For TSB investigators, “what happened” is only part of the story

By Kathy Fox,
Chair, Transportation Safety Board

This article was first published in the February 26, 2018, edition of The Hill Times.

Whenever investigators from the Transportation Safety Board (TSB) deploy to the scene of an accident, we seek to answer two basic questions: what happened, and why. To do that, we need information. But too often we run into an old problem: for many aircraft, there are no cockpit voice, video, or data recorders—no "black boxes"—required onboard. Information contained in these recording devices is especially important when there are no witnesses or survivors and wreckage is too damaged to be of assistance.

Last month, the TSB released its investigation report into a fatal 2016 aviation accident in Îles-de-la-Madeleine, Quebec. Fortunately for investigators, the pilot had developed and installed a lightweight recorder of sorts, even though it was not required by regulation. It was an initiative that proved invaluable, providing the TSB with cockpit audio along with acceleration and GPS data—in short, allowing us to piece together a detailed history of the flight.

But without this recording device, we might never have learned what happened. Just as important, we wouldn't have been able to rule out other hypotheses that were considered during the course of the investigation.

Looking ahead, the TSB will release its investigation report later this year into another highly publicized air accident—that of a privately operated Cessna C500 Citation that crashed minutes after departing the airport in Kelowna, BC, in October 2016. As we have already said publicly, that aircraft was not required to have any recorders onboard, and the absence of data has made investigators' work particularly challenging.

The need for data, however, goes well beyond aircraft. In the Marine industry, numerous vessels (depending on their size and area of operation) are already required to be equipped with Voyage Data Recorders, which track and record many of the same vehicle performance parameters as their aviation equivalents. And draft legislation is currently proposing to modernize Canada's railway industry, by introducing locomotive voice and video recorders. Bill C-49, which has recently completed a second reading in the Senate, would require their installation in the cabs of lead locomotives operating on main track, and it would permit access to those recordings to Transport Canada and to the railway companies, but only under specified conditions.

The TSB has been calling for voice recorders in locomotives since 2003.Today marks the sixth anniversary of the fatal crash of VIA Rail 92, which derailed just outside Burlington, ON, in 2012—killing the three crew inside the locomotive and leaving dozens of passengers injured. It was following that accident that the TSB first called for the adoption of in-cab video recorders, in order to better understand the interactions of crew, especially as audio alone can sometimes be inconclusive. This is particularly true when it comes to understanding issues such as crew interaction, task saturation, workload management, stress, fatigue, or distraction.

The benefits of all this information are obvious: once safety deficiencies have been identified, TSB investigators can communicate them to industry, to the regulator, and to all Canadians. Furthermore, recordings should also be available to operators to pro-actively identify systemic issues that need to be addressed, before they lead to an accident. We also recognize that employees may have privacy concerns, which is why it is so important to implement the necessary safeguards to balance the rights of workers with public safety interests.

Nonetheless, there are still many aircraft—not to mention vessels and locomotives—that are not yet required to carry some form of recorder. It's time that changed. As technology continues to make it easier and cheaper to capture and store more data, the TSB will continue to push for access to more of the kind of information that helps us do our job. Because long after the question of "what happened" has been answered, it's the "why" that will lead to improvements, and help ensure that the lessons of one tragedy are used to avoid similar accidents in future.

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