TSB releases proceedings on transportation safety summit

Flow of risk-related information in an organization depends in part on “effective safety management processes,” the Transportation Safety Board of Canada noted in a release Thursday.

TSB, which investigate incidents involving aviation, marine, rail and pipelines, announced Thursday the release of the Proceedings of the TSB Transportation Safety Summit.

The summit was held April 21-22 2016 in Ottawa.

“More than 70 senior executives and leaders representing operators, labour organizations, industry associations, and regulators attended the summit,” said TSB, which is a separate organization from Transport Canada.

The theme for the summit was information flow because some investigations “revealed risks that had not been addressed because information had not been transmitted effectively or acted upon by the operator,” TSB said in a release.

The flow of information in an organization “depends on a supportive safety culture and effective safety management processes,” TSB added.

TSB is a separate organization from the federal department of transport.

In its annual report to Parliament released July 20, TSB said it is concerned that if Transport Canada “does not adopt a balanced approach that combines inspections for compliance with audits of safety management processes, unsafe operating practices may not be identified, thereby increasing the risk of accidents.”

TSB added that “some transportation companies are not effectively managing their safety risks, and [Transport Canada] oversight and intervention have not always proven effective at changing companies’ unsafe operating practices.”

In the aviation industry, TSB added in the annual report, the requirement for safety management systems only applied to large carriers.

“This means that although air taxis, commuter airlines, helicopter operators, and flight training schools are responsible for over 90% of all commercial aviation accidents and fatalities, they are still not mandated to operate under a system that could manage their risks effectively,” TSB added.

In an investigation report into a 2013 accident – released earlier this month – TSB said it “has been calling” on Transport Canada “to implement regulations requiring all operators in the aviation industry to have formal safety management processes, and for TC to oversee these companies’ safety management processes.”

That report was on an incident when a King Air ran out of fuel and made an emergency landing in Quebec outside of an airfield June 10, 2013. During a 20-minute inspection flight to and from Montréal/St-Hubert Airport, the plane ran out of gas. The pilot diverted to St-Mathieu-de-Beloeil airport but did not make the field.

“The aircraft was extensively damaged, and the four occupants sustained minor injuries,” TSB said in the report.

Safety culture was a factor in the freight train accident that killed 47 in Lac-Mégantic, Quebec in July, 2013, TSB said in a report released Aug. 19, 2014.

“A company’s policies determine how safety objectives will be met by clearly defining responsibilities; by developing processes, structures and objectives to incorporate safety into all aspects of the operation; and by developing the skills and knowledge of personnel,” TSB said in its report of the Lac-Mégantic derailment. “Procedures are directives for employees and set management’s instructions. Practices are what really happens on the job, which can differ from procedures and, in some cases, increase threats to safety.”

In Lac-Mégantic, an unattended train hauling 72 crude oil tanker cars derailed. In its investigation, TSB made 18 findings as to causes and contributing factors.

“When making significant operational changes on its network, Montreal, Maine & Atlantic Railway did not thoroughly identify and manage the risks to ensure safe operations,” TSB said in its report. “Despite being aware of significant operational changes at Montreal, Maine & Atlantic Railway, Transport Canada did not provide adequate regulatory oversight to ensure the associated risks were addressed.”

It also made 16 findings as to risk.

“If Transport Canada does not audit the safety management systems of railways in sufficient depth and frequency and confirm that corrective actions are effectively implemented, there is an increased risk that railways will not effectively manage safety,” TSB said in its report into the Lac-Mégantic disaster.