Effective February 22, 2023
1. Context
1.1 As stated in subsection 7(1) of the Canadian Transportation Accident Investigation and Safety Board Act (CTAISB Act), the object of the Board is to advance transportation safety by conducting independent investigations of selected occurrences to make findings as to causes and contributing factors; identifying safety deficiencies; making recommendations designed to eliminate or reduce any such safety deficiencies; and reporting publicly on its investigations and on the findings in relation thereto.
1.2 The Board shares information arising from its investigations by means of a variety of transportation safety communication products including safety investigation reports and updates, safety information letters, safety advisory letters, safety concerns, safety recommendations, and the Watchlist.
1.3 As required by the CTAISB Act, the Board notifies in writing any minister or person who has a direct interest in any of its findings, safety deficiencies it has identified, or safety recommendations.
2. Definitions
2.1 “Change agent” means a regulator, organization, or person who is able to influence and effect change to reduce the risk associated with and/or eliminate identified safety deficiencies.
2.2 “Minister” means the member of Cabinet responsible for any federal government department or agency defined as the “appropriate Minister” in the Financial Administration Act.
2.3 “Person” means any person other than a minister who, in the opinion of the Board, has a direct interest in any of its findings, safety deficiencies it has identified, or safety recommendations.
2.4 “Report” is defined in the Policy on Occurrence Classification.
2.5 “Transportation safety advisory letter” means a letter sent to regulatory and/or industry stakeholders to inform them of safety deficiencies posing low to medium risk identified during an investigation and to suggest remedial action be taken to reduce risks to safety.
2.6 “Transportation safety concern” means a statement in an investigation report that signals to the regulator and industry that the Board has identified a safety deficiency posing a high risk for which it does not yet have sufficient information to indicate that it is systemic.
2.7 “Transportation safety information letter” means a letter sent to regulatory and/or industry stakeholders to inform them of safety deficiencies identified during an investigation that pose low risk and do not require immediate remedial action.
2.8 “Transportation safety recommendation” means a recommendation made by the Board as part of its mandate to eliminate or reduce systemic safety deficiencies that pose the highest risk to the transportation system and warrant the highest level of attention of regulators and industry.
2.9 “Transportation safety investigation update” means an update to provide factual, validated information about an occurrence; an overview of the investigation process, its progress, and its status; the context of pressing safety communications released during the investigation; actions taken in response to the occurrence; and/or safety communications and other important information having some bearing on the investigation.
2.10 “Stakeholder” is defined in the Policy on Interaction with Stakeholders.
2.11 “Watchlist” means the periodically published list of the key safety issues identified by the Board that need to be addressed to make Canada’s transportation system even safer. The aim of the Watchlist is to focus the attention of regulators and industry on the actions required to reduce the risks that these issues pose.
3. Policy objective
3.1 The objective of this policy is to define transportation safety communication products and the criteria for their publication, and to state Board expectations with respect to actions to be taken by regulatory and/or industry stakeholders in response to them.
4. Policy requirements
4.1 General
4.1.1 Transportation safety communication products (except for the Watchlist and final investigation reports, which each have their own release schedule) can be issued at any stage of the investigation.
4.1.2 The following safety communication products are published on the TSB website:
- Transportation safety investigation updates and reports
- Transportation safety letters
- Transportation safety information letters
- Transportation safety advisory letters
- Transportation safety concerns
- Transportation safety recommendations
- Watchlist
4.1.3 Any communication channel may be used to share safety communication products.
4.2 Transportation safety investigation reports
4.2.1 The investigation report identifies safety deficiencies that need to be addressed by regulators and other change agents to advance transportation safety. The report may also include safety action taken and safety action required to reduce risk in the transportation system.
4.2.2 In accordance with subsection 24(2) of the CTAISB Act and as outlined in the TSB’s Policy on Representations on Confidential Draft Reports, the Board sends a confidential draft of the investigation report to each minister and any other person (organization or individual) who, in the opinion of the Board, has a direct interest in the Board’s findings so that they can comment on it.
4.2.3 As a courtesy to those preparing to respond publicly to investigation reports when they are released, the Board may provide an embargoed advance copy of the final report to directly interested ministers, organizations, and individuals.
