Annual Report to Parliament 2004-2005

Transportation Safety Board

Annual Report to Parliament 2004-2005

Transportation Safety Board of Canada
Place du Centre
200 Promenade du Portage
4th Floor
Gatineau, Quebec K1A 1K8
(819) 994-3741

© Minister of Public Works and Government Services
Cat. No. TUI-2005
ISBN 0-662-69103-0


Place du Centre
200 Promenade du Portage
4th Floor
Gatineau, Quebec K1A 1K8

17 August 2005

The Honourable Lucienne Robillard, P.C., M.P.
President of the Queen's Privy Council for Canada
House of Commons
Ottawa, Ontario K1A 0A6

Dear Minister:

In accordance with subsection 13(3) of the Canadian Transportation Accident Investigation and Safety Board Act, the Board is pleased to submit, through you, its annual report to Parliament for the period 1 April 2004 to 31 March 2005.

Yours sincerely,

Signature of Charles H. Simpson, Acting Chairman

Charles H. Simpson
Acting Chairperson


  1. Members of the Board
  2. Chairperson's Message
  3. Senior Management
  4. Mission of the TSB
  5. Independence
  6. Occurrences, Investigations and Safety Action
  7. Liaison with Canadian Transportation Community
  8. International Cooperation and Knowledge Transfer
  9. Marine Occurrence Statistics and Investigations
  10. Pipeline Occurrence Statistics and Investigations
  11. Rail Occurrence Statistics and Investigations
  12. Air Occurrence Statistics and Investigations
  13. Appendix A - Glossary


  1. Occurrences Reported to the TSB
  2. Investigations in Process / Completed
  3. Safety Action by the TSB
  4. Board Assessment of Responses to Recommendations
  5. Marine Occurrences and Fatalities
  6. Pipeline Occurrences
  7. Rail Occurrences and Fatalities
  8. Air Occurrences and Fatalities


Charles H. Simpson

Acting Chairperson Charles H. Simpson

Transportation executive experience includes Executive Vice-President, Operations, for Air Canada; President of the Canadian Air Line Pilots Association; and Vice-President of the International Federation of Air Line Pilots' Associations.

Jonathan Seymour

Member Jonathan Seymour

Transportation policy and marine management experience includes Executive Director of International Maritime Centre-Vancouver; chartering, commercial and general manager for several shipping companies; marine policy advisor to the British Columbia government; and policy and economic consultant.

Wendy A. Tadros

Member Wendy A. Tadros

Transportation and legal experience includes Director of Legal Services for the National Transportation Agency of Canada; Inquiry Coordinator for "The Road to Accessibility: An Inquiry into Canadian Motor Coach Services"; and counsel to the Canadian Transport Commission before the Commission of Inquiry into the Hinton Train Collision.

James P. Walsh

Member James P. Walsh

Was the Member of the House of Assembly in Newfoundland and Labrador for the district of Conception Bay East - Bell Island from 1989 to 2003. Most recently, served as Minister of Works, Services and Transportation, and also served as Minister of Tourism and Culture, Parliamentary Secretary to the Minister of Finance and Treasury Board, and Parliamentary Secretary responsible for the Newfoundland and Labrador Housing Corporation. Also served as Caucus Chairman and Vice-Chair of the Public Accounts Committee. In 2003, received the distinction of Honorary Life Member of the Transportation Association of Canada.

R. Henry Wright

Member R. Henry Wright

Management and consulting experience includes auditor for the Ontario Ministry of Community and Social Services; senior management administrator of several non-profit organizations; and consultant in government and public relations.


The mandate of the Transportation Safety Board of Canada is clear and very focussed - we investigate accidents in the rail, air, pipeline and marine modes of transportation to determine what happened and why it happened. Our ultimate product is information and knowledge, imparted to individuals, transportation companies, business associations, manufacturers and regulators to assist in ensuring that unsafe actions or conditions are not repeated or allowed to persist.

For the past two years, we have placed a particular management focus on ensuring that key information is available to agents of change and the public at large in a more comprehensive and timely fashion. We reduced the number of in-process investigations by 35%, reduced the average time to complete an investigation by roughly 10%, and greatly increased the availability of information derived from our investigations on our Web site. Public use of our Web site has doubled during this reporting period.

These improvements are very positive indicators that the changes implemented by the management team are having the desired effect and that the organization is better positioned to contribute to the advancement of transportation safety in Canada and around the world.

