TSB Transportation Safety Summit

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sst-tss-201604-02.pdf234.28 Ko

Statement of Safety Issue Support:
Review of findings and systemic risks

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Faye Ackermans
Board Member, Transportation Safety Board of Canada
Ottawa, Ontario, 21 April, 2016

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Slide 2: Reports reviewed for information flow

Pipeline Reports:

  • 3 reports from 2013-2014
  • 2 reports included a total of 3 causal or contributory findings and 4 risk findings.

Rail Reports:

  • 58 reports from 2011-2014
  • 6 reports included a total of 6 causal or contributory findings and 5 risk findings.

Slide 3: Reports reviewed for information flow

Marine:

  • 35 reports from 2012-2014 reviewed
  • 7 reports included a total of 4 causal or contributory findings and 9 risk findings.

Air:

  • 38 reports from 2013-2014 reviewed
  • 7 reports included a total of 8 causal or contributory findings and 11 risk findings.

Slide 4: INFORMATION NOT FLOWING DUE TO

Risks accepted as part of the job, or risk adaptation has occurred:

  • 3 reports
  • 1 causal/contributory
  • 3 risk findings

P13H0103 (R4); M14P0110 (R1,2); M12C0058 (F3)

Slide 5: INFORMATION NOT FLOWING DUE TO

Unsafe practices condoned in a poor safety culture:

  • 3 Reports
  • 5 causal/contributory
  • 7 risk findings

A13W0120 (F1,5; R1); A14A0067 (F1,6; R 9, 10, 11, 17, 18, 20); R13D0054 (F12,15)

Slide 6: INFORMATION NOT FLOWING DUE TO

Weak incident reporting or investigation processes did not identify risks and therefore opportunities to mitigate were missed:

  • 4 reports
  • 1 causal/contributory
  • 6 risk findings

M13M0287 (R7); R11Q0050 (R2); M12N0017 (F2; R1,5,6); R11T0161 (R4)

Slide 7: INFORMATION NOT FLOWING DUE TO

Safety management practices did not exist, or existed only on paper, or were not used, allowing issues to go unaddressed:

  • 4 Reports
  • 4 Causal/contributory
  • 4 Risk Findings

A13A0075 (R 7,8); R13D0054 (F13,14); M14P0023 (R3); A14W0046 (F2,3; R1)

Slide 8: INFORMATION FLOWING BUT

Weak Safety processes did not result in risk mitigation:

  • 7 Reports
  • 4 causal/contributory
  • 4 risk findings

M12C0058 (F4); M12N0003 (F12; R1); R12T0038 (R1); A14C0112 (F2); A14Q0060 (R2); R11Q0050 (F3); M13L0067 (R3)

Slide 9: INFORMATION FLOWING BUT

Information known but it did not reach the right people:

  • 5 reports
  • 3 causal/contributory
  • 5 risk findings

R12W0182 (R2); R12E0182 (F3,4,5; R1); R11T0016 (R1); A14Q0011 (R1); R11T0161 (R5)

Slide 10: INFORMATION KNOWN BUT

Design parameters not recognized as potentially problematic:

  • 2 Reports
  • 3 causal/contributory
  • 3 risk findings

P13H0107 (F 5,6; R1,2,3); A14C0112 (F4)