ICAO/ASPA Regional Seminar

Mexico City, Mexico10-11 April 2007

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Briefing Outline

• TSB Mandate & Role

• TSB Investigation Operations

• SMS & TSB Investigations

• TSB Products & Services

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Mandate of the BoardAct of the Canadian Parliament

(Bill C - 23)

Canadian Transportation Accident

Investigation and Safety Board Act

Marine PipelineAirRail

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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

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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.

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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.

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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

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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

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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

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• Reportable Aviation Incidents

• Airplane MCTOW ≥ 5 700 kg

• Rotorcraft MCTOW ≥ 2 250 kg

Occurrence Reporting(TSB Regulations)

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•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

Occurrence Reporting(TSB Regulations)

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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

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TSB Investigation Methodology

• Collect data to determine “WHAT’’ happened

• Determine the safety-significant events

• Collect additional data to determine “WHY” it happened

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TSB Investigation Operations

• Data Collection Sources (Examples)• Witness Interviews• Recorders• TC Records• Airline Records• Manufacturer Records• Etc…

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Privilege/Protected Data

• TSB Act & Regulations• On-board Voice & Video

Recordings• Witness Statements• Medical Information • Identity of Reporters

• Privacy Act• Personal Information

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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

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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!

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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

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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

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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.

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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

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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

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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

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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.

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What’s new for TSB with SMS..?

• Sources for information will change (e.g.):• Audit information - Company• Occurrence reporting information

will likely increase.

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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

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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/

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Charles LaurenceSenior Investigator

Transportation Safety Board of CanadaPhone: 819-994-8035Cellular: 613-853-9655

Facsimile: 819-953-9586Email: charles.laurence@tsb.gc.ca

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