The Transportation Safety Board of Canada’s (TSB) Watchlist identifies the key safety issues that need to be addressed to make Canada’s transportation system even safer.
The eight issues on this list are supported by a combination of investigation reports, Board safety concerns and Board recommendations. Some of them have been on the Watchlist since 2010, and one issue – fatigue management -- has been extended to the three transportation modes in this year’s edition. All of them, however, require a concerted effort from the regulator and industry stakeholders.
TSB Watchlist 2020 – Release transcript
For 10 years, the Transportation Safety Board of Canada (TSB) has been issuing its Watchlist of key safety issues—the ones that most need to be addressed to make Canada’s transportation system even safer. Over the past decade, we’ve used that list, and the attention it generates, to better focus the efforts of key industry and regulatory stakeholders, including various levels of government. That means the Watchlist is always evolving: if sufficient progress is made to reduce the risks, old issues are removed, just as new issues are added when they arise.
Before I go into detail about the issues on Watchlist 2020, I’d like to acknowledge what the transportation industry, and the entire country, has been going through because of the COVID-19 pandemic. These are challenging times—unprecedented, really. We know that companies large and small are hurting, and no one really knows when we will return to “normal” or what that “normal” may look like.
That said, the TSB’s focus on safety remains the same as always. Watchlist 2020 is a good example of that: several issues remain from previous years, but we’ve also removed one issue, split another into two, and added a new one. These safety issues need to be addressed, especially as transportation activity ramps up again.
The new issue on this year’s edition, the risk of unplanned or uncontrolled movement of railway equipment, is one that’s been on the minds of many Canadians, especially given a series of high-profile accidents in the past few years. All Canadians remember the 2013 tragedy at Lac-Mégantic, of course, but more recent occurrences in British Columbia and Saskatchewan have also taken a deadly toll. In fact, the number of uncontrolled movements is climbing, with last year’s total of 78 well above the 10-year average. For the safety of railway workers and the travelling public, these numbers need to go down. That will require collaboration between Transport Canada (TC), the railways, and their labour representatives as they devise strategies and implement physical and administrative defences to reduce the risks.
The issue we removed from the Watchlist, slow progress responding to TSB recommendations, was first highlighted in 2016. At the time, there were 52 outstanding TSB recommendations that were at least 10 years old, more than half of them over 20 years old. Put simply, Transport Canada wasn’t doing enough, quickly enough. I’m happy to report there has been significant progress, particularly in aviation, and a substantial reduction of this backlog, along with a commitment by TC to maintain this positive momentum. That doesn’t mean the problem is entirely gone, but with many of the remaining outstanding recommendations already supporting other Watchlist issues, the Board feels enough progress has been made to take this one off the list.
And then there are the twin issues of safety management and regulatory oversight or surveillance —in many ways, two sides of the same coin. Both these issues cross over into multiple sectors of our transportation system. In previous Watchlist editions, these were a single issue, known as safety management and oversight. This year, we’ve separated them —recognizing that, even though they are related, they are nonetheless distinct, and that each will need its own unique solution.
With regard to safety management, our investigations continue to show that some transportation operators are not managing their safety risks effectively , and many are still not required to have formal safety management processes in place . Even those operators with a formal SMS, or Safety Management System, are not always able to demonstrate that it is producing the expected safety improvements. We see this in every sector —for instance in rail, where recent TSB investigations have identified both a rising rate of main-track accidents and numerous instances of hazards not being identified.
As for regulatory surveillance, Canadians expect —and rightfully so —that it is safe for them to travel on and use services provided by companies that are inspected and approved by Transport Canada. However, TC hasn’t always been able to confirm that this is the case, nor does TC always intervene to ensure that operators take appropriate corrective action and in a timely manner. For instance, in the Marine sector, small vessels— even those carrying up to 12 passengers— go largely uninspected. What’s needed is both a wider application of SMS regulations —so that more sectors of the transportation industry are required to have an SMS
—along with a balance between traditional TC inspections (for compliance with regulations) and audits to show that company safety processes are working as intended.
The remainder of the issues on this year’s Watchlist are carryovers from previous editions. In some cases, progress has been made, just not enough yet to remove them from the Watchlist.
I’m talking specifically about runway overruns at Canadian airports, where new draft regulations are a start, but don’t meet international recommendations, and still won’t prevent a recurrence of the 2005 Air France accident at Toronto’s Pearson International Airport. Meanwhile, the rate of runway incursions, which occur when an aircraft or vehicle mistakenly occupies an active runway, has also increased. Despite gradual, incremental changes by the industry to address this, we need to see more action —specifically, a greater focus on direct-to-pilot warnings, or in-cockpit electronic awareness aids.
On a similar note, progress to improve commercial fishing safety has been slow, sporadic, and localized. Ten years after we first made this a Watchlist issue, too many fishermen still aren’t making it home, and TSB reports continue to identify unsafe conditions such as : failure to carry essential lifesaving equipment, poor knowledge of a vessel’s stability limits , or even not wearing a Personal Flotation Device. It’s time for a widespread behavioural change, one that leads to a stronger safety culture and is overseen by a coordinated effort from federal and provincial authorities. Yes, there will always be economic pressures —we know that— but when almost all accidents are preventable, the bottom line is that fish harvesters need to place a much higher priority on their lives over … the bottom line .
As for following railway signals, we know that Transport Canada and Canada’s railways are working on a plan for what’s known as “enhanced train control” —a technological defense that would help ensure that trains are automatically slowed or stopped if the signals governing speed and operating limits are not recognized and followed. But we still don’t know the details, or the timelines. This needs to change, especially when the number of occurrences is on the rise, and the consequences can be deadly.
Finally, one of the most pervasive issues that remains on the Watchlist is fatigue. This issue is also multimodal, affecting crews in the air, marine, and rail sector, who work long or irregular schedules, at times crossing multiple time zones in a single shift. What’s needed? Broadly speaking, more education and awareness among crews, plus a need for operators to introduce plans to mitigate fatigue, and for rules and regulations to receive a comprehensive update in light of the most recent knowledge from fatigue science.
Will fixing these issues be easy? Of course not. Government and industry stakeholders still need to work together —in some cases more than they already are, and in other cases in new and different ways.
And the TSB will continue to follow up on each of these issues, reporting progress as it happens and bringing attention where needed.
Canadians from coast to coast to coast can count on it.
Every year, there are millions of successful takeoffs and landings on Canadian runways. However, an accident can occur when an aircraft or vehicle incurs upon a runway surface that is actively in use.
Commercial fishing safety
The Transportation Safety Board of Canada (TSB) has long sought to improve commercial fishing safety. The TSB has been monitoring commercial fishing safety since 1999 and this issue has been on the TSB Watchlist since 2010.
Following railway signal indications
Train crews do not consistently recognize and follow railway signals. This poses a risk of train collisions or derailments, which can have catastrophic consequences.
Despite the millions of successful movements on Canadian runways each year, aircraft sometimes depart from the end of the runway surface during landings or rejected takeoffs.
Some transportation operators in the air, marine and rail sectors are not managing their safety risks effectively, and many are still not required to have formal safety management processes in place.
In the transportation industry, crews often work long and irregular schedules—sometimes in challenging conditions or crossing multiple time zones—that are not always conducive to proper restorative sleep.
Regulatory surveillance has not always proven effective at verifying whether operators are, or have become, compliant with regulations and able to manage the safety of their operations.
Unplanned/uncontrolled movement of rail equipment
Unplanned/uncontrolled movements of rail equipment create high-risk situations that may have catastrophic consequences.