As anyone that follows this site is aware, this past summer a draft report that contains the findings from the TSB's investigation of sr111 was circulated to the parties involved in the tragedy of sr111. There is a comment period now in progress as I post this where those who received this draft will be allowed to submit their thoughts on the findings. The family members (next of kin to the victims) have been told that they are banned from seeing this confidential report and thus are denied the ability to submit their comments or concerns.

NOTE THE SENTENCES IN BOLD TYPE. If the statements in the following article are accurate, the family members of sr111 SHOULD get a copy of the draft and be allowed to comment as well.

Here are some excerpts from the magazine entitled
OHS Canada, published in Canada. It is “Canada’s
Occupational Health & Safety Magazine.” The author is William
Glenn who is the associate editor of OHS Canada. This
is from the July/August (’01?) issue. They maintain a site
at
http://www.ohscanada.com/current_issue/current-issue.asp
http://www.ohscanada.com/current_issue/current-issue.asp

The article mainly talks about the
analysis of a train wreck (Edson) that occurred in 1996. I
thought I would print the interesting excerpts that
describe what the TSB does in any accident investigation
and a few comments on sr111.

“With an annual
budget of $25 million and a staff of some 230 safety
experts, the TSB is a relatively obscure but quietly
effective agency of the federal government. Created under
the Canadian Transportation Accident Investigation
and Safety Board Act (CTAISBA) back in 1990, it has
been given the mandate to advance transportation
safety by conducting independent investigations into
air, rail, marine, and pipeline accidents-the
provinces have jurisdiction over the roads and highways-
and to make findings “as to their causes and
contributing factors”. “The TSB takes a slightly
different philosophical approach than most other
organizations in the accident investigation business. “We’re
not out to find ‘the cause’ of an accident,” explains
Bill Tucker, director-general of investigation
operations. “We are out, as an agency, to advance
safety.” “Every accident is unique, Tucker says, the inevitable
end result of a complex mix of causes, contributing
factors and pure happenstance. No one can travel back in
time and prevent an incident from occurring. But, if
you do your job with meticulous care, you can
identify most, if not all, of the safety flaws that might
cause problems in the future, he says. “Tucker
joined the ideological predecessor of the TSB, the
Canadian Aviation Safety Board, on a temporary two-year
assignment 18 years ago. He’s been crawling over derailed
engines and poking through mangled airplanes ever since.
“I’ve been involved in thousands of investigations over
the years,” he says, “and I can’t think of a single
accident that had only one cause.” “We always have
far too much to do,” says Tucker. “More than 4,000
accident occurrence calls come into TSB offices every
year. We have to collect basic data on every one of
those incidents in order to populate our live database.
That’s a big hunk of the workload.”

Investigators are dispatched to more than 1000 of
those reported accident sites every year to collect
additional data. Preliminary assessments are undertaken for
several hundred occurrences and more than a hundred full
investigations are launched each year. The TSB will dive
into only those cases that show a “reasonable
potential to result in safety action or which generate a
high degree of public concern for transportation
safety,” says Tucker. The TSB Head Office in Hull,
Quebec, houses the board and its administrative staff,
and there’s a modern laboratory across the river in
Ottawa. Because it’s important that its investigators get
to an accident as quickly as possible, the TSB also
maintains eight regional offices across the country.
To safeguard its independence, the TSB reports to
Parliament through the President of the Queen’s Privy
Council. The TSB’s new executive director, David Kinsman,
who came on board earlier this year following a
37-year hitch in the Canadian Armed forces, professes to
be “only part way up the learning curve.” But based
on what he’s seen so far, he believes that the
organization is as “fully independent as any agency can be. We
don’t report through any department that could be seen
to have a vested interest in our work.” An
independent investigation is also a more effective
investigation. That’s why CTAISBA, the act that set up the TSB,
includes protections against the release of witness
statements and restrictions on the use of TSB information or
conclusions in legal or disciplinary
proceedings. Current board chairman Benoit Bouchard, a former federal
minister of transport, was responsible for ushering the
act that created the TSB through the House of Commons
back in 1989. Following a stint as Canada’s ambassador
to France, he came home in 1996 to head the very
organization he helped create seven years earlier. “I’m
not sure if I tried to [bring in the legislation]
today that I would succeed,” says Bouchard. The fact
that Parliament gave the board and its investigators
“so much independence is astounding,” he adds. The
board operates at arm’s length from the government and,
in turn, the TSB investigators operate at arm’s
length from the board. The considerable powers
available to TSB investigators are set forth in section 19
of the board’s enabling legislation. Investigators
can enter any vessel, plane, rolling stock, vehicle,
pipeline, building or other premises to search for and
seize anything relevant to an investigation. They can
seal off an accident site or prohibit access to any
equipment. Anyone in possession of information deemed
relevant to an investigation can be required to give a
statement under oath, provide copies or extracts of
records, or even undergo a medical
examination. However, the TSB’s operating ethos is one of openness and
fairness: investigations are designed to advance safety
while respecting the rights of those involved. That
means no cowboy stuff. TSB staff also perform a
delicate diplomatic dance at every accident site. It’s
important not to step on too many toes. “The first thing to
do is establish good relationships with all the
major players before the big accident,” explains
Tucker. “We don’t try to take the reins and say ‘I’m in
charge,’” he says.

