TSB releases Watchlist 2018: a call to action on safety management and fatigue issues across the transportation industry
The NTSB’s Most Wanted List frequently has been discussed here. The 2018 Edition of the Transportation Safety Board of Canada was recently issued and is remarkably similar to the MWL issued down South. In some ways that’s comforting.
Excerpts to the Watchlist are included immediately below; followed by the ’17-’18 NTSB equivalent.
[Click on a heading to see the full text.]
Today, the Transportation Safety Board of Canada (TSB) released Watchlist 2018 and identified seven key issues requiring government and industry’s attention to make Canada’s transportation system even safer in the air, marine and rail sectors. This fifth Watchlist edition, like previous ones, builds on hundreds of investigations, compelling findings and data, and active TSB recommendations.
A major safety hazard, crossing all three transportation modes, is employee fatigue. Pervasive, especially in a 24/7 industry where crews can work long and irregular schedules across multiple time zones, fatigue has been found to be a risk or contributing factor in more than 90 TSB investigations since 1992.
“At the TSB we recognize that fatigue can affect performance. We see it in one investigation after the other, across all modes of transportation,” says TSB Chair Kathy Fox. “Transport Canada, operators, unions, and employees all share the responsibility for preventing and managing fatigue at work. This also calls for a profound change in attitudes and behaviours, both at the management and operational levels.”
Watchlist 2018 spells out clear actions that are necessary to effectively address each of the issues. For example, fatigue management requires, at a minimum, adequate duty-time regulations based on fatigue science, fatigue management plans that are tailored to company operations, and awareness training for employees and managers to help them prevent fatigue and know how to mitigate the symptoms before an accident happens.
This year, three items were removed from the Watchlist due to actions taken by stakeholders and/or progress achieved in reducing the underlying safety deficiencies. They are: the transportation of flammable liquids by rail, the need for on-board voice and video recorders in main-track locomotives, and the issue of unstable approaches that are continued to a landing at Canadian airports. The TSB will continue to monitor progress in those areas through its investigations, active recommendations and outreach activities.
“That’s the good news,” said Ms. Fox. “What’s more troubling is the ongoing status of some persisting issues that have been on the Watchlist for some time.”
Again this year, Watchlist 2018 highlights the following issues as systemic risks to transportation safety:
- The disturbing safety record of the fishing industry, which has caused an all-time high of 17 fatalities so far in 2018
- The lack of additional physical defences to ensure that railway signals are consistently followed
- Runway overruns and the risk of collisions from runway incursions at Canadian airports
Contributing to the problem are important gaps still remaining in the safety management and oversight regime for federally-regulated transportation companies. In addition, the slow pace of the regulatory process to implement TSB recommendations only serves to perpetuate safety risks, putting Canada behind some international standards. More than 60 TSB recommendations are still outstanding after a decade, a third of which are more than 20 years old.
The TSB will closely monitor progress on Watchlist 2018 and report publicly on what change agents promise versus what they deliver.
“Advancing safety is all about change,” Ms. Fox concluded. “And change is all about looking at how things have always been done and finding ways to do them better. The safety of Canadians everywhere, and the integrity of our infrastructure and environment, depend on it.”
From 2013 to 2017, NAV CANADA recorded an average of 445 runway incursions each year. The incursion rate per aircraft movement gradually increased from 6.6 incursions to 7.8 per 100 000 arrivals and departures over this time period.
While the majority of these incursions posed little to no risk, there were 21 high-severityFootnote1 events in each of the past 2 years. These could have led to a collision with aircraft, damage, injuries, and loss of life.
Aviation industry stakeholders have addressed factors that can lead to runway incursions by implementing incremental improvements to policies, procedures, technologies, and infrastructure. For example, in Canada, in-cockpit aids to increase situational awareness, such as electronic flight bags with moving maps, are becoming more prevalent.
Despite actions taken, there has been an 18% increase in the overall rate of runway incursions from 2013 to 2017.