4.3 Transportation safety letters
4.3.1 Directors of investigations (DOIs) are responsible for issuing safety letters before an investigation has been completed to inform regulatory and/or industry stakeholders of safety deficiencies that require stakeholder attention.
4.3.2 Responding to a safety letter
4.3.2.1 Recipients of a safety letter are asked to provide a response in writing to the DOI within 90 days of receipt. A response to a safety letter should inform the DOI of any action taken or proposed to be taken. This action can then be added, as applicable, to the final report if an investigation is ongoing.
4.3.3 Publishing safety letters
4.3.3.1 Safety letters are generally published on the TSB website within 90 days after they were issued.
4.4 Transportation safety concerns
4.4.1 Safety concerns are usually published in the final investigation report. However, they may be published before the final report when the Board deems it appropriate to convey important safety information before the investigation is finalized.
4.4.2 The Board encourages the change agents to whom a safety concern is directed to inform the Board in writing of any action taken or proposed to be taken in response to the safety concern within 90 days of receipt.
4.5 Transportation safety recommendations
4.5.1 Recommendations are usually published in the final investigation report. Not all investigation reports include recommendations. The Board issues recommendations before the final report is published when it deems that urgent safety action is required.
4.5.2 Responding to a recommendation
4.5.2.1 In accordance with subsection 24(6) of the CTAISB Act, the minister or ministers to whom a recommendation is notified shall provide a written response to the Board within 90 days of being notified of a recommendation, indicating the action that has been taken or that is proposed to be taken in response to it. If a minister indicates in the response that no action will be taken or if the action to be taken differs from the action that was recommended, the rationale for that decision shall be provided in the response.
4.5.2.2 Although there is no legislated requirement for any person other than a minister to respond to the Board’s recommendations, the Board encourages change agents to whom a recommendation is addressed to formally reply within 90 days in the interest of advancing safety.
4.5.2.3 Ministers’ and other change agents’ responses to the Board’s recommendations are published on the TSB website.
4.5.3 Assessing responses to recommendations
4.5.3.1 The TSB assesses the response to a recommendation against the Assessment rating guide in Appendix A to identify the extent to which the safety deficiency has been or is being addressed.
4.5.3.2 The TSB endeavours to complete its formal assessment of the initial response within 60 days of receipt.
4.5.3.3 The TSB periodically asks for a written update from ministers and others on progress being made to address the safety deficiency, assesses their responses, and follows up, as described in Appendix B.
4.5.4 Publishing information
4.5.4.1 Change agents who have responded to a recommendation are provided the results of assessments of their responses at least two business days before being posted on the TSB website.
4.5.5 Granting ministers’ requests for extension of time pursuant to subsection 24(8) of the CTAISB Act
4.5.5.1 he Board has sole discretion to grant an extension to the 90-day initial response period.
4.5.5.2 The Board considers the reasons given for the delay in determining whether to grant an extension.
4.5.5.3 Where the Board is satisfied that the Minister is unable to reply to the Board within the 90-day period, the period may be extended as the Board deems necessary.
4.6 Watchlist
4.6.1 Each edition of the Watchlist is informed by outstanding TSB recommendations and systemic issues that have emerged from investigations, findings, and occurrence data.
4.6.2 The Board encourages regulators and/or stakeholders to take safety actions to significantly mitigate the level of risk posed by Watchlist issues.
4.6.3 The TSB periodically consults with industry to assess progress on Watchlist issues and gather feedback to inform the next edition of the Watchlist.
5. Authorities
5.1 This policy is issued under the authority of the Board in accordance with subsection 8(1)(c) of the CTAISB Act. It was approved by the Board on February 22, 2023 after consultation with the Executive Committee.
5.2 This policy will be reviewed and may be updated in response to changes in legislation, government priorities, or TSB strategic direction, but at least once every 5 years.
6. Roles and responsibilities
6.1 Chair
The Chair is responsible for initiating the periodic review and update of this policy by the Board.
6.2 Chief operating officer
The chief operating officer is responsible for overall implementation, monitoring, and oversight of this policy, as well as for seeking interpretation and guidance from the Board from time to time.
6.3 Directors
The directors are responsible for communicating and implementing this policy and associated procedures in their respective branches.
