ARCHIVED - Transportation Safety Board of Canada

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The Chair's Message

I am proud to assume the leadership of the Transportation Safety Board of Canada, an organization that is recognized worldwide for its professional competence and important contributions to transportation safety.

In a time when Canadians expect safe transportation, the TSB actively promotes a culture of safety by conducting independent accident investigations, by identifying safety deficiencies and by making recommendations we believe will advance safety in our marine, pipeline, rail and aviation sectors. One investigation at a time, the TSB has established its credibility with industry and regulators, and continues to build public awareness of its role in the transportation field and in the need for independent accident investigation. This past year, we managed to identify a wide range of safety deficiencies and to convey important safety messages to regulators and the transportation industry.

The TSB recognizes that, in order to be effective, we must demonstrate not only technical competency but relevance to Canadians. The TSB was challenged this year by the need to complete an increasing number of very complex investigations while at the same time significantly reducing the number of investigations in progress. We understand the need to reduce the average time it takes to complete an investigation while ensuring we maintain the high quality Canadians expect in all of our work. Our goal is to build upon well-established strengths while focusing on areas where improvements are required. This is a question of balancing the number of new investigations against the available resources.

While we did not fully achieve all of the objectives listed in the Report on Plans and Priorities, we have made progress in our priority investments to implement new ways of improving the TSB's contribution to promoting transportation safety and strengthening the organization's internal management. One of our accomplishments was the launching of a large part of the TSB Investigation and Information Management System. Although this tool is not yet entirely functional, it already enables us to better manage our business while meeting government information and technology management requirements.

Once again this year, various indicators show that Canada maintains a very good transportation safety record. For example, TSB recommendations continue to be positively received and some safety action is taken as a result of our work. Furthermore, a review of transportation accident rates over the past 10 years continues to reveal a progressive downward trend. We therefore believe that the contribution made by this organization in the reduction of risks in the Canadian and international transportation system, in concert with the work of many other organizations, is having a beneficial impact.

In submitting this report for tabling in Parliament and examining our accomplishments for the year, I believe that the TSB met the challenges that it faced and that the entire TSB team remained committed to promoting transportation safety for all Canadians.

Section 1: Overview

1.1 Management Representation Statement

I submit, for tabling in Parliament, the 2006-2007 Departmental Performance Report for the Transportation Safety Board of Canada. This document has been prepared based on the reporting principles contained in the Guide for the Preparation of Part III of the 2006-2007 Estimates: Reports on Plans and Priorities and Departmental Performance Reports: It adheres to the specific reporting requirements outlined in the Treasury Board Secretariat guidance; It is based on the department's Strategic Outcome and Program Activity Architecture that were approved by the Treasury Board; It presents consistent, comprehensive, balanced and reliable information; It provides a basis of accountability for the results achieved with the resources and authorities entrusted to it; and It reports finances based on approved numbers from the Estimates and the Public Accounts of Canada.   _____________________________________ Wendy A. Tadros Chair

1.2 Raison d'être

The Transportation Safety Board of Canada (TSB) is an independent agency created in 1990 by an Act of Parliament (Canadian Transportation Accident Investigation and Safety Board Act). It operates at arm's length from other government departments and agencies such as Transport Canada, the Department of Fisheries and Oceans, and the National Energy Board to ensure that there are no real or perceived conflicts of interest. Under the legislation, the TSB's only object is the advancement of transportation safety in the federally regulated elements of the marine, pipeline, rail and air transportation systems. This mandate is fulfilled by conducting independent investigations that can include, if necessary, public inquiries into transportation occurrences. The purpose of these investigations and inquiries is to make findings as to the causes and contributing factors of the occurrences and to identify safety deficiencies. Therefore, recommendations may be made to improve safety and reduce or eliminate risks to people, to property and to the environment. The TSB has the exclusive authority to make findings as to causes and contributing factors when it investigates a transportation occurrence.

The jurisdiction of the TSB includes all marine, pipeline, rail or aviation transportation occurrences in or over Canada that fall under federal jurisdiction. The TSB may also represent Canadian interests in foreign investigations of transportation accidents involving Canadian registered, licensed or manufactured ships, railway rolling stock or aircraft. In addition, the TSB carries out some of Canada's obligations related to transportation safety at the International Civil Aviation Organization (ICAO) and the International Maritime Organization (IMO).