Additional technological improvements could be made, for example, runway status lights, a form of direct-to-pilot warning. These exist in at least 23 international locations, though none has yet been installed in Canada.
When a runway overrun occurs during landing or a rejected takeoff, it is important that an aircraft have an adequate safety area beyond the end of the runway to reduce adverse consequences. There is currently no requirement in Canada for runways to meet international standards and recommended practices for RESAs.
Operators of airports with runways longer than 1800 m must conduct formal runway-specific risk assessments and take appropriate action to mitigate risks of overrun to people, property, and the environment.
Transport Canada must adopt at least the ICAO standard for RESAs, or a means of stopping aircraft that provides an equivalent level of safety.
Although SMS has been on the TSB Watchlist since 2010, there has been little progress on expanding the application of SMS to a broader range of companies. In aviation, for instance, although many companies have begun to voluntarily implement SMS, over 90% of all Canadian aviation commercial operators are still not required by regulation to have an SMS.Footnote1 Similarly, despite repeated calls from the TSB, many commercial marine vessels and the companies that operate them are not required to have an SMS.Footnote2 By contrast, all federally regulated railways have been required to have an SMS since 2002—although recent TSB investigationsFootnote3 have found these are not always effective at identifying hazards and mitigating risks.
This issue will remain on the Watchlist until:
- Transport Canada implements regulations requiring all commercial operators in the air and marine industries to have formal safety management processes, and effectively oversees these processes.
- Transportation operators that do have an SMS demonstrate to Transport Canada that it is working—that hazards are being identified and effective risk-mitigation measures are being implemented.
- Transport Canada not only intervenes when operators are unable to manage safety effectively, but does so in a way that succeeds in changing unsafe operating practices.
At October 2018, 62 recommendations (more than 10% of all TSB recommendations) that were issued more than 10 years ago still had not been fully addressed.Footnote1 There are various reasons for the slow implementation of recommendations, including protracted studies; delays in publishing regulations; changes in course of action; lack of consensus among stakeholders; voluntary rather than mandatory measures, which also create uneven safety standards; jurisdictional issues; and the need to harmonize standards across jurisdictions.
This issue will remain on the Watchlist until the following measures have been taken:
- Transport Canada takes the actions needed to reduce the number of active recommendations that are more than 10 years old so that all recommendations that would bring Canada in line with international standards are addressed, and so that there is a marked reduction in the remaining outstanding recommendations for which the regulator has indicated its agreement.
- Change agents targeted by the existing 28 dormant recommendations demonstrate to the TSB that the residual risk has been reduced to an acceptable level so that these recommendations can be closed.
- The Government of Canada reviews and improves interdepartmental processes for expedited implementation of safety recommendations in the air, rail, and marine modes of transportation.
Fatigue is pervasive in modern societies that rely heavily on 24/7 industries like transportation. A Statistics Canada study released in 2017Footnote1 revealed that about a third of Canadian adults slept less than the recommended 7 to 9 hours per night.Footnote2 Short sleep duration and poor sleep quality were also reported as relatively common.
Fatigue can impact human performance in ways that can lead to accidents. This is why the Transportation Safety Board of Canada (TSB) routinely investigates if fatigue was present in an occurrence, if it played a role, and if the operator had practices in place to effectively manage the associated risks.Footnote3
Transport Canada (TC), also aware that fatigue is an issue requiring attention, held an international multi-modal forum in June 2018, focusing on measures that can reinforce transportation safety through better recognition and management of fatigue
Air sector: Need to update and modernize flight and duty-time regulations
Flight operations take place around the clock, and sometimes over long distances, which involves crossing multiple time zones. Fatigue-related impairment has a detrimental effect on aviation safety. Transport Canada has determined that regulations currently in place to manage fatigue in flight operations are not supported by current fatigue science and do not meet the standards of the International Civil Aviation Organization (ICAO). Work to modernize flight and duty-time regulations has been ongoing for several years; Transport Canada has not yet published the final regulations, however.
If you see any major differences, please note them in the comments. Your expertise would be appreciated.
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