Canadians expect - even demand - a safe and sound transportation system along our waterways, pipelines, railways and in our skies. The work of the TSB over the past year has contributed to the reinforcement of a strong safety culture, both at home and abroad. We are an integral element of an effective network of people and organizations committed to the safety of Canadians. The results highlighted in this year's annual report clearly reflect the value the TSB brings to the transportation system and to Canadians.

Signature of Charles H. Simpson, Acting Chairman

Charles H. Simpson
Acting Chairperson


Executive Director D. Kinsman
General Counsel A. Harding
Director General, Investigation Operations T. Burtch
Director, Corporate Services J. L. Laporte
Director, Marine Investigations F. Perkins
Director, Rail/Pipeline Investigations I. Naish
Director, Air Investigations N. Stoss
Director, Engineering N. Cerullo


We conduct independent safety investigations and communicate risks in the transportation system.


To encourage public confidence in transportation accident investigation, the investigating agency must be, and be seen to be, objective, independent and free from any conflicts of interest. The key feature of the TSB is its independence. It reports to Parliament through the President of the Queen's Privy Council for Canada and is separate from other government agencies and departments. Its independence enables it to be objective in arriving at its conclusions and recommendations. The TSB's continuing independence and credibility rest on its competence, openness, integrity and the fairness of its processes.


In 2004, a total of 1935 accidents and 1476 incidents were reported in accordance with the TSB's regulations for mandatory reporting of occurrences.1 The number of accidents in 2004 decreased by 2% from both the 1973 accidents reported in 2003 and the 1999-2003 annual average of 1978 accidents. The number of reportable incidents reached 1476 in 2004, up from 1390 in 2003 and the 1999-2003 average of 1361. There were also 679 voluntary incident reports. Fatalities totalled 185 in 2004, up from 172 in 2003 but down from the 1999-2003 average of 202.


Figure 1 - Occurences Reported to the TSB


All reported occurrences were examined in accordance with the Board's Occurrence Classification Policy to identify those with the greatest potential for advancing transportation safety. Investigations were undertaken for 72 of the approximately 4000 occurrences reported to the TSB in fiscal year 2004-2005. In that same period, 115 investigations were completed, compared to 73 in the previous year.2 The number of investigations in process decreased to 99 at the end of the fiscal year from 142 at the start. Average time to complete an investigation decreased to 619 days in fiscal year 2004-2005 from 684 days in the previous year. Information on all reported occurrences was entered into the TSB database for historical record, trend analysis and safety deficiency validation purposes.

While the Board's operations are for the 2004-2005 fiscal year, occurrence statistics are for the 2004 calendar year. Comparisons are generally to the last 5 or 10 years. For definitions of terms such as accident, incident and occurrence, see Appendix A.

Investigations are considered complete after the final report has been issued.


Figure 2 - Investigations in Process / Completed



Marine 4 9 8
Pipeline 0 5 0
Rail 3 6 10
Air 4 9 6
TOTAL 11 29 24
Note:  A total of four Safety Concerns were identified for Marine in 2004-2005.
A total of three Safety Concerns were identified for Rail in 2004-2005.
A total of five Safety Concerns were identified for Pipeline in 2004-2005.

In accordance with the Canadian Transportation Accident Investigation and Safety Board Act, a federal minister who is notified of Board recommendations must, within 90 days, advise the Board in writing of any action taken or proposed to be taken in response, or the reasons for not taking action. The Board considers each response, assessing the extent to which the related safety deficiency was addressed. When a recommendation generates responses from within and outside Canada, the Board's assessment is based primarily on the Canadian response.


Marine 0 4 3 4
Pipeline 0 0 0 0
Rail 2 2 1 0
Air 1 1 0 0
TOTAL 3 7 4 4


As part of the TSB's effort to keep abreast of technological change and to maintain contact with the transportation industry in Canada, TSB staff and Board members attend and participate in various conferences and technical meetings pertinent to transportation safety.

Members of the Board participated in visits and conferences with the Railway Association of Canada in British Columbia, the British Columbia Towboat Conference in Victoria, the International Pipeline Conference in Calgary and the Air Transport Association of Canada. Members of the Board also made presentations to the Canadian Transportation Lawyers Association in Calgary, the International Pipeline Conference in Calgary and the Pipeline Research Council International, Inc. Conference in Montebello.

