When is a TSB recommendation made?

ISSN 2369-873X

17 February 2014
Posted by: Kathy Fox

Every year, thousands of aviation, rail, marine and pipeline occurrences are reported to the TSB. After assessing and documenting each one, we conduct between 50 and 70 comprehensive, independent investigations.

Our goal is to advance transportation safety. That means we focus on those occurrences where we have the most to learn, and then we share those safety lessons with the regulators, industry, and the Canadian public.

When is a TSB recommendation needed?

In each investigation, the TSB explains what happened and why. We identify the factors that caused and contributed to the occurrence, as well as any unaddressed risks that exist.

We’re also proactive, communicating key safety issues to those who can best effect change, often before the final report is published. In fact, by the time a report reaches the public, corrective safety action has often been taken, helping to reduce the risk of a similar accident from happening in the future.

Sometimes, though, TSB investigations uncover high-risk problems, or those that underscore Canada-wide safety issues. These can be tougher to fix, and so the Board makes a TSB recommendation. Most often, these are directed to Transport Canada, but that doesn’t mean industry can’t make changes on its own.

A TSB recommendation for flight data recorders

Earlier this summer, the TSB published its report on the 2011 crash of a de Havilland Otter in the Yukon. Although our investigators determined that there had been a loss of control and that the aircraft broke up in mid-flight, many questions remained unanswered. In fact, given the combination of the pilot’s death and the lack of recorded data, the ultimate cause could not be found.

This wasn’t the first time we’d run into similar challenges during an investigation. So the Board issued a TSB recommendation to Transport Canada, urging them to work with industry to implement lightweight flight recording devices for smaller operators not currently required to carry the so-called “black box.”

The reason for this is straightforward. Access to more recorded data will help investigators identify what happened and why in the event of future accidents.

TSB recommendations at work: ‘Fully Satisfactory’ means a safer Canada

Since its creation in 1990, the TSB has issued over 500 recommendations. The responses to these recommendations are reassessed regularly, and as of 2013 approximately 74% have received our highest rating of “Fully Satisfactory.” Clearly, then, TSB recommendations can be a powerful tool for change—in all four modes of transportation.

In the marine sector, for example, survival suits are now required for crew members on commercial vessels, and passengers on Canada’s ferries must receive a safety briefing before each voyage. In aviation, terrain awareness warning systems are now required in private and commercial aircraft with six or more passenger seats.

Canada’s rail industry has also heeded TSB recommendations to reduce the number of accidents involving longer, heavier trains. The introduction of tougher survivability standards for locomotive event recorders has also helped investigators access vital data after an accident.

Pipelines are safer, too. Emergency shut-down procedures have been beefed up thanks to our recommendations, and pipeline companies now have in place safety programs to anticipate, prevent, manage and address potentially dangerous situations.

Old TSB recommendations: pushing for change

Those are all good things, and Canada is undeniably safer because of TSB recommendations. However, much work remains.

Too many TSB recommendations have not yet obtained the “Fully Satisfactory” rating. That means there are plenty of areas for improvement. To get there—to make Canada’s transportation network as safe as it can be—the TSB will continue to push for change.

Image of Kathy Fox

Kathy Fox is the TSB Chair and has more than four decades of aviation experience. She is a member of the Quebec Air and Space Hall of Fame, and was awarded the prestigious David Charles Abramson Memorial Flight Instructor Safety Award for her exceptional leadership and devotion to the advancement of Canadian aviation safety. Kathy is also pretty good with a paddle, and is a veteran of numerous expeditions to Canada’s Far North.

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