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Dartmouth, Nova Scotia, 12 February 2016 – In its investigation report (A14A0067) released today, the Transportation Safety Board of Canada (TSB) found that a lack of visual references and low visibility due to weather led to a collision with terrain involving a Piper PA-31 in Grand Manan, New Brunswick. The captain and a paramedic, who was not wearing a seatbelt, sustained fatal injuries. The other pilot and second passenger sustained serious injuries.

On the early morning of 16 August 2014, during the hours of darkness, a Piper PA-31 aircraft operated by Atlantic Charters was returning to Grand Manan from Saint John New Brunswick following a medevac flight. There were two pilots, a paramedic and a nurse on board. While attempting to land a second time on Runway 24, the aircraft contacted a road approximately 1500 feet from the runway, continued through 100 feet of brush, became briefly airborne and struck the ground approximately 1000 feet from the runway threshold. The aircraft was destroyed.

The investigation determined that the weather at the time of both approaches was likely such that the captain could not see the required visual references to ensure a safe landing. For undetermined reasons, the captain started a steep descent 0.56 nautical miles from the threshold, which went uncorrected until it was too late to recover, and the aircraft struck terrain short of the runway. Approach-and-landing accidents are on the TSB's Watchlist.

The investigation also determined that having only one headset on board prevented a shared situational awareness among the crew. The company did not provide any formal crew resource management (CRM) training, and such training was not required by regulation. However, there is a risk that pilots will be unprepared to avoid or mitigate abnormal situations in flight if CRM training is not provided, as called for in a TSB recommendation A09-02.

Additionally, the investigation found that Transport Canada's (TC) surveillance activities of Atlantic Charters had not identified the discrepancies in the company's operating practices related to  continuing airworthiness. If TC does not adopt a balanced approach that combines thorough inspections for compliance with audits of safety management processes, unsafe operating practices may not be identified. This highlights another issue on the TSB's Watchlist: Safety management and oversight.

The aircraft was not equipped with a flight data recorder or a cockpit voice recorder, nor was it required. However, data recordings from lightweight flight recorder systems, as called for in TSB recommendation A13-01, could have provided useful information to investigators and enhance TSB's ability to identify safety deficiencies.

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Seventh agreement reached between Air Canada and its unions over the past year and a half MONTREAL, Feb. 12, 2016 /CNW Telbec/ - Air Canada said today that it welcomes confirmation
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Richmond Hill, Ontario, 11 February 2016 – In its investigation report (R14T0180) released today, the Transportation Safety Board of Canada (TSB) determined that worn components on a rail car led to the derailment and collision between a Canadian National (CN) freight train and a VIA Rail (VIA) passenger train near Gananoque, Ontario, in August 2014. There were no injuries, but rail cars on both trains were damaged. The fuel tank on the VIA locomotive was punctured, releasing about 1000 litres of diesel fuel. The last six cars on the CN train derailed.

On 01 August 2014, a CN freight train was proceeding eastward on the north main track of the CN Kingston Subdivision when it derailed just east of Gananoque. The CN crew subsequently made an emergency radio broadcast. At about the same time, a VIA passenger train was proceeding westward on the south main track. Upon hearing the emergency radio broadcast, the VIA crew initiated an emergency brake application. As the two trains were slowing to a stop, a derailed centre beam bulkhead flat car from the CN train struck the lead locomotive of the VIA train and then scraped along the north side of the VIA locomotive and the 5 passenger coaches.

The investigation determined that the derailment occurred as a result of excessive truck hunting on the empty centre beam bulkhead flat car. Truck hunting is the side-to-side movement of wheel sets within a freight car truck. Under certain conditions, the truck hunting can become excessive which can lead to wheel lift or wheel climb, either of which can cause a derailment. In this occurrence, the excessive truck hunting was influenced by the type of car, the speed of the train, the worn condition of the constant contact side bearings (CCSB) and the friction wedge, as well as by the truck type. When inspectors visually inspect these rail cars, they look for contact between the CCSB and the car body underframe. However, the investigation determined that visual inspections alone may not have been enough.

As seen in this occurrence, and in another similar derailment (R14T0160), certain older cars with worn and ineffective CCSBs are at risk of derailing due to excessive truck hunting. Further, there are about 48,000 bulkhead flatcars and centre beam bulkhead flatcars throughout North America that may remain susceptible to truck hunting. As such, the Board is concerned that current detector systems and visual inspection programs may not identify those cars more susceptible to truck hunting prior to them encountering conditions known to initiate excessive truck hunting, increasing the risk of derailments.

Following the occurrence, both CN and Canadian Pacific reintroduced speed restrictions for all empty centre beam bulkhead flat cars. Furthermore, CN undertook a program to upgrade the CCSBs on two series of centre beam flat cars.

