Journal of Accident Investigation

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The NTSB Investigation Journal of Accident Investigation Special Features presents articles that treat policy issues related to
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transportation safety. These papers Gateways
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may be solicited from within the government or from public sources. These
Provide a point to aggregate
articles are intended to represent Information a balanced across many view of the various aspects of an important safety issue. They do not
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represent an official view of the Safety Board.
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Central area (or website) for
collaboration on a specific
investigation where all information
related to an investigation is
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sets of activities related to an
investigation are organized
Charles H. Simpson, Transportation Safety Board of Canada
NTSB JOURNAL OF ACCIDENT INVESTIGATION, SPRING 2006; VOLUME 2, ISSUE 1
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I am highly appreciative of the invitation to contribute to this second edition of the NTSB’s
Journal of Accident Investigation. The Journal clearly enjoys a global readership and, as such,
it provides an incomparable venue in which to share perspectives, experiences, and lessons
learned. Many subjects could, and will, benefit from discussion in the pages of the Journal.
However, I will focus my comments on a subject that is critical to all organizations, but
particularly investigative organizations, around the world. I refer specifically to the challenge
of information management.
National safety investigation agencies are universally charged with investigating occurrences
in federally regulated sectors of the transportation industry. Their primary objective is to
identify risks and ensure that mistakes are not repeated or that unsafe conditions are not
allowed to persist. To achieve this, the Transportation Safety Board of Canada (TSB) has
the sole authority under Canadian law to conduct safety investigations into transportation
occurrences in the rail, marine, air, and pipeline industries, to collect and analyze the
facts, and to convey the resultant information to agents of change via such mechanisms as
investigation reports and recommendations. As in most countries, the TSB is not empowered
to direct changes; change decisions and implementation are the purview of regulators and
industry itself.
The primary products of the TSB are, therefore, information and knowledge. It is critical
that the information it imparts be viewed as credible, comprehensive, and compelling in all
respects in order that those who have the power to implement change will be motivated to
take immediate remedial action. By extension, excellence in how information is gathered,
employed, stored, and distributed is absolutely fundamental to the TSB in the achievement
of its mandate.
Over the past several years, our management team has harbored a growing concern that
the information management business practices in use at the TSB were not supporting its
overall objective well. A comprehensive risk assessment confirmed that significant gaps
did, indeed, exist. For example, traditional, paper-based techniques were no longer able to
contend with the proliferation of electronic information. The discipline of centrally stored