TSB reassessment of outstanding safety recommendations: slow progress, continued action needed
Gatineau, Quebec, 27 June 2022 — Today, the Transportation Safety Board of Canada (TSB) released its annual reassessment of responses to 53 of its outstanding safety recommendations in the air, marine, and rail transportation sectors. There are currently no outstanding recommendations in the pipeline transportation sector.
These reassessments show some progress across Canada’s transportation system with responses to two recommendations receiving the highest rating of Fully Satisfactory: one in the air transportation sector and the other in the marine transportation sector. However, there has been minimal movement on some key safety issues across all three sectors, which continues to raise concerns from the Board.
The TSB issues safety recommendations as a call to industry and regulators to address systemic problems that pose a serious safety risk to Canada’s transportation system. Each year, the TSB reassesses outstanding recommendations as part of its ongoing efforts to urge the regulators or industry to act on the safety issues identified in investigations.
This brings the total of TSB recommendations assessed as Fully Satisfactory to 84.1%, a slight decrease of 0.4% over 2021 (84.5%). As of March 31, 2022, 84 recommendations still remain outstanding, roughly half of which date back almost 10 years.
Air transportation sector
In the air transportation sector, the Board closed two recommendations among the 26 reassessed. Recommendation A19-01 was closed as Fully Satisfactory following Transport Canada’s amendments to the Canadian Aviation Regulations (CARs) to eliminate the ambiguity associated with the use of safety belts on board aircraft. Recommendation A18-06 was closed after receiving a rating of Unsatisfactory, with no further actions planned by the United States Federal Aviation Administration.
Two recommendations issued to Transport Canada in 2018, during an investigation into a loss of control and collision with terrain of a West Wind Aviation ATR 42-320 in Fond-du-Lac, Manitoba (A17C0146), were assessed by the Board this year. Both received a rating of Satisfactory Intent (A18-02 and A18-03), as a result of progress being made to ensure locations with inadequate de-icing and anti-icing equipment are being identified and action is being taken to ensure that the proper equipment is available, and to increase compliance with relevant sections of the CARs and reduce the likelihood of aircraft taking off with contaminated critical surfaces.
Marine transportation sector
In Canada’s marine transportation sector, 18 marine recommendations were reassessed, Recommendation M94-06 was closed as Fully Satisfactory. The Large Fishing Vessel Inspection Regulations now require that large fishing vessels be fitted with water level detectors in all watertight compartments below the waterline that are not intended to carry liquids. The changes contained in these new regulations are expected to mitigate the risk associated with this safety deficiency.
However, in response to Recommendation M16-03 which calls for stability assessments for small fishing vessels, Transport Canada will not be taking further regulatory action. The department has indicated that the inspection of fishing vessels below 15 gross tonnage is risk-based, in order to focus on areas of higher risk. Transport Canada noted that regulatory compliance is the responsibility of the vessel’s authorized representative, and that authorized representatives should be aware of regulations and safety publications.
The Board is concerned about Transport Canada’s proposed approach to addressing the underlying safety deficiencies associated with M16-03 and, in general, the verification of compliance with regulatory requirements within the fishing industry. As TSB statistics have demonstrated, fish harvesting continues to be a hazardous occupation, and the fishing industry continues to represent a high-risk sector in the transportation system. As in previous years, the majority of the fatalities (8 of the 11) were related to commercial fishing (Canadian-flag vessels in Canadian waters). Commercial Fishing Safety has been an issue on the TSB Watchlist since its inception in 2010.
Rail transportation sector
As for the rail transportation sector, none of the nine responses to rail transportation safety recommendations the Board reassessed in 2021–22 were closed as Fully Satisfactory. The nine responses obtained Satisfactory Intent (4) and Satisfactory in Part (5).
This year, Transport Canada continued its work to update the regulatory regime for railway employee qualifications and training. This means that, while the action is not yet sufficiently advanced to reduce the risks to transportation safety, progress is being made toward addressing the safety deficiency identified in Recommendation R18-02 calling for training and qualification standards for railway employees in safety-critical positions. The Board therefore reassessed the response to the recommendation as showing Satisfactory Intent.
The Board also reassessed the response to Recommendation R14-05 on the auditing of safety management systems, one of the recommendations issued as a result of the TSB’s investigation into the 2013 runaway and main-track derailment in Lac-Mégantic, Quebec (R13D0054). Transport Canada indicated that it completed audits of all federally regulated railway companies’ safety management systems and that it is in the early stages of implementing a targeted audit framework for measuring the effectiveness of the safety management system processes. The Board is encouraged by the progress and therefore considers this response to show Satisfactory Intent.
Regarding Recommendation R13-01 on physical fail-safe train controls, the Board considers the responses from the Railway Association of Canada and Transport Canada to be Satisfactory in Part and strongly encourages both organizations to accelerate the pace of enhanced train control implementation.
The TSB is an independent agency that investigates air, marine, pipeline, and rail 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.
For more information, contact:
Transportation Safety Board of Canada