GATINEAU, QC, May 3, 2012 /CNW/ - Highlighting outstanding safety concerns with the transportation system, the Transportation Safety Board of Canada (TSB) today released its annual reassessments of responses to Board recommendations. There were some advances, but challenges still remain.
"When investigations uncover serious safety deficiencies, we make recommendations so that future accidents may be avoided," explained Wendy Tadros, Chair of the TSB. "That is why we look to regulators and industry for the effective and timely implementation of our recommendations."
Safety in Canada's rail industry saw positive movement in 2011-12, with four recommendations attaining the Board's highest rating of "fully satisfactory." Safety at railway crossings, however, continues to pose significant risks, as recommendations targeting the adoption of the Grade Crossing Regulations, signage for low ground clearance vehicles, vehicle collision defenses in the high speed corridor and emergency contact signage remain unresolved. Despite recent action taken by Transport Canada (TC) to review the issue of locomotive voice recorders, the Board is concerned that in the absence of this technology, data critical to our investigations will not be captured.
In the marine sector, safety has improved slightly. Following a number of regulatory changes by TC impacting voyage data recorders and emergency preparedness on passenger ferries, the TSB has reassessed TC's responses to two recommendations as fully satisfactory. With eleven recommendations pertaining to small passenger and small fishing vessels still outstanding-some dating as far back as 1992-the safety of these vessels remains a top concern for the Board.
In contrast to the rail and marine sectors, only one air recommendation achieved a "fully satisfactory" assessment, leaving thirty two active recommendations with significant room for improvement. Since 2000, the Board has made five recommendations aimed at enhancing crew resource management, which have just recently received TC's priority status. TC has also submitted several proposed amendments to the Canadian Aviation Regulation Advisory Council. While little action has been taken since, the Board is pleased by TC's pilot project, which will fast-track four recommendations made in 2011.
"Every year we take stock of whether improvements have been made and what still needs to be done to address important safety issues," added Tadros. "This year there is some progress, and that is encouraging, but in many areas we still see safety risks, risks that will persist until concrete action is taken."
The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
Marine Recommendations Reassessments
Safety in Canada's marine sector has improved slightly, but complex and lengthy regulatory processes continue to hinder progress. Of the 19 outstanding marine recommendations assessed in 2012, two progressed to "fully satisfactory", two regressed and 13 remained unchanged. The remaining two recommendations were assessed for the first time in 2012.
Fully Satisfactory Recommendations
In 2000, the Board recommended that Transport Canada (TC) require small passenger vessels to provide pre-departure briefings, be equipped with deployable liferaft and accessible lifesaving equipment, and have the means to immediately alert others during emergency situations (recommendation no. M01 03). Since then, TC has amended several regulations and shared safety guidance with small passenger vessel owners.
The Board also identified a need for large passenger vessels to carry voyage data recorders (M08 03). TC has amended the Voyage Data Recorder Regulations so that as of January 2012 they will address this requirement, and it has tasked its inspectors to monitor and enforce compliance through regular inspections.
The Board has identified a number of issues involving fishing vessels. The design and construction of fishing vessels operating in ice (M08 04) pose significant concern. While TC's proposed amendments to the Fishing Vessel Safety Regulations will reduce risks, more than 6,000 registered fishing vessels will be exempt from construction improvements, leaving them exposed to safety deficiencies.
Other safety deficiencies involving passenger and fishing vessels have been highlighted by the Board. Dating back as far as 1992, Board recommendations have targeted anti-exposure work suits (M92 07), stowage and launching of liferaft (M93 03), stability booklet information (M94 33), periodic liferaft inspections (M97 01), emergency position indicating radio beacons (M00 09) and fire-extinguishing systems (M05 05). Although TC has proposed amendments to four safety and fishing vessel regulations, the underlying safety deficiencies will not be addressed until implementation is achieved.
The Board has also expressed concern regarding the fishing industry's overall safety culture (M03-02), best practices (M03 07) and use of hatch covers (M00-06), issues that continue to be met with limited progress. Additionally, the Board has recommended that TC collaborate with Canadian and international partners to address emergency preparedness (M03 03), liferaft testing (M05 03) and the transfer of maintenance and failure records to new vessel owners (M09 01).