A transportation occurrence is any accident or incident associated with the operation of an aircraft, ship, railway rolling stock, or pipeline. It also includes any hazard that could, in the Board's opinion, induce an accident or incident if left unattended.

1.3 Operating Framework

The TSB is primarily funded by Parliament through a program expenditures vote and, as a departmental corporation, it has authority to spend revenues received during the year. The TSB operates within the context of Canada's very large, complex, dynamic and ever-changing transportation system. For more details on the operating context, see the Transport Canada website and the National Energy Board website.

Many individuals and groups cooperate with the TSB in the fulfillment of its mandate. During the course of an investigation, the TSB interacts directly with

• individuals such as survivors, witnesses and next-of-kin;
  
• operators;
  
• other organizations and agencies such as medical examiners, police, manufacturers, owners and insurance companies; and
  
• other federal government departments and agencies.

Their cooperation is essential to the conduct of the TSB's business, whether they contribute information or support services. For more details on the investigation process, visit the TSB website.

The TSB is one of many organizations involved in improving transportation safety nationally and internationally. Even if the TSB is operating at arm's length from other federal departments in the transportation field, it cannot achieve its strategic outcome without the cooperation of the other organizations. The TSB presents findings and issues recommendations in such a manner that other organizations feel compelled to act but it has no formal authority to regulate, direct or enforce specific actions. Its success implies ongoing dialogue, information sharing and strategic coordination with organizations such as Transport Canada, the National Energy Board and the Canadian Coast Guard.

The TSB must also continuously be in contact with industry and foreign regulatory organizations, and exchange information with them. Through various means, the TSB must present compelling arguments that will convince these "change agents" to take the necessary action in response to identified safety deficiencies.

The TSB has established memoranda of understanding with other federal government departments for the coordination of activities and the provision of support services. These agreements provide the TSB with access to a range of support services that can rapidly supplement internal resources (for example, assistance in the recovery of a wreckage, the documentation of evidence, and the examination or testing of components). The agreements also define operating practices to ensure good coordination of activities and to avoid potential conflicts that could arise from the simultaneous implementation of various organizational mandates. Such agreements are currently in place with the Department of National Defence, the Royal Canadian Mounted Police, the Canadian Coast Guard, Human Resources and Social Development Canada, and the National Research Council. Similarly, the TSB has established strategic cooperation alliances with provincial and territorial medical examiners and with certain provincial government departments for rail occurrences that fall under their jurisdiction.

Further alliances have been established with the TSB's counterpart agencies in other countries such as the United States, Australia, the Netherlands, New Zealand, France, and the United Kingdom. The TSB cooperates on a reciprocal basis with foreign safety investigation agencies through the ad hoc exchange of specialized services or the provision of assistance as a means of coping with capacity gaps. As one of the world leaders in its field, the TSB regularly shares its investigation techniques, methodologies and tools with other organizations. For example, the Recorder Analysis and Playback System (RAPS), originally developed by the TSB for decoding and analyzing flight data recorders (FDRs) and cockpit voice recorders (CVRs), is now used for safety investigations in more than 10 countries. Similarly, the TSB has contributed to the training of investigators from numerous countries, either by integrating foreign investigators into its in-house training programs or by sending senior staff to teach abroad. The TSB also gives information and copies of its reports to sister organizations, and participates in international working groups and studies to influence opinion within the transportation industry and to keep abreast of technological change.

1.4 Risks and Challenges

The TSB faces many risks and challenges that have a potentially significant impact on the organization's ability to achieve its mandate. Managers are aware of these risks and challenges and are expected to take appropriate action to mitigate the risks while ensuring the delivery of their mandate. The most important challenges for 2006-2007 are described in the following paragraphs.

Prioritizing and Managing the Workload

The TSB is facing a number of internal and external demands not only to sustain existing activities but also to undertake new initiatives to meet government change requirements, such as human resources modernization and procurement reform, and to mitigate risks in areas such as information technology security and business continuity planning. The challenge lies in achieving all of this within a limited resource base. The TSB must therefore find the right balance between the level of activity to be undertaken and the capacity of available human and financial resources. This implies an ongoing review of products, services and processes to ensure that resources are applied in the best possible way to achieve optimum results.

