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Liste de surveillance 2020

La Liste de surveillance du Bureau de la sécurité des transports du Canada (BST) contient les principaux enjeux de sécurité auxquels il faut remédier pour rendre le système de transport canadien encore plus sécuritaire.

Les huit enjeux de cette liste ont fait l’objet de rapports d’enquête, de signalements de préoccupations liées à la sécurité et de recommandations du Bureau. Certains figurent sur la Liste de surveillance depuis 2010, et l’un d’entre eux, soit la gestion de la fatigue, a été étendu aux trois modes de transport dans la présente édition. Tous nécessitent un effort concerté des organismes de réglementation et des intervenants de l’industrie.

Publication de la Liste de surveillance 2020 du BST - Transcription

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.

Liste de surveillance

Risque de collisions dues aux incursions sur pistes
Risque de collisions dues aux incursions sur pistes

Chaque année, des millions de décollages et d’atterrissages ont lieu sans incident sur les pistes des aéroports canadiens. Toutefois, un accident peut survenir lorsqu’un aéronef ou un véhicule s’engage sur une piste en service.

Sécurité de la pêche commerciale
Sécurité de la pêche commerciale

Le Bureau de la sécurité des transports du Canada (BST) cherche depuis longtemps à améliorer la sécurité de la pêche commerciale. Le BST surveille la sécurité de la pêche commerciale depuis 1999, et cet enjeu figure sur la liste de surveillance du BST depuis 2010.

Respect des indications des signaux ferroviaires
Respect des indications des signaux ferroviaires

Les équipes de train ne sont pas toujours en mesure de reconnaître ou de respecter les signaux ferroviaires. Cela pose un risque de collisions ou de déraillements de trains, qui peuvent avoir des conséquences catastrophiques.

Sorties en bout de piste
Sorties en bout de piste

Chaque année au Canada, malgré les millions de mouvements sans incident sur les pistes d’aéroports, des aéronefs dépassent parfois l’extrémité de la piste au moment de l’atterrissage ou d’un décollage interrompu.

Gestion de la sécurité
Gestion de la sécurité

Certains transporteurs aériens, maritimes et ferroviaires ne gèrent pas efficacement leurs risques en matière de sécurité, et plusieurs ne sont toujours pas tenus de mettre en œuvre des processus formels pour la gestion de la sécurité.

Gestion de la fatigue
Gestion de la fatigue

Dans l’industrie du transport, les équipages doivent souvent composer avec de longues heures de travail et des horaires irréguliers, parfois sur plusieurs fuseaux horaires ou dans des conditions difficiles, qui ne sont pas toujours propices à un sommeil réparateur

Surveillance réglementaire
Surveillance réglementaire

La surveillance réglementaire ne s’est pas toujours avérée efficace pour vérifier si des exploitants sont conformes aux règlements — ou s’ils ont acquis une telle conformité — et s’ils sont capables de gérer la sécurité de leurs activités.

Mouvements imprévus ou non contrôlés d’équipement ferroviaire
Mouvements imprévus ou non contrôlés d’équipement ferroviaire

Les mouvements imprévus ou non contrôlés de l’équipement ferroviaire peuvent engendrer des situations très risquées aux conséquences potentiellement catastrophiques