you might want to consider whether contract provisions for any carrier wishing to provide helicopter services in the offshore would be of value.
In looking at what improvements should be made, a starting point may be TSB recommendations from our past aviation investigations. If you think this might be useful, I could have my staff suggest relevant recommendations for your consideration.
Helicopters operate worldwide and there are many strong players in aviation accident investigation. You may also wish to look at the work of our international counterparts. In North America, the United States conduct a huge number of aviation investigations.
Great Britain, Sweden, Norway and Finland, the Netherlands, France and Russia all have excellent capabilities.
In the Far-East, Japan, Korea and Taiwan are leaders. Down Under, Australia and New Zealand both excel at accident investigation.
Now I would be pleased to answer your questions. If required, I would be happy to speak about the facts that we've published to date on the Cougar 491 accident but in the interest of accuracy, I will not be providing detailed technical information or explanations beyond that scope.
I'd also like to remind you that I will not be able to comment on any ongoing aspects of the investigation but would be happy to speak in general terms about the TSB and its processes.
I thank you for your understanding.
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