Published in Transportation Safety Board of Canada
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Gatineau, Quebec, 8 February 2016 – Amid persistent concerns about marine safety associated with teamwork on the bridge, the Transportation Safety Board of Canada (TSB) and the Canadian Marine Pilots Association (CMPA) are launching a campaign to raise awareness of this issue.

"Transportation safety is paramount for all of us at the TSB," said Captain Marc-André Poisson, TSB's Director of Marine Investigations. "We want to remind everyone that bridge crews and pilots share responsibility for the safe conduct of vessels in pilotage waters."

The Marine Accident Investigators International Forum (MAIIF) and the International Maritime Pilots' Association (IMPA) have collaborated to develop a poster for display on bridge decks of ships navigating in pilotage waters across the world. The TSB is partnering with the CMPA to ensure the message is heard aboard Canadian and foreign vessels plying our waters.

"We're happy to be working with the TSB and our international partners to spread this important message," added Captain Simon Pelletier, President of IMPA and the CMPA. "We have a shared concern about safety, and proper teamwork and communication on the bridge can help everyone stay safe."

While the IMO and most Member States have demonstrated due diligence and have implemented mandatory training for ships' crews and pilots, the number of accidents in which the cause or a finding as to risk is related to the pilot/bridge team relationship continues to be a concern.

Poster and accompanying materials.

Published in Transportation Safety Board of Canada
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News Article / February 4, 2016

By Lieutenant(N) Sylvain Rousseau

On January 24, 2016, a CC-130H Hercules aircraft from 413 Transport and Rescue Squadron, based at 14 Wing Greenwood, Nova Scotia,

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MONTREAL, Feb. 4, 2016 /CNW Telbec/ - Air Canada has been recognized for the third year in a row as one of "Montreal's Top Employers" in an annual employer survey by Mediacorp
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Traffic increased 7.1 per cent for the month MONTREAL, Feb. 3, 2016 /CNW Telbec/ - For the month of January, Air Canada reported a system-wide capacity increase of 7.1 per cent
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MONTREAL, Feb. 3, 2016 /CNW Telbec/ - Air Canada announced today it will launch new, year-round Air Canada Express service between Hamilton and Montreal. The new non-stop, daily flights reestablish Air Canada's
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News Article / February 1, 2016

By Ryan Melanson

When Lieutenant-General Michael Hood thinks about his most important duties as commander of the Royal Canadian Air Force, it isn’t current fighting

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Richmond, British Columbia, 1 February 2016 – In its investigation report (M15P0035) released today, the Transportation Safety Board of Canada (TSB) highlighted the lack of safety oversight as a significant risk in the foundering and abandonment involving the self-propelled barge Lasqueti Daughters. Although the vessel was declared a constructive total loss, there were no injuries.

On 14 March 2015, the self-propelled barge, with 17 people on board, departed Campbell River, British Columbia. Partway into the voyage, the sea and wind conditions deteriorated resulting in water pooling on board and making its way into the forward storage compartment. The vessel began foundering and was subsequently abandoned, however it remained afloat and was eventually towed to shore and intentionally beached.

The investigation determined that the weather and sea conditions encountered by the Lasqueti Daughters resulted in water being shipped onto the main deck via the spaces between the bow ramp, the bulwarks, and the main deck. Because the main deck, which had been recently replaced, was not watertight, it allowed water to downflood into the forward storage compartment. The investigation also found that the crew attempted to pump out the storage compartments using the on-board pumps; however, the emergency pump did not pump water, likely due to an air lock, and the remaining pumps could not cope with the ingress of water. As the water continued to enter, the vessel began to founder.

In this occurrence, the owner's safety program did not cover the marine transportation of workers and equipment required for silviculture operations. The investigation noted that if a company's health and safety program covers only some of its operations, there is a risk some hazards will not be identified or addressed. Further, if organizations with overlapping areas of responsibility, in this case, WorkSafeBC, the British Columbia Forestry Safety Council and Transport Canada (TC) do not share information and collaborate amongst themselves as well as with owners and masters, then there is a risk that gaps in safety oversight will occur. The investigation also determined that the vessel did not hold the required TC inspection certificate, nor was there any inspection or verification by TC of the vessel's condition; as such there was no opportunity to identify and address safety deficiencies. The vessel was not operating under a safety management system (SMS), nor was it required to.

The TSB has identified Safety management and oversight as a Watchlist issue. As this occurrence demonstrates, some marine operations are not effectively managing their safety risks. The TSB is calling for all operators in the marine industry to have formal safety management processes with oversight conducted by TC. When companies are unable to effectively manage safety, TC must not only intervene, but do so in a manner that succeeds in changing unsafe operating practices.

Published in Transportation Safety Board of Canada
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