ICAO/ASPA Regional Seminar Mexico City, Mexico 10-11 April 2007

1. ICAO/ASPA Regional SeminarMexico City, Mexico10-11 April 2007

2. Briefing Outline • TSB Mandate & Role • TSB Investigation Operations • SMS & TSB Investigations • TSB Products & Services

3. Mandate of the Board Act of the Canadian Parliament (Bill C - 23) Canadian Transportation Accident Investigation and Safety Board Act Marine Pipeline Rail Air

4. Mandate of the Board • To advance transportation safety by: • Conducting independent investigations • Identifying safety deficiencies • Make findings as to causes and contributing factors • Making recommendations • Reporting publicly

5. Mandate of the Board • In or over Canada; • In or over any place that is under Canadian air traffic control; and • In or over any other place, if • Canada is requested to investigate • Canadian Aircraft is involved.

6. Mandate of the Board • Not the function of Board to assign fault or determine civil or criminal liability • …but shall not refrain from fully reporting on the causes and contributing factors. • The findings are not binding on the parties to any legal, disciplinary or other proceedings.

7. Investigator Powers • Enter, Search, Seize • Test things seized, even to destruction • Prohibit access to the occurrence area • Require a person to produce information • Make copies information

8. Investigator Powers (cont.) • Require a medical examination • Require the provision of medical information • Cause an autopsy to be performed • Require person to permit an autopsy

9. Occurrence Reporting(TSB Regulations) • Accidents are reportable • resulting directly from the operation of an aircraft • serious injury or fatality • aircraft damage or failure that adversely affects the structural strength, performance or flight characteristics • aircraft missing

10. Occurrence Reporting(TSB Regulations) • Reportable Aviation Incidents • Airplane MCTOW ≥5 700 kg • Rotorcraft MCTOW ≥2 250 kg

11. Occurrence Reporting(TSB Regulations) • Reportable Aviation Incidents (Examples) • engine failure/shut down • smoke/fire, control difficulty • failure to remain on runway • depressurization/emergency descent • fuel shortage/emergency/priority handling • collision, risk of collision, loss of separation • declared emergency

12. TSB Investigation Operations • Receipt of Initial Notifications • Assessment of Safety Potential • Decision to Investigate • TSB Notification to: • Transport Canada • Involved Airline, Manufacturer, etc • Foreign States, etc

13. TSB Investigation Methodology • Collect data to determine “WHAT’’ happened • Determine the safety-significant events • Collect additional data to determine “WHY” it happened

14. TSB Investigation Operations • Data Collection Sources (Examples) • Witness Interviews • Recorders • TC Records • Airline Records • Manufacturer Records • Etc…

15. Privilege/Protected Data • TSB Act & Regulations • On-board Voice & Video Recordings • Witness Statements • Medical Information • Identity of Reporters • Privacy Act • Personal Information

16. TSB Use of Privilege/Protected Data • TSB Act & Privacy Act apply • Information collected only used for safety purposes • Protection of the identity of reporters • Privileged information cannot be used for liability or disciplinary purposes • TSB reports cannot be used for liability or disciplinary purposes

17. TSB Investigation Operations • Observers are Appointed • Minister’s Representatives • Accredited Representatives • Others, who are able to contribute to the Board’s objective. • (Owner, Operator, Manufacturer …) • Appointment is not automatic!

18. So, an accident happens… • Mandatory Report to TSB by: • owner, operator, pilot-in-command, any crew member, air traffic controller • TSB Regulations detail what has to be reported • TSB will request additional data to assess the occurrence • TSB provides its decision regarding the investigation

19. So, an accident happens… • TSB will request: • Company point-of-contact for the investigation for… • requesting information from the company • providing information to the company • arranging interviews • arranging access to property & persons

20. So, an accident happens… • TSB will request: • Company point-of-contact for the investigation. • Company subject-matter experts to assist the investigation team. • Additional information held by the company.

21. So, an accident happens… • Determine Why It Happened • Underlying & Contributing Factors • Risk Analysis • Defence & Barrier Analysis • Control Option Analysis • Recommend Corrective Actions • To Reduce Risk Potential • To Reduce the Severity of Consequences

22. So, an accident happens… • TSB produces a Confidential Draft Report • Distributes the report for comment by Draft Reviewers (Airline, manufacturer, TC, implicated crew, and others…) • Amends the report, if required • Issues the TSB Final Report

23. What’s new with SMS..? • Aeronautics Act provisions address the requirements for SMS (e.g.): • Companies responsible for safety management, including Quality Control, audits, and etc • Confidential and non-punitive reporting programs

24. What’s new for TSB with SMS..? • TSB Investigation operations will not be adversely affected: • CTAISB Act and TSB Regulations still apply. • Reporting to the TSB still required. • CTAISB Act powers to acquire information will still exists.

25. What’s new for TSB with SMS..? • Sources for information will change (e.g.): • Audit information - Company • Occurrence reporting information will likely increase.

26. TSB Use of Privilege/Protected Data • TSB Act & Privacy Act apply • Information collected only used for safety purposes. • Protection of the identity of reporters • Privileged information cannot be used for liability or disciplinary purposes • TSB reports cannot be used for liability or disciplinary purposes

27. TSB Products & Services • TSB Web Site: www.tsb.gc.ca • Reports, Safety Studies, Statistics … • Investigation Process, Policies … • Subscription Service: • http://listserv.tsb.gc.ca/en/subscribe/

28. Charles LaurenceSenior InvestigatorTransportation Safety Board of CanadaPhone: 819-994-8035Cellular: 613-853-9655Facsimile: 819-953-9586Email: charles.laurence@tsb.gc.ca