ICAO/ASPA Regional Seminar Mexico City, Mexico 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 MarinePipeline AirRail

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 Reportable Aviation Incidents Airplane MCTOW kg Rotorcraft MCTOW kg Occurrence Reporting (TSB Regulations)

11 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)

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 Ministers Representatives Accredited Representatives Others, who are able to contribute to the Boards 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 Whats 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 Whats 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 Whats 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: – Reports, Safety Studies, Statistics … – Investigation Process, Policies … Subscription Service: –

28 Charles Laurence Senior Investigator Transportation Safety Board of Canada Phone: Cellular: Facsimile:

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