Unchanged / Unable To Assess
The Board was unable to reassess one recommendation (M04 01), which targets the requirement for small passenger vessels operators to have safety management systems, because the information TC provided was unclear.
|Recommendation||Past Rating||New Rating||Progress||Issue|
|M92-07||Satisfactory intent||Satisfactory intent||Same||Anti-exposure work suits|
|M93-03||Satisfactory intent||Satisfactory intent||Same||Stowage and launching of liferaft|
|M94-33||Satisfactory intent||Satisfactory intent||Same||Small fishing vessel - stability booklet information|
|M97-01||Satisfactory intent||Satisfactory intent||Same||Periodic inspection of liferaft|
|M00-06||Satisfactory intent||Satisfactory intent||Same||Hatch covers|
|M00-09||Satisfactory intent||Satisfactory intent||Same||Emergency position indicating radio beacons|
|M01-03||Satisfactory intent||Fully satisfactory||Better||Emergency preparedness and survivability|
|M03-02||Satisfactory intent||Satisfactory intent||Same||National strategy for safety culture in fishing industry|
|M03-03||Satisfactory intent||Satisfactory intent||Same||Emergency preparedness|
|M03-07||Satisfactory intent||Satisfactory intent||Same||Promoting safe practices on board small fishing vessels|
|M04-01||Satisfactory intent||Unable to assess||n/a||Management of safety by passenger vessel operators|
|M05-03||Satisfactory in part||Satisfactory in part||Same||Standards for testing rigid and inflatable liferaft|
|M05-05||Satisfactory intent||Satisfactory intent||Same||Design, inspection, and testing of the CO2 system|
|M05-06||Satisfactory in part||Satisfactory in part||Same||Structural fire protection|
|M08-03||Satisfactory intent||Fully satisfactory||Better||Carriage of voyage data recorders|
|M08-04||Satisfactory intent||Satisfactory in part||Worse||Design and construction of fishing vessels operating in ice|
|M09-01||Satisfactory intent||Satisfactory intent||Same||Continuity of maintenance and failure records|
|M11-01||New||Satisfactory intent||n/a||Stability guidance information for sail training vessels|
|M11-02||New||Satisfactory in part||n/a||Stability guidance information for sail training vessels|
Rail Recommendations Reassessments
Transportation safety in Canada's rail sector continues to see positive movement. Of the 16 outstanding rail recommendations reassessed in 2012, four progressed to "fully satisfactory" and 11 remained unchanged.
Fully Satisfactory Recommendations
In 2001, the Board recommended that Transport Canada (TC) and the Railway Association of Canada ensure that maintenance standards and practices address the level of risks in heavy tonnage "other than main tracks" (R01-04). To ensure railway personnel consistently and accurately assess track conditions, TC approved the new Track Safety Rules, which come into effect on May 25, 2012.
Following a 2004 derailment in Whitby, Ontario, the Board recommended that TC work with the Railway Association of Canada to implement rail traffic control protocols and training that will recognize periods of high workload and make safety paramount (R06-01). In collaboration with industry stakeholders, TC has evaluated the approaches at both Canadian National (CN) and Canadian Pacific and concluded that the industry has developed satisfactory processes for predicting and recognizing periods of high workload as experienced by rail traffic controllers.
In Canada, the railway industry did not track wheel sets or the date they were removed from original cars. Due to incomplete product recalls, the Board recommended that TC ensure that railways adopt procedures and technologies to track all wheel sets (R08-02). Railways have since begun using ID tags and an electronic system to track wheel sets, which will substantially reduce or eliminate the underlying safety deficiency.
In 2009, the Board noted CN's inefficient use of safety management systems and recommended that it take effective action to identify and mitigate risks to safety, and that TC require CN to do so (R09 03). This recommendation led CN to improve its risk assessment practices and safety culture, resulting in a decrease in non-main track derailments, employee injuries and crossing accidents. TC has also revised its guidelines on safety management systems and developed additional tools to help railways improve their safety management systems.
Occurrences at railway crossings continue to pose safety risks. In 2009, the Board made recommendations for improving the visibility of emergency contact signage (R09 02), implementing standards for low ground clearance advance warning signs (R09 04) and assessing the effectiveness of vehicle collision defenses along the Quebec-Windsor corridor (R09 01). While TC is working toward making progress on the Grade Crossing Regulations and advance warning highway signs, it is not yet known when or if proposed regulations and signs will be implemented. TC has deferred railway crossing safety assessments of the Quebec-Windsor corridor to rail companies.