7. References
7.1 This policy is based on the following acts, regulations, and policies:
- Canadian Transportation Accident Investigation and Safety Board Act
- Transportation Safety Board Regulations
- Policy on Occurrence Classification
- Policy on Representations on Confidential Draft Reports
- Policy on Interaction with Stakeholders
8. Enquiries
8.1 For more information about this policy, contact the TSB:
1-800-387-3557
1-819-994-3741
communications@bst-tsb.gc.ca
Appendices
Appendix A – Assessment rating guide for responses to transportation safety recommendations
Assessment of response
Responses to safety recommendations are assessed according to the extent to which the underlying safety deficiency has been or is being addressed.
| Assessment rating | Criterion |
|---|---|
Fully Satisfactory |
Assign if the action taken will substantially reduce the risk and/or eliminate the safety deficiency. An acceptable alternative course of safety action to the one suggested by the recommendation may have been taken. |
Satisfactory Intent |
Assign if the planned action, when fully implemented, will substantially reduce the risk and/or eliminate the safety deficiency, and meaningful progress has been made since the recommendation was issued. However, for the present, the action taken is insufficient to reduce the risks to transportation safety. |
Satisfactory in Part |
Assign if the planned action or the action taken will reduce but not substantially reduce the risk and/or eliminate the safety deficiency, and meaningful progress has been made since the recommendation was issued. |
Unsatisfactory |
Assign if no action has been taken or proposed that will reduce the risk and/or eliminate the safety deficiency. This rating may also be assigned when a recommendation has been issued and outstanding for more than 5 years and there is no precise action plan or timeline provided to complete the required safety action. This rating applies to situations where, in the Board's view, the safety deficiency will continue to put persons, property, or the environment at risk. |
Unable to assess |
Assign if no response has been received to the recommendation or if the response received does not contain sufficient details to enable the Board to make a meaningful determination on whether the risk associated with the safety deficiency will be reduced or eliminated. A response simply agreeing that a safety deficiency exists cannot be assessed. |
Not yet assessed |
Assign if the recommendation has been recently issued and a formal response has not yet been received and/or formally assessed by the Board. Under the CTAISB Act, the Minister has 90 days to respond to TSB recommendations. The TSB will normally complete its formal assessment of the response within 60 days of its receipt. |
Note: If a change agent provides compelling evidence that the safety deficiency no longer exists then a Fully Satisfactory rating may be assigned.
Status of recommendation
Depending on the assessment rating received, the status assigned to the recommendation will be Closed, Active or Dormant according to the criteria below.
| Status | Criterion |
|---|---|
Closed |
The assessment is that the safety deficiency is rectified, the residual risk is low, or the Board has determined that no further action will be taken. |
Active |
The assessment is that the residual risk associated with the safety deficiency is sufficient to warrant continued TSB involvement. |
Dormant |
The assessment is that there is a residual risk associated with the safety deficiency but no further action is planned, and continued assessment will not likely yield further results. |
Appendix B – Following up on and monitoring recommendations
The TSB will continue to monitor all active and dormant recommendations and update the assessment any time new information becomes available that could significantly change the most recent TSB assessment. The following table summarizes the TSB’s follow-up action for each rating and status.
| Assessment rating | Status | TSB follow-up action |
|---|---|---|
Fully Satisfactory |
Closed |
No follow-up required |
Satisfactory Intent |
Active |
|
Satisfactory in Part |
Active |
|
Dormant |
The TSB will not reassess the residual risk associated with the safety deficiency regularly. However, occasional reviews will be conducted to see if any dormant recommendations should be reactivated and/or if the residual risk associated with the safety deficiency should be reassessed. The Board may also reassess the residual risk associated with the safety deficiency of a dormant recommendation at any time if circumstances change or actions have been taken which significantly change the level of the residual risk. |
|
Closed |
No follow-up required |
|
Unsatisfactory |
Active |
|
Dormant |
The TSB will not reassess the residual risk associated with the safety deficiency regularly. However, occasional reviews will be conducted to see if any dormant recommendations should be reactivated and/or if the residual risk associated with the safety deficiency should be reassessed. The Board may also reassess the residual risk associated with the safety deficiency of a dormant recommendation at any time if circumstances change or actions have been taken which significantly change the level of the residual risk. |
|
Closed |
No follow-up required |
|
Unable to Assess |
Active |
|