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TSB releases Watchlist 2018

TBS explains this fifth Watchlist edition, like previous ones, builds on hundreds of investigations, findings and data, as well as active TSB recommendations. The Watchlist 2018 also spells out what TSB describes as clear actions needed to address each of the seven key issues.

“The Transportation Safety Board plays a very important role in ensuring that Canada’s transportation sector remains one of the safest in the world, and I welcome the publication of their 2018 Watchlist,” said Marc Garneau, Canada’s Federal Minister of Transportation. “I am pleased to see that the hard work done by Transport Canada has resulted in good progress on many fronts since the last edition in 2016.”

Employee Fatigue was the first issue presented by TSB, describing this issue as a major safety hazard crossing into all three transportation sectors it investigates – air, marine and rail. TSB describes Employee Fatigue as pervasive, especially in a 24/7 industry where crews can work long and irregular schedules across multiple time zones. TSB reports, that since 1992, fatigue has been a risk or contributing factor in more than 90 of its investigations.

“At the TSB we recognize that fatigue can affect performance. We see it in one investigation after the other, across all modes of transportation,” said 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.”

In presenting possible solutions, TSB explains 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.

TSB explains three items were removed from last year’s Watchlist due to actions taken by stakeholders and/or progress achieved in reducing the underlying safety deficiencies. These three issues include: 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.

Fox then points to TSB concerns about the ongoing status of issues – “systemic risks” – that continue to be placed on the Watchlist, including:

– 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; and

– Runway overruns and the risk of collisions from runway incursions at Canadian airports.

TSB then explains there are important gaps still remaining in the safety management and oversight regime for Federally regulated transportation companies, as well as the slow pace of the regulatory process to implement TSB recommendations. TSB states this is putting Canada behind some international standards. More than 60 TSB recommendations are still outstanding after a decade, explains TSB, a third of which are more than 20 years old.

“Advancing safety is all about change,” said Fox. “And change is all about looking at how things have always been done and finding ways to do them better.”

Garneau points to the following issues that have been removed from TSB’s Watchlist, including:


Unstable approaches:
– Transport Canada issued a Civil Aviation Safety Alert and published an Aviation Safety Letter to provide air operators with safety awareness information, applicable research, as well as strategic recommendations related to unstable approaches;

– The Department has also developed and promoted guidance materials for the industry to help reduce unstable approaches and runway excursions. Topics include runway maintenance and lighting systems, airport winter maintenance and changes to the reporting of runway surface conditions; and

– Transport Canada is working with industry experts to revise airport standards to include additional visual aids that will help pilots in assessing the remaining landing distance available. Transport Canada is also exploring solutions to provide more timely and advanced information to flight crews on runway and weather conditions.

On-board voice and video recorders:
– The Transportation Modernization Act brought amendments to the Railway Safety Act mandating the installation of locomotive voice and video recorders. Transport Canada is currently developing regulations for locomotive voice and video recorders; and

– This will further strengthen the safety of Canada’s rail transportation system for all Canadians, including railway employees, by providing information that will lead to a  better understanding of the events leading up to an accident, as well as help prevent future accidents.

Transportation of flammable liquids by rail:
– Transport Canada issued directives to improve the safe transportation of dangerous goods by rail. This included the retrofitting of tank cars and accelerating the removal of the least crash-resistant rail tank cars for crude oil and other dangerous goods;

– The removal of the least crash-resistant rail tank cars was accelerated as follows: phase out unjacketed – without a layer of thermal protection –  CPC 1232 tank cars that transport crude oil 17 months early, from April 1, 2020 to November 1, 2018; and

– phase out DOT 111 tank cars and unjacketed CPC 1232 tank cars that carry condensates — other highly volatile flammable liquids over six years early, from April 30, 2025 to January 1, 2019.

In relation to fatigue management and other key issues raised by TSB, Garneau released the following statement:

“There are other important issues on the Watchlist that the department continues to address. Among those, fatigue of transportation workers. This issue was addressed at a recent Transport Canada/McGill University forum this past June. The Fatigue Forum in Transportation brought together participants from all modes, stakeholders, and academic experts on fatigue science to discuss risks and best practices relating to fatigue management.

“Transport Canada continually examines existing fatigue management requirements to determine if amendments are required to update the regime and works in partnership with key federal partners and stakeholders in developing any options. The department is proposing new pilot fatigue rules to make air travel safer for Canadians, with the intent of publishing the final regulations in the Canada Gazette, Part II, in 2018. With respect to rail, Transport Canada has also published a Notice of Intent for amending current hours of work requirements and developing regulations that reflect up-to-date science on managing fatigue in the rail industry.

“The Department is improving safety management and oversight in all modes by evaluating its oversight tools to ensure their continued effectiveness. Transport Canada works actively to enhance the safety of all Canadians by improving the safety of air, rail and marine sectors and the transportation of dangerous goods.  

“On commercial fishing safety, the Fishing Vessel Safety Regulations that came into force in July 2017 updated the safety equipment and vessel stability requirements, as well as introduced safe operating procedures for small fishing vessels. Transport Canada is continuing with its development of Phase 2 amendments to the Regulations, which will address vessel construction requirements, and is consulting with stakeholders in order to hear their views. In addition, the Small Vessel Compliance Program and its new component for small commercial fishing vessels helps owners and operators understand and meet the legal requirements that apply to their vessels.   

“Transport Canada is committed to working on these as well as other issues that remain on the list, as well as committed to taking measures to address outstanding Transportation Safety Board recommendations.

“Safety and security are my top priorities, and I share the Transportation Safety Board’s goal of continuously looking for ways to improve the safety of Canada’s transportation system.”