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Presentation to ISASI 2016 Kathy Fox Chair, Transportation Safety Board of Canada Reykjavik, Iceland 20 October 2016 Investigations: Putting the pieces together Operational Technical Human 2 Investigations: Putting the pieces together


  1. Presentation to ISASI 2016 Kathy Fox Chair, Transportation Safety Board of Canada Reykjavik, Iceland 20 October 2016

  2. Investigations: Putting the pieces together Operational Technical Human 2

  3. Investigations: Putting the pieces together Operational Technical Human Organizational 3

  4. Balancing competing priorities Service Safety 4

  5. “No big deal?” 5 TSB investigation A11O0031

  6. “The lack of a top-down safety culture” TSB investigation A13W0120 6

  7. “When is enough … enough? ” TSB investigation A13H0001

  8. A systems-level approach to SMS only works if all companies have: • the ability to proactively identify safety deficiencies • the capability to rectify them • a top-down, organization-wide commitment to doing so • balanced regulatory oversight 8

  9. QUESTIONS? 9

  10. 10

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