Following a 1999 occurrence, the Board identified a need for locomotive data recorders to include on board voice recording systems (R03-02). In March 2012, TC referred the issue to the Advisory Council on Railway Safety, which is expected to make a recommendation within a year. In 2000, the Board also signaled a concern regarding the widespread practice of crew members not calling signals effectively and made a recommendation for implementation of additional backup safety defences (R00 04). This safety deficiency has yet to be addressed and continues to pose a threat to the public, as evidenced by several recent occurrences, including occurrence numbers R12T0038, R11Q0011, R10V0038, R09V0230 and R11E00631.
Over the past 11 years, the Board has made several other recommendations, including those on grade crossing regulations (R01 05), ground hazard research (R07 03), non-pressurized tank car construction standards (R07 04) and tank car stub sill failures (R10 01). While TC has made some progress towards addressing these files, regulatory delays continue to allow some of these safety deficiencies to persist.
|Recommendation||Past Rating||New Rating||Progress||Issue|
|R91-01||Satisfactory Intent||Satisfactory Intent||Unchanged||Right of way access control|
|R93-11||Satisfactory in Part||Satisfactory in Part||Unchanged||Trucks transporting dangerous goods stopping at crossings|
|R00-03||Satisfactory Intent||Unsatisfactory||Worse||Immediate reporting of operational delays|
|R00-04||Satisfactory in Part||Satisfactory In Part||Unchanged||Consistent recognition of signals|
|R01-04||Satisfactory Intent||Fully Satisfactory||Better||Heavy tonnage other than main tracks|
|R01-05||Satisfactory Intent||Satisfactory Intent||Unchanged||Grade crossing regulations|
|R03-02||Satisfactory in Part||Satisfactory in Part||Unchanged||Locomotive voice recorders|
|R06-01||Satisfactory in Part||Fully Satisfactory||Better||Rail traffic control workload|
|R07-03||Satisfactory Intent||Satisfactory Intent||Unchanged||Ground hazard research|
|R07-04||Satisfactory Intent||Satisfactory Intent||Unchanged||Non-pressurized tank car construction standards|
|R08-02||Satisfactory Intent||Fully Satisfactory||Better||Tracking railcar wheel sets|
|R09-01||Satisfactory Intent||Satisfactory Intent||Unchanged||Safety inspections of level crossings|
|R09-02||Satisfactory Intent||Satisfactory Intent||Unchanged||Emergency contact signage at railway crossings|
|R09-03||Satisfactory Intent||Fully Satisfactory||Better||TC safety management systems oversight and CN's risk assessment practices|
|R09-04||Satisfactory Intent||Satisfactory Intent||Unchanged||Low ground clearance signs at railway crossings|
|R10-01||Satisfactory Intent||Satisfactory Intent||Unchanged||Tank car stub sill failures|
1 The investigations into occurrence numbers R12T0038 and R11E0063 are currently underway and have not yet been made public.
Air Recommendations Reassessments
Limited progress has been made in Canada's aviation sector to address outstanding safety deficiencies. Regulatory delays continue to allow unsafe conditions to persist. Of the 33 outstanding air recommendations assessed in 2012, one progressed to "fully satisfactory", two regressed and 27 were unchanged. The remaining three recommendations saw slight improvements in 2012.
Fully Satisfactory Recommendations
Following a 1992 occurrence in Red Lake, Ontario, the Board recommended that Bombardier amend two Twin Otter manuals to include safety limitation warnings (recommendation no. A94 17). To ensure the safe operation of this aircraft, an advisory circular and an updated manual were published. The Board now considers the risks associated with the safety deficiency to be sufficiently mitigated.
In 2003, the Board underlined the importance of cockpit image recorders and recommended that regulatory authorities require aircraft be fitted with such systems (A03 08). Due to technical and social issues, Transport Canada (TC) will not pursue Canadian measures until international solutions have been adopted. The Board has therefore downgraded its assessment from "satisfactory intent" to "unsatisfactory".
Between 2000 and 2009, the Board made a number of recommendations concerning crew resource management, including pilot decision making training standards (A00 06), approaches into convective weather (A07 01), pilot landing decisions in deteriorating weather (A07 03), landing distance considerations (A07-05) and crew resource management training (A09 02). TC has since elevated these five recommendations to its list of regulatory priorities and is scheduled to submit proposals for consultation in spring 2012.