Field Work By TSB Staff –Mentions
sr111
Field work by TSB staff can last from single day to
several months, and require the attention of a lone
investigator or the services of 20 to 30 in-house experts and
outside observers. The subsequent, post-field phase can
take up to six months or even longer to
complete. During an investigation, each event in the accident
sequence is examined for unsafe acts and unsafe
conditions. Staff also probe for the underlying factors that
can lead to those conditions. This can shift the
focus of an investigation from the circumstances of the
particular accident to more general safety problems endemic
in a sector or industry- key risk factors such as
crew fatigue, inadequate training or the corporate
safety culture. Safety is not a matter of technology,
says Bouchard, “it’s a matter of
culture.” Risk analysis” is employed to estimate qualitatively
both the nature and the extent of the risks to public
safety. Concurrently “defense analysis” looks at the
adequacy of the barriers, both physical and
administrative, that have been erected between those risks and
vulnerable people, property and the environment. From
guardrails, alarm systems and signals to crew training,
operating standards and regulatory controls, the efficacy
of each element must be carefully examined and
assessed. Then all this data and analysis has to be distilled
into a clear, cogent and convincing report. The target
is to complete an investigation- from the moment the
occurrence notification first comes into the TSB offices
until the final report is released to the general
public- within one calendar year. Some simpler
investigations may be completed earlier and very complex or
unusual cases can take considerably longer. Swissair
Flight 111 plunged into the ocean off Peggy’s Cove, Nova
Scotia in September, 1998, and the release of the TSB’s
final report on that crash is still some months
away. At one time we were very concerned about [the]
mechanics [of an accident], and we were very concerned
about operations,” says Bouchard. But then several
horrendous air crashes in other countries showed how
important it was to treat the survivors and the families of
accident victims with dignity and respect. “It was
appalling to see the way the families of the victims were
being treated,” he says. “I said then, that if it
happens in Canada, I want us to be more
humane.” Canada’s turn to deal with a major air crash came within
months, and the TSB has been true to its chairman’s word.
Hours after Swissair 111 crashed into the ocean off
Peggy’s Cover, long after authorities had given up all
hope for the 229 men, women and children aboard,
Bouchard recounts, “we kept saying we were searching for
bodies and hoping to rescue survivors.” You have to
maintain “the conviction that people remain the top
priority of the board,” he says. “Only then will they
trust you to look after the concerns of the next of
kin, as well as the accident investigation.” In
the case of the massive Swissair investigation, the
board has already issued one safety letter, two sets of
safety advisories, and three sets of safety
recommendations (containing a total of 11 different items). In
addition, there’s been a lot of unofficial communication
between the investigating officers and the parties
involved, adds Harris, “that’s already resulted in safety
action.” Without sacrificing any of the TSB’s renowned
thoroughness, executive director David Kinsman is looking for
ways to speed up the process. “In this day and age,
when people are looking for instant information, you
may have difficulty sustaining a process that takes a
year to produce a report,” he says.

Kinsman acknowledges that many of his
organization’s recommendations don’t wait for the release of an
occurrence report. Each report lists all the pertinent
safety actions that have been implemented by the
operator and the regulator during the course of the
investigation , often as a result of prompting by the TSB
staff. Adds Tucker, “If they modified their training, or
redesigned a faulty widget, or drafted new operating regs,
we’ll credit them in the final report. We don’t wait
till the end before we recommend what should be done.
The aim is to improve safety now.” There are
three ways they do this: through safety information
letters, safety advisories and safety recommendations.
A “safety letter is a timely ‘heads-up’ sent to the
attention of the manufacturers, operators or a regulator
that discloses an immediate defect or problem. No
response to a TSB safety letter is necessary. A
“safety advisory”, which can hit more concerns than a
letter advises readers about a more general deficiency
that probably needs to be fixed. “It’s a kind of a
less formal, ‘small-r’ recommendation,” says Tucker,
often sent to a region of the country or a subgroup of
the industry that might not be aware that a problem
exists.