Maintaining a Knowledgeable and Professional Workforce

The TSB, like many organizations, faces a specific challenge with respect to its workforce. Many positions are "one deep" - meaning that there is only one person responsible for a specific task or function. Over the next few years, the TSB must continue to operate while many of its key employees move into retirement. The TSB must also contend with a high turnover rate in some of the functional support areas of Corporate Services due to the high demand for such specialists across the Public Service. The TSB must ensure that it is adequately prepared to fill any gaps and to secure the proper transfer of knowledge to new employees. The 2005 Public Service Employee Survey has provided the TSB with a current assessment of employee satisfaction and concerns. Sustained efforts will be required to respond to any employee concerns, including any issues related to career development and job classification.

Implementing and Sustaining the TSB Investigation and Information Management System

The TSB has invested substantial resources, time and effort in the development of an internal information system to better manage its business while meeting government requirements with respect to information management and technology. As the rollout of the Investigation and Information Management System is undertaken, the TSB will encounter specific challenges with respect to change management and temporarily increased workloads for some employees. These challenges will need to be addressed through training and ongoing reviews and monitoring of the operation of the system. Furthermore, significant work remains to be done to complete the development of the full functionality required. This residual work will have to be done in parallel with the initial rollout. In order to make the implementation and sustainability of the system a success, the management team must ensure that full employee buy-in and participation is achieved. Sustained investments will also be required to operate and maintain the new system work environment. Not meeting these challenges would result in the loss of resources invested to date and would have a significant impact on the delivery of products and services, given that the TSB has made a conscious decision not to revert to old tools and systems. Anything less than full adoption and use of the system would result in a loss of productivity and create inefficiencies in work processes.

Sustaining External Communications

The TSB has improved stakeholder awareness of the agency and its work, and has better positioned itself to influence key change agents to take actions that lead to improvements in transportation safety. For this planning period, the challenge will be to strike the best balance between enhanced external communication activities and changing stakeholder expectations. The TSB must ensure that external communication products and services are available, up-to-date and of a high quality in order to retain the levels of integrity and credibility required to achieve its mandate.

1.5 Resources

The following table summarizes the total financial and human resources allocated to the TSB in 2006-2007, as well as the actual resources utilized for the delivery of the mandate. Section 3 of this report provides detailed information on the overall financial results of the TSB and Appendix E presents the audited financial statements.

Financial Resources (in thousands of dollars)

2006-2007
Planned Spending	Total Authorities	Actual Spending
30,909	31,667	30,884

Human Resources (full-time equivalents)

2006-2007
Planned	Actual	Difference
234	226	8

1.6 Link to the Government of Canada Results

The following table shows how the TSB's only program activity and its related resources contribute to one of the results planned for the Government of Canada in the area of social affairs.

Expected Results
Government of Canada Outcome Area	Social Affairs: safe and secure community.
Strategic Outcome	To advance transportation safety, thereby reducing risks to people, property and the environment.
Expected Results	Increased awareness of safety issues and a strengthened safety culture on the part of governments, industry and public.
Program Activity	To conduct safety investigations.
Expected Results	The timely implementation of safety actions by stakeholders to improve transportation safety for Canadians.

1.7 Departmental Performance Summary

In its 2006-2007 Report on Plans and Priorities, the TSB had identified five priorities. All were strategic investments aimed at enhancing the TSB's contribution to transportation safety in Canada and internationally and strengthening the organization from within.

Overall, progress was achieved against all priorities. However, not all objectives were fully achieved, due to our limited human resources capacity and events outside of our control. On many occasions throughout the year, managers were faced with the difficult choice of reallocating people from one project or investigation to another. The table below provides a quick overview of the results achieved this year against our priorities.