In addition, the Executive Director continued to maintain close ties with the community by attending meetings such as the Canadian Business Aircraft Association's Annual General Meeting and Annual Stakeholders' Meeting, the Helicopter Association of Canada Annual Convention, the Canadian Aviation Executives' Safety Network Annual Meeting, the Transport Canada-sponsored Canadian Aviation Safety Seminar, the Canadian Air Traffic Controllers' Annual Convention and the Railway Association of Canada Annual General Meeting.

Library staff participated in the formation of the Canadian Transportation Research Gateway, a collection of Web resources on transportation research in Canada. The Gateway was formed through a collaboration of Canadian transportation libraries, the Canadian Transportation Agency, Transport Canada and the Transportation Development Centre, the Transportation Association of Canada and the Transportation Safety Board.

Marine staff gave presentations to the Comité régional sur les communications d'urgence in Quebec, and a multimodal presentation was given to senior Sûreté du Québec personnel in Montréal. In the Central region, presentations were made to police, harbour masters, fire departments, emergency medical services units, the U.S. Coast Guard and U.S. border police, two International Shipmasters lodges and the Canadian Power and Sail Squadron. In the Western region, presentations were made to the Canadian Coast Guard Auxiliary, Washington Marine Group, Orient Steamships Canada Ltd., Fairmont Shipping Canada Ltd. and Valles Steamship Canada Ltd., the Chamber of Shipping and the Institute of Chartered Shipbrokers. The Vancouver office staff are directly involved in the proceedings of the Marine Action Group (MAG) and have made a dozen presentations to fishing and other marine interests. Other activities included participation in meetings with the Canadian Maritime Law Association, the Canadian Marine Advisory Council (both national and regional) and the Society of Naval Architects and Marine Engineers.

Pipeline staff made presentations about the TSB's mandate, investigative process and reporting requirements to a wide range of pipeline companies in both eastern and western Canada. Companies included El Paso Canada Pipeline, EnCana Corporation, Marathon Canada Ltd.-Corridor Resources, Canada-Nova Scotia Offshore Petroleum Board, Shell Canada, Heritage Gas, Petro-Canada, Imperial Oil, Exxon Mobil, Sable Pipeline, Exxon's fractionation plants in Point Tupper and Goldsboro, Global Santa Fe, TransCanada PipeLines, Enbridge, Terasen Pipelines, Maritimes & Northeast Pipeline, Alliance Pipeline, and Edmonton and Regina Emergency Measures District.

Rail staff made presentations at the Atlantic Regional Railway Conference in Moncton and to Canadian Pacific Railway in Calgary. Both formal and informal meetings were held with Canadian industry and regulatory bodies.

TSB Air staff participated in annual meetings with departments and associations within the aviation community and provided formal briefings to the Air Transportation Association of Canada, the Northern Air Transport Association, the Canadian Space Agency meeting on the Human Spaceflight Emergency Disaster Contingency Plan, the National Police Convention, the Recreational Aircraft Association, and the Northwest Territories Government Forestry Services. Staff also participated and provided briefings during disaster response planning exercises with the Montréal Airport and the Edmonton International Airport Aircraft Rescue and Fire Fighting service.

The TSB's Engineering facilities continued to provide briefings and visits of particular interest to industry groups. This year, the Engineering Branch examined the fuel cell explosion on Bell 206 helicopters with Transport Canada (TC) and a fractured main rotor Starflex on a Eurocopter AS 350 helicopter for TC. It also tested marine lights for TC and participated as an observer for a rail site survey. It examined a failed rail line heater for OC Transpo and participated in a shared evaluation of CVR and FDR (cockpit voice recorder and flight data recorder) and track-train dynamics for the National Research Council.

Macro-analysis staff met with B.C. Ferries, the B.C. Chamber of Shipping, the B.C. Pilotage Authority, the B.C. Safety Authority and researchers from the University of British Columbia to explore ways to improve the TSB's occurrence data products and services. Further, the Macro-analysis Division provided active support to Transport Canada's multidisciplinary research project on grade-crossing accidents.


The TSB's mission is to advance transportation safety, not only in Canada but worldwide. This cooperation comes in many forms, through participation in safety symposiums, international safety organizations and international investigations.

Over the past year, Board members attended the 49th Aviation Safety Seminar in Tucson, Arizona, and the Air Line Pilots Association Annual General Meeting, the official opening of the U.S. National Transportation Safety Board Academy and a meeting of the International Transportation Safety Association, all in Washington, D.C. The Executive Director also attended and made two formal presentations at the International Transportation Safety Association meeting.