TC has made some progress towards addressing outstanding safety deficiencies by drafting several notices of proposed amendments, which it has or will soon present to the Canadian Aviation Regulation Advisory Council. These safety deficiencies include quick access recorder data (A03 07), runway end safety area requirements (A07 06), propulsion system reliability (A07 08), flight recorder duration and power supply (A99 02 and A99 03). TC has also published proposed amendments that seek to address ground proximity warning systems (A95 10) and is finalizing the draft of a new Canadian Aviation Regulations subpart that will address two oversight-related recommendations (A09 05 and A09 06).
TC is piloting an accelerated rulemaking process that seeks to fast-track changes required to reduce the risk posed by four safety deficiencies identified in 2011: safe ditching and successful evacuation (A11 03), emergency underwater breathing apparatuses (A11 04), emergency egress for seaplanes (A11 05) and personal flotation devices (A11 06). Due to limited new information from TC, the Board maintained its previous assessment of four recommendations concerning take-off performance monitoring systems (A06 07), carry-on baggage (A07 07), bounced landing training (A09 01) and visual glide slope indicator training (A09 04).
|Recommendation||Past Rating||New Rating||Progress||Issue|
|A94-17||Unsatisfactory||Fully satisfactory||Better||Amendments to DHC-6 aircraft flight manual|
|A95-10||Satisfactory intent||Satisfactory intent||Same||Ground proximity warning systems|
|A99-02||Unsatisfactory||Satisfactory intent||Better||Flight recorder duration and power supply: duration of cockpit voice recorder information|
|A99-03||Unsatisfactory||Satisfactory intent||Better||Flight recorder duration and power supply: independent power source for cockpit voice recorders|
|A00-06||Satisfactory intent||Satisfactory intent||Same||Pilot decision making|
|A01-03||Satisfactory in part||Satisfactory in part||Same||Material flammability test requirements for aircraft wiring|
|A03-07||Satisfactory in part||Satisfactory intent||Better||Quality of cockpit voice recorder recording: quick access recorder data|
|A03-08||Satisfactory intent||Unsatisfactory||Worse||Accident investigation issues: image (video) recording|
|A04-01||Satisfactory intent||Satisfactory intent||Same||Use of standard weights in small aircraft|
|A06-07||Unsatisfactory||Unsatisfactory||Same||Take-off performance monitoring system|
|A07-01||Satisfactory in part||Satisfactory in part||Same||Risks in approaches into convective weather|
|A07-02||Satisfactory in part||Satisfactory in part||Same||Approaches into convective weather|
|A07-03||Satisfactory intent||Satisfactory intent||Same||Pilot decision making|
|A07-04||Satisfactory intent||Satisfactory in part||Worse||Pilot decision making|
|A07-05||Satisfactory intent||Satisfactory intent||Same||Landing distance considerations|
|A07-06||Satisfactory in part||Satisfactory in part||Same||Runway end safety area requirements|
|A07-07||Satisfactory in part||Satisfactory in part||Same||Carry-on baggage|
|A07-08||Satisfactory intent||Satisfactory intent||Same||Propulsion system reliability|
|A07-09||Satisfactory in part||Satisfactory in part||Same||Underrated hydraulic cut-off switch|
|A08-01||Satisfactory intent||Satisfactory intent||Same||Regulation of passenger-carrying balloons|
|A08-02||Satisfactory intent||Satisfactory intent||Same||Emergency fuel shut-off|
|A09-01||Satisfactory in part||Satisfactory in part||Same||Bounced landing training|
|A09-02||Satisfactory intent||Satisfactory intent||Same||Crew resource management training|
|A09-03||Satisfactory in part||Satisfactory in part||Same||Availability of eye-to-wheel height information|
|A09-04||Satisfactory in part||Satisfactory in part||Same||Knowledge of visual glide slope indicator system limitations|
|A09-05||Satisfactory intent||Satisfactory intent||Same||Oversight|
|A09-06||Satisfactory intent||Satisfactory intent||Same||Oversight|
|A11-01||Satisfactory intent||Satisfactory intent||Same||Main gearbox certification extremely remote provision|
|A11-02||Satisfactory intent||Satisfactory intent||Same||Main gearbox certification adequacy of the 30 minute main gearbox run dry requirement|
|A11-03||Satisfactory intent||Satisfactory intent||Same||Safe ditching and successful evacuation|
|A11-04||Satisfactory intent||Satisfactory intent||Same||Emergency underwater breathing apparatus|
|A11-05||Satisfactory intent||Satisfactory intent||Same||Emergency egress for seaplanes|
|A11-06||Satisfactory intent||Satisfactory intent||Same||Wearing of personal flotation devices|
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