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Chapter

Management and Organizational Studies 1022F/G Chapter Notes -Wake Turbulence, Jet Blast, Dangerous Goods


Department
Management and Organizational Studies
Course Code
MOS 1022F/G
Professor
Suzanne Kearns

Page:
of 7
Chapter 8: Accident Investigation and the
Transportation Safety Board of Canada
History and Organization of the TSB
-- (Mar. 29, 1990): Canadian Transportation Accident Investigation and Safety Board
Act came into place
>> responsible for creation of Transportation Safety Board
-- TSB: independent agency responsible for investigating marine, pipeline, railway,
aviation transport occurrences; sole purpose to advance transport safety in
Canada
-- reports to Parliament via President of Queen’s Privy Council for Canada
-- headed by Chairperson & up to 4 board members
-- head office: Gatineau, Quebec engineering lab: Ottawa, Ontario
-- 1/3 of 230 employees located in field/regional offices across Canada; allows for
rapid response
The mandate of the TSB is to Advance Safety in the marine, pipeline, rail, and air
modes of transportation by:
1. Conducting independent investigations, including public inquiries when
necessary, into selected transportation occurrences in order to make findings
as to their causes and contributing factors
2. Identifying safety deficiencies, as evidences by transportation occurrences
3. Making recommendations designed to eliminate or reduce any such safety
deficiencies
4. Reporting publicly on our investigations and on the findings relation thereto
-- TSB independent & free from potential conflicts of interest in investigating
process to instill confidence in public regarding transportation accident
investigation process
>> may work in cooperation w/ TC, RCMP, DND
-- independence allows for complete objectivity in development of findings as to
what caused an accident/safety recommendations
-- purpose of TSB’s investigative work is to determine what caused/contributed to
accident
TSB Investigations
-- appx. 4000 transportation occurrences reported to TSB
-- formal investigation conducted in 2-3% of reported occurences/year
-- others: collect data on pertinent circumstances for future research/use as
required to advance safety
-- deploy investigation team & assess whether full out investigation is needed
-- if Canada interests involved, TSB occasionally aids in foreign investigations
>> i.e. if aircraft is registered, licensed, or manufacture in Canada
-- investigators share stand-by duty & assigned investigator-in-charge
-- deployed as team of two – technical investigator & operational investigator
TSB’s Investigation Process
Field Phase
-- investigation team assembled
>> make up of [operations, equipment, maintenance, engineering, scientific,
human performance specialists] team based on
circumstance of occurrence/investigation needs
>> 1-2 for straightforward investigation; 10+ for major investigation
-- last 1day – several months
-- secure & examine occurrence site
-- examine equipment, vehicle, wreckage
-- interview witnesses/company/gov’t personnel
-- collect pertinent info
-- select & remove specific wreckage items for further exam
-- review documentation
-- identify potential unsafe acts/unsafe conditions
Post-Field Phase
--might take several months
-- examining all records associated with aircraft/pilot/aviation company involved
-- examining wreckage, systems, components in lab
-- analyzing CVR & FDR reports
-- using computer-based reconstruction to simulate accident & develop timeline of
events
-- consider pilot toxicology/autopsy reports
-- conducting additional interviews
-- if safety deficiencies suspected/confirmed, TSB advise person/authority ASAP (no
questions asked)
>> might make formal recommendations to repeated safety deficiencies
Report Production Phase
-- initial draft approve/amend/returned (if approved) sent as confidential draft
report to persons/corps whose interests may be affect by report/who are most
qualified to comment dispute/correct/contradict
-- release final accident report depends on complexity
>> TSB takes time to do thorough investigation & produce report that
advances safety & meets expectation of Canadian
Public/transportation industry
Cooperation
-- may include government, aircraft manufacturer, engine manufacturer, airline,
witnesses, survivors, next of kin, medical examiners, police, fire depts., SAR teams
-- police officers usually first to arrive at scene of accident; their responsibility to
secure site, preserve evidence, document situation, assist coroner & look for
signs of criminal activity
-- sometimes coroner & medical examiner remove corpses fm fuselage & determine
cause of death
>> turn bk over to TSB after this is done
-- police/coroner/transportation company notify kin of accident
>> TSB might interview kin; no names released
Observers
-- Minister of Transport commonly designates person to attend as observer (CTAISB
Act, subection 23(2))
-- observer obtain factual info fm ongoing investigation, advise dept of any
significant regulatory factors, identify deficiencies that require immediate
corrective actions, coordinate require support to occurrence investigation
-- TSB may grant observer status to persons w/ direct interest in investigation @
own discretion if they might contribute positively to investigation
Investigation Reports
-- release factual info about occurrence thru-out investigation
-- info that impacts safety shared ASAP w/ individual/groups that implement
changes to improve safety
>> info in form of recommendations, safety advisories, safety info letters [in
any format that will allow safety message to be passed, so corrections
may be applied ASAP
-- CVR & witness statements protected by law; no public release
Definition of Accident