Marine staff continued to participate on various International Maritime Organization (IMO) committees and sub-committees, and particularly in the Human Element and Casualty Analysis working groups and correspondence groups. The TSB has contributed to the identification and validation of marine safety issues for IMO committees and assisted in the development and subsequent amendments of the IMO Code for investigating marine casualties and incidents. The TSB is a founding member of the Marine Accident Investigators' International Forum and this year made presentations at the annual meeting in South Africa. Marine staff were again requested to present a marine accident investigation course, sponsored by the IMO and held at the International Maritime Academy at Trieste, Italy. A monthly column about noteworthy Canadian marine investigations is prepared for the Marine Engineers Review, a noted U.K. publication. Informatics hosted a site for the Marine Accident Investigators' International Forum, where they posted the results of a survey on the implementation of the IMO Code for investigation of marine accidents.

Air staff completed its support to the Gabinete de Prevençao e Investigaçao de Acidentes, the accident investigation authority of Portugal, in its release of the final investigation report on the 2001 Air Transat accident in the Azores. Air staff also attended the 2004 International Society of Air Safety Investigators Conference and presented a discussion paper on the theme "Investigate, Communicate, Educate - Are We Doing Things Right?" The TSB participated as part of the Canadian delegation at the International Civil Aviation Organization (ICAO) 35th Assembly. It consulted with the Director General of the Swedish Board of Accident Investigation on the fundamentals of national legislation for accident investigation authorities. The TSB briefed the Republic of Congo Civil Aviation Administration delegation on Canada's approach to accident safety investigation. It participated in the Flight Safety Foundation International Safety Symposium and held meetings with France's Bureau d'Enquêtes et d'Analyses on international investigations and inter-agency procedures. The TSB participated in the 21st meeting of the Group of Experts on Accident Investigation of the European Civil Aviation Conference. Air Branch investigators continued to represent the TSB as accredited representatives in numerous foreign accident investigations involving Canadian-manufactured, designed or certified products, or when Canadian passengers had been exposed to risk.

Engineering staff participated in the Accident Investigation Recorders (AIR) Working Group held in Washington in June 2004, the RAPS Users Conference in Ottawa in June 2004, and the FDR Parameter Working Group. A TSB staff member has been designated the Canadian representative for the ICAO Flight Recorder (FLIREC) Panel. Engineering staff examined aircraft instruments for investigations carried out by Zimbabwe and Japan. Staff also attended engine teardown at Pratt & Whitney as an accredited representative for Italy and helped the U.S. National Transportation Safety Board in failure analysis due to facility problems.

Rail staff made a presentation on organizational and cultural impacts on safety at the International Rail Safety Conference in Perth, Australia. Staff also attended the International Pipeline Conference in Calgary. At both the Perth and Calgary events, conference attendees came from a wide range of countries. Formal meetings were held with the South African rail regulator in Ottawa and with the new British Rail Accident Investigation Branch of the Department of Transport, the British rail regulator, and the Health and Safety Executive. These discussions were wide-ranging, covering regulatory and investigative philosophies and processes, as well as issues related to operational approaches to investigation. Finally, the TSB established a link to a new Internet domain for the International Rail Safety Conference. This will make the majority of papers that have been presented at the conference over the years available to a wider audience.

Pipeline staff held formal and informal discussions with regulatory, industry and investigative bodies at an international conference with their counterparts from South America, Asia and North America. The Manager of Pipeline has been corresponding with his counterpart in Brazil, providing details on the regulatory and investigative regime in Canada.

Human Performance staff participated in human factors working groups at international transportation meetings, including International Maritime Organization meetings in London and ICAO meetings in Montréal. They also attended the ICAO Threat and Error Management Symposium in Seattle and the Association of Professional Sleep Societies Conference in Philadelphia. Human Performance staff also delivered the Human Factors in Investigations course to external participants, including provincial and federal investigative and regulatory bodies (Department of National Defence, National Energy Board, Transport Canada-Rail, and Workers' Compensation Board of B.C.), industry (Air Line Pilots Association, Canadian Pacific Railway, Quebec North Shore and Labrador Railway Company) and academia (University of British Columbia).

Macro-analysis staff participated in the International Civil Aviation Organization's Safety Indicators Study Group. The Macro-analysis Division also provided several statistical reports to international agencies and industries.

Table of Contents | Next