Recently released AQONs for November '13 RRAT Supp Estimates yielded this ATsB answer to Senator Xenophon's QON 144:
Senator Xenophon asked:
I note that the Canadian TSB has been commissioned to undertake an independent review of the ATSB’s reporting processes.
a. Who commissioned the review?
b. Why was the TSB chosen, and who made that choice?
c. What is the process for the review?
Answer:
a. The ATSB Commission agreed to enter into an MOU with the TSB of Canada to facilitate the review, on 24 July 2013. The MOU was executed by the ATSB Chief Commissioner and the Chair of the TSB on 29 July 2013.
b. The TSB was identified by the Chief Commissioner as well placed to conduct the review because the TSB has a similar legislative framework to the ATSB and a long-standing commitment to systemic investigation to improve safety.
c. The review will involve the TSB conducting a comparative analysis of ATSB and TSB investigation methodologies, including a comparison against ICAO Annex 13. As part of the review, the TSB will analyse a selection of ATSB investigations, including the Pel-Air investigation, to assess how the investigation methodology was applied. The review will also assess the ATSB’s approach to the management and governance of the investigation process, the investigation reporting process and external communications.
The TSB expects to publish its report by May 2014.
b. above is worth reviewing...
"...because the TSB has a similar legislative framework to the ATSB and a long-standing commitment to systemic investigation to improve safety..."
I would suggest that other than the
legislative framework there is very little tangible similarities in the two agencies...
But perhaps the biggest point of difference is the culture within, examples are many. However the following blog piece (with vid) by the TSB Chair Wendy Tadros IMO amply demonstrates the cultural difference:
Looking back on a year of successes
February 4th, 2014
Posted by: Wendy A. Tadros
The start of a new year is filled with potential, and turning that calendar page provides a great opportunityto look forward to new challenges ahead. But it’s also a perfect time for taking stock, to look back and reflect on what has been accomplished over the previous 12 months. A little over one year ago, the Transportation Safety Board (TSB) launched this blog. We were excited, and as our social media program was still in its initial stages, we wanted to supplement our Twitter and Flickr pages with a more personal view of the TSB, one that showed what goes on behind the scenes, and offered a glimpse into the lives of the men and women whose dedication and expertise help make Canada safer. Yes, we continued to produce our investigation reports on accidents from coast to coast to coast, but we wanted this blog to take a wider view, placing the emphasis on the human interest stories—especially the ones that don’t always get told.
In other words, we wanted to give Canadians a fuller picture of who we are and what we do, to answer some of their questions, and then invite them to join the conversation.
And that‘s exactly what we’ve done. We’ve blogged about topics such as getting to accidents sites in really remote areas, a young Marine cadet’s first encounter with tragedy at sea, and even a TSB employee whose hobby is being an aviation consultant for Hollywood blockbuster movies!
But we’ve also used the blog as an opportunity to shine a spotlight on key issues and investigations—and to that end we’ve written about the recurring problem of floatplane safety, as well as what it’s like to be on site in the days following a devastating train accident.Looking ahead, 2014 is already shaping up to be a busy year. The coming months will see the release of several long-awaited TSB investigations, including into the deadly 2011 crash of a Boeing 737 in Resolute Bay, Nunavut; and the tragic 2013 derailment and fire in Lac-Mégantic, Quebec. As always, though, we won’t wait until the final release of a report to communicate safety information; if we discover risks that need to be communicated sooner, we’ll do that.
In the meantime, watch this space. We have lots of stories to tell, and plenty of TSB people who want to tell them. Because whether they’re putting together the pieces of a shattered airliner, interviewing crew members from a capsized fishing vessel, or computer modeling the deadly results of a train derailment or pipeline explosion, our people have a passion for their work—a passion they’re happy to share.
And one we think you’ll enjoy reading about.
[YOUTUBE]
Introducing our blog: the TSB Recorder - YouTube
Versus Beaker's blog that no one within the ATsB can contribute to and hardly anyone comments on:
Beaker's blog
Full, frank & open vs mi..mi..mi..Beaker obfuscation & spin..
Another big point of difference is the TSB/ATsB claims of being totally independent...one is legitimate:
Aren’t we just part of Transport Canada?...and one is no more than a charade (perfectly highlighted by the PelAir debacle)..
Finally there is the 'no blame' game contention..
TSBC:
Human factors and accident investigation: avoiding the blame game
Like many other investigators at the TSB, I often encounter those who assume “human error” is to blame for an accident. And while I understand this reaction— it’s easy, especially with hindsight, to judge a person or an organization for failing to do something— blame is a knee jerk response that does little to promote safety for the future.
Instead, the goal of a human factors specialist is to understand the actions of the people involved, thereby making informed assessments as to whether conditions will repeat themselves or an accident will reoccur.
A simple assumption
I start with a simple assumption: that the people involved didn’t wake up that morning and plan to have an accident. Thus the question shifts from “what did these people do wrong?” to “why did their actions make sense to them at that time?” Other questions soon follow, including:
1) Are other people or organizations likely to find themselves in the same situation and make the same decisions?
2) What factors in the work environment led to these actions?
3) What can be put in place to change those factors for the better?
Typically, accidents happen when actions and circumstances come together at just the right time. Many of the variables or changes can seem insignificant at the time, with people often reporting that they did little different from any other day. To get to the bottom of things, I focus on how work is supposed to be carried out (standard operating procedures, training manuals, etc). Then I compare it to how work really gets done, and again to what happened on the specific day in question.
Understanding the adaptations
Understanding these differences, or adaptations, is critical—it helps me understand the drivers for the choices people make. For instance, as adaptations are identified, we assess the extent to which they have become the “unofficial” workplace standard, and how these new (and possibly undocumented) adaptations impact the workplace. For example: are other employees aware of the changes? Is management?
The boundaries of human capacity
In any workplace, people are always juggling a variety of tasks—and with differing levels of success. Human factors investigators assess all relevant aspects of human performance: perception, attention, memory, and planning—all to determine whether the demands of the job exceed a person’s ability to perform a task reliably. We use the results from established research studies to define the boundaries of human capacity and then develop a compelling argument to explain why the event happened.
Hopefully, by identifying the factors that led to an accident (or which might increase the risk of another accident taking place), we can better understand how our complex transportation system really works. And while there is never an “ah-ha moment” in which a single cause is identified as solely responsible, our work helps shine a spotlight on the management and operational characteristics that place excessive demand on people. - See more at:
Human Factors and accident investigation ? Avoiding the blame game - The TSB Recorder
Versus...well let's just say the word
PelAir shall we??...
Yep Beaker has done us all a favour by bringing in the Canucks...
