"Our previous fiscal year was one of both continuity and change for the TSB," comments TSB Chair Kathy Fox. "As we continued to strive for a safer transportation system, at times under challenging circumstances, we communicated more safety information than ever through our investigation reports and public communications."
The year in results
· The TSB launched 66 investigations and completed 50 across all four transportation sectors (air, marine, pipeline, and rail).
· Limited-scope Class 4 investigations accounted for 52% of the total cases closed during the year. In them, the TSB quickly gathers, analyzes and reports the facts of straightforward occurrences, freeing up resources for more complex investigations that have greater potential for advancing transportation safety.
· Engineers, technicians and human factors specialists began 247 projects and completed 231 technical reports in 2019-20 in support of investigations. They also began 23 projects and completed 16 technical reports for foreign investigation agencies.
· A strategy to guide interactions with Indigenous peoples during investigations was developed and training was implemented across the TSB, in alignment with the government's priority of reconciliation and renewed relationship with Indigenous peoples.
· In 2019-20, the TSB received 274 new SECURITAS reports, a 59% overall increase from 2018-19. By transportation mode, this resulted in a 91% increase of reports in aviation; 42% increase in marine and 34% increase in rail.
Involvement at the international level
The January 2020 downing of Ukrainian International Airlines Flight 752 marked a tragic start to this new decade. The TSB appointed an Expert in accordance with Annex 13 to the Convention on International Civil Aviation and deployed two investigators to Tehran to visit the accident site and meet with investigators from the Aircraft Accident Investigation Bureau of the Islamic Republic of Iran (AAIB) who is leading the investigation. While our involvement is limited as prescribed by Annex 13, we continue, to the greatest extent possible, to do our part to find out what happened and why-for the families and for all Canadians.
Safety Issue Investigation and safety communications
Following a five-year investigation into safety issues in the air-taxi sector, the TSB issued its report, shedding light on risks in an important part of Canada's aviation industry. Air taxi operators play a crucial role in moving people and goods-particularly in remote locations-but have a troubling and persistent accident history. In this final report, we recommended that both Transport Canada and industry associations step up to take concrete measures to raise the bar on air-taxi safety.
Throughout the year, the TSB also issued 26 new safety communications, mainly directed to regulatory agencies and industry stakeholders.
As well, the Board reassessed the progress achieved on a number of active recommendations. As a result:
· By April 2020, 13 outstanding recommendations had been closed as Fully Satisfactory.
· Since 1990, the Board has made 609 recommendations, the responses to 83% of which have led to a Fully Satisfactory assessment (up from almost 81.5% at the end of 2018-19).
· Nonetheless, there were still 92 outstanding recommendations, slightly less than half of which date from 10 years ago or more.
Beyond the COVID-19 pandemic
An important focus looking forward will be to respond to the effects of the COVID-19 pandemic. Canada's response to this worldwide event accelerated our move to a digital workplace. Steps we had already taken, including introducing electronic and portable business tools, have allowed us to continue operating with little disruption throughout the ongoing pandemic period.
This solid foundation will serve us well as we continue to advance transportation safety during what promises to be a time of substantial change, not only in how and where we do our work but also in the transportation industry itself.
The Annual Report for 2019-20 is available on the TSB website and includes the list of all investigation reports released during the year with examples of safety actions taken.
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.
- 30 -