Finally, the “safety recommendations”, commonly part of
the formal occurrence report, contain a broader
discussion of concerns and potential safety problems.

However, if circumstances dictate, an interim safety recommendation may be circulated in advance of the final report. Once the board is satisfied, the report is distributed, on a confidential basis, to all persons with a direct interest in the proceedings (or PDIs as they are known). The crew, the operator, the manufacturer, Transport Canada (or the NEB) and even a victim's next of kin have a chance to review the findings and make comments. "Everyone gets to have their say," says Tucker and each receives an individual letter that itemizes the disposition of his or her comments and suggestions.

The TSB used to issue reports crammed with “many,
many” recommendations that ranged from big sweeping
changes to “little, piddling” suggestions, says Tucker.
These days, it prefers to describe a safety deficiency
and “let the regulator and the industry figure out
how to fix it.” He admits a lot of basic psychology
is being applied here. “We want to motivate people
to make change. We use the failures in the system to
indicate what may be weaknesses,” he says. And those
weaknesses constitutes “a compelling argument for making the
needed changes.” The TSB is not in the business
of judging guilt, says chairman Bouchard. “If
there’s a problem in responsibility, that’s the business
of the courts. We don’t want to be political. We
don’t want to name names.” The TSB takes the broader
view in its reports. “If you implement that correction
there, if you take into account these factors here,”
says Bouchard, “you’ll help avoid another accident
like this in the future.” Bouchard is confident
that the system works. “Canadians are not flashy,” he
says, “but they are very efficient at what they do. I’m
pleased to say this little board in Canada has resulted
in tremendous changes in the transportation sector
around the world.”

Editorial:

This is
an editorial by David Dehaas, editor of OHS
Canada.

Rethinking Blame

One of the biggest problems in getting
the truth in accident investigations is our mantra
that “We’re not looking to lay blame, we just want to
find out what happened.” The theory behind this notion
is that people will speak freely if they think they
won’t be held responsible for their actions and
inactions, that their co-workers won’t afterward accuse them
of ratting on them and that their employers won’t
retaliate against them if they cough up the true
facts. That might be good if a) it were true- which it’s not;
and , b) if anybody believed it- which no one in his
or her right mind does (although everyone pays pious
lip-service to it). Of course accident investigations
are about blame: Safety is about responsibility, and
failures in the system are about individuals who have
failed to discharge their responsibilities. And they
should be held accountable. An honest investigation will
lay blame where it belongs- usually in large measure
with the people whose job it is to create, monitor,
manage and enforce safety systems and
standards. But most accident investigations are conducted by
precisely those people and it should not come as a surprise
that they tacitly lay the blame on the operational
personnel (and make it stick by hushing things up because,
after all, “we’re not looking to blame anyone”. It’s a
neat trick and it works almost every time. The
investigation by the TSB into the head-on collision between a
freight train and runaway rail cars in Edson, Alberta in
1996 is a good example of how it ought to be done, as
you will see in “A Matter of Culture.” (That’s the
article I took the excerpts from). A quick look at the
preliminary facts would have concluded overwhelmingly that
this was worker error- no question about it, the crew
in the rail yard didn’t properly apply the brakes to
the runaway cars. That’s where most investigations of
industrial accidents would have stopped, the workers would
have been blamed- and nothing beyond a few “safety
talks” would have been done about it. But a real
investigation, as the TSB is in the habit of performing, doesn’t
stop until all the facts and all the factors are laid
bare. Their report on the accident tells a very
different story. Faulty equipment. Defective brakes. A lack
of standards. No supervision. A vital safety device
that was missing. A written warning from the safety
committee that was ignored. Instructions from the regulator
that were neither applied nor followed up. A fatal
ergonomic flaw in a control panel. In the end, whether
there was worker error was very debatable; and even if
there was, that error turns out to have been both
incidental and inevitable. Instead of telling the
primary witnesses- usually the victim and his or her
operational co-workers-that we’re not looking for blame, we
should tell them, “Look, you and your co-workers are
going to totally wear this accident and nothing will be
done to prevent the next one if you don’t tell us
everything you know.” A good accident investigation
traces the tell tale events of the accident quickly up
the organizational ladder to the point where they
hit- or ought to have hit- the systems designed to
prevent them. That’s where the blame lies. That’s where
people need to be held accountable. And that’s where the
changes need to be made if we are really serious about
preventing the same accident from happening again.

I just wanted to make sure and thank Mikey (hrsar) for sending that article.