TSB Priorities
TSB Priorities	Type	Performance Status	Planned Spending (in thousands of dollars)	Actual Spending (in thousands of dollars)
1) Continuous Improvement of Internal Processes and Practices	Ongoing	Meets expectations in part	550	480
2) Continuous Improvement of Human Resources Management	Ongoing	Meets expectations	0	0
3) Sustainable Communication Services and Products	Ongoing	Meets expectations in part	30	23
4) Business Continuity Planning	New	Meets expectations	145	122
5) Ongoing Development of Partnerships	Ongoing	Meets expectations in part	0	0

Continuous Improvement of Products and Services

In 2006-2007, the TSB deployed a large part of its Investigation and Information Management System, which follows central documentation principles and allows us to collaborate and share information and employ consistent procedures and processes across all sectors.

As the rollout of the system modules proceeded, we ensured that a robust change management strategy was in place to support users in the new way of conducting business. We also fostered a culture of continuous improvement by developing a long-term sustainability strategy for its operational processes, tools and systems. This strategy included end-user support, training and ongoing reviews. At the same, work continued on the development of outstanding modules. During the latter part of the year, as a result of a re-evaluation of user needs, the development emphasis shifted from the Report Production and Corporate Management modules to focus on development of the following modules: the Committees Gateway, the Workload Management Milestone and Phases, the Workload Management Monitoring Tools, the Investigation Management Dashboard and the Safety Communications Tracking System. Development in these areas is ongoing.

Continuous Improvement of Human Resources Management

The TSB continued focusing on the strategic management of human resources by effectively implementing the final phase of its human resources modernization initiatives. Many of TSB's activities related to the Public Service Modernization Act involved the monitoring of delegated managers' level of adherence to the central agencies and TSB policies and processes. To ensure the required level of understanding of the Act by all TSB employees, activities such as ongoing training to delegated managers and continued communication - in the form of information sessions, meetings and Information Bulletins - were conducted. The development and implementation of the human resources planning process within the department was also a crucial step towards supporting capacity, retention, knowledge transfer, succession and staffing activities for the coming years. During this exercise, each branch developed its respective Human Resources Plan, which was then used to feed into the overall Human Resources Plan at each of the Directorate levels. This resulted in an overall Human Resources Plan, which was incorporated into the TSB Business Plan for 2007-2008.

Sustainable Communication Services and Products

The TSB continues to raise public awareness about its mission and mandate in a number of ways. In 2006-2007, TSB staff and Board members participated in various conferences and technical meetings pertinent to transportation safety to keep abreast of technological change and to make presentations on safety issues of particular interest to the audiences. In addition, some of the remarks made by TSB employees during news conferences or interviews, as well as technical and feature articles they wrote have been published in specialized magazines. In these ways, the TSB has taken advantage of various forums as opportunities to share lessons learned from its investigations. An ambitious list has been assembled for the coming year to build on the work already done and to forge increased awareness among industry and the public.

As part of its strategy for releasing reports, five news conferences were convened in locations across Canada where significant accidents occurred. In order to ensure sustainability and currency, the Communications Division continued to review and revise its communications tools, products and processes.

"During a news conference to release details of the investigation regarding the capsizing of the Ryan's Commander off the coast of Newfoundland and Labrador, TSB Chair, said that the lessons learned from the loss of this vessel, already had a huge impact on improving safety in the design of vessels and will continue to be the catalyst in improving a safety culture for years to come." Source : The Navigator, vol. 10, No.1, January 2007

To save time and money in the translation and revision process, while improving the quality and uniformity of TSB reports and other internal and external communication products, we purchased software that will allow all staff to have access next year to an electronic lexicon containing a centralized repository of TSB terms and definitions.

Business Continuity Planning

The TSB has spent two years creating and implementing business continuity plans. To that end, we identified this year the essential services and the assets necessary to carry out our mandate. We have also conducted evaluations of the possible impact that service interruptions could have on our activities. Having completed these steps, we will be able to develop and test emergency operational plans and business resumption plans in the next fiscal year. These plans will include measures in the event of disasters affecting the TSB or of pandemics.

Ongoing Development of Partnership

The TSB works in partnership with numerous organizations in its operational and administrative activities. Over the past two fiscal years, we have conducted a strategic review of our partnerships, which has led to the development of a policy framework that includes guidelines for the establishment of new partnerships. This new framework, to be implemented over the course of the next fiscal year, will include a mechanism for periodic reviews and renewals of all new and existing partnership agreements.

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