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Québec, Quebec, 2 November 2018 – In its investigation report (M17C0232) released today, the Transportation Safety Board of Canada (TSB) found that unsuitable equipment and inadequate work procedures on the general cargo vessel Amazoneborg led to a crewmember falling overboard and subsequently losing his life.

On 29 September 2017, the general cargo vessel Amazoneborg was docked in the Port of Trois-Rivières, Quebec. The third officer was assigned to take the vessel's draft measurements as part of routine cargo operations. Some time after going to read the draft marks amidships on the seaward side, the third officer was reported missing. Search and rescue authorities conducted a search of the area without success. The third officer's body was found eight days later near Champlain, Quebec.

The investigation found that the third officer used a rope ladder to read the seaward draft marks in the middle of the vessel. When resting flat against the vessel's hull, this ladder leaves little room for hand and foot holds, making it unsuitable for this task. Additionally, the ladder was rigged to the guardrail in such a way that there was no safe way to access the ladder from the deck. The third officer may have fallen while climbing over the vessel's guardrail to use the ladder, or while using the ladder.

While a permit was required to work overboard on the vessel, there were no instructions or procedures for taking draft measurements in the company or vessel manuals. The investigation found that no one was aware of the third officer's actions, no fall protection system or personal flotation device was used, and no one was present to initiate emergency response when the third officer went overboard. If routine tasks are not addressed in the shipboard operating procedures, there is a risk that these tasks will not be conducted safely and that unsafe practices will persist, endangering the lives of crewmembers.

Following the occurrence, the vessel's operator discontinued the use of rope ladders and replaced them with embarkation ladders. The use of a fall protection system, personal flotation device and the presence of second crewmember with access to lifebuoys and a communication system are now required for working overboard. The company also explained the various methods available for taking draft measurements to its crews.

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Winnipeg, Manitoba, 30 October 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18C0018) on the April 2018 brake failure of a privately operated Cessna Citation Bravo 550 aircraft that then collided with a Morningstar Partners Ltd. Bombardier CL-600-2B16 aircraft, at Winnipeg/James Armstrong Richardson International Airport, Manitoba.

The TSB conducted a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues.

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Gatineau, Quebec, 29 October 2018 – Today, the Transportation Safety Board of Canada (TSB) released Watchlist 2018 and identified seven key issues requiring government and industry’s attention to make Canada’s transportation system even safer in the air, marine and rail sectors. This fifth Watchlist edition, like previous ones, builds on hundreds of investigations, compelling findings and data, and active TSB recommendations.

A major safety hazard, crossing all three transportation modes, is employee fatigue. Pervasive, especially in a 24/7 industry where crews can work long and irregular schedules across multiple time zones, fatigue has been found to be a risk or contributing factor in more than 90 TSB investigations since 1992.

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

Watchlist 2018 spells out clear actions that are necessary to effectively address each of the issues. For example, 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.

This year, three items were removed from the Watchlist due to actions taken by stakeholders and/or progress achieved in reducing the underlying safety deficiencies. They are: 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. The TSB will continue to monitor progress in those areas through its investigations, active recommendations and outreach activities.

“That's the good news,” said Ms. Fox. “What's more troubling is the ongoing status of some persisting issues that have been on the Watchlist for some time.”

Again this year, Watchlist 2018 highlights the following issues as systemic risks to transportation safety:

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

Contributing to the problem are important gaps still remaining in the safety management and oversight regime for federally-regulated transportation companies. In addition, the slow pace of the regulatory process to implement TSB recommendations only serves to perpetuate safety risks, putting Canada behind some international standards. More than 60 TSB recommendations are still outstanding after a decade, a third of which are more than 20 years old.

The TSB will closely monitor progress on Watchlist 2018 and report publicly on what change agents promise versus what they deliver.

“Advancing safety is all about change,” Ms. Fox concluded. “And change is all about looking at how things have always been done and finding ways to do them better. The safety of Canadians everywhere, and the integrity of our infrastructure and environment, depend on it.”

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Winnipeg, Manitoba, 26 October 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (R18W0133) on the May 2018 derailment of a Canadian Pacific Railway train near Winnipeg, Manitoba.

The TSB conducted a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues.

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Richmond, British Columbia, 25 October 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (M18P0073) on the April 2018 sinking of fishing vessel Western Commander in Hecate Strait, British Columbia. Two of the crew members survived but one crew member subsequently died.

The TSB conducted a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues.

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Edmonton, Alberta, 22 October 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18W0052) on the April 2018 loss of nose wheel on touchdown of a Beechcraft 1900D aircraft, operated by Air Georgian Ltd., at Calgary International Airport, Alberta.

The TSB conducted a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues.

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Dartmouth, Nova Scotia, 19 October 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18A0018) on the March 2018 in-flight electrical arcing on board a Bombardier DHC-8-402 aircraft, operated by Porter Airlines, near Fredericton Airport, New Brunswick.

The TSB conducted a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues.

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Toronto, Ontario, 9 October 2018 – In its investigation report (R17T0164) released today, the Transportation Safety Board of Canada (TSB) determined that a combination of six conditions contributed to the wheel of a covered hopper car climbing over the rail on the high side of a curve, resulting in a derailment in July 2017 in Strathroy, Ontario.

On 19 July 2017, a westbound Canadian National (CN) freight train derailed 14 cars near the Metcalfe Street West crossing in the town of Strathroy, Ontario. One of the cars that derailed was a dangerous goods residue tank car that had last contained liquefied petroleum gas. It came to rest on its side. There was no release of dangerous goods and there were no injuries.

The investigation found that a wheel on the 109th car in the train, a covered hopper car loaded with cement, had climbed the north rail of a slight left hand curve, immediately west of the Carroll Street crossing. The lead wheels on the 110th car, a residue tank car, also derailed. These 2 cars continued in a derailed condition for about 1.15 miles (1.85 km) until the train traversed the Caradoc Street crossing. At that point, the cement car re-railed itself, but the residue tank car remained derailed. Upon reaching the platform of the VIA Rail station in Strathroy, the residue tank car separated from the cement car, leading to the derailment of 13 additional cars.

The investigation determined that there were numerous “non-condemnable” factors that contributed to wheel climb that led to the derailment, including a number of mechanical conditions on the first car to derail and various track conditions in the vicinity.

Following the occurrence, CN purchased specialized tools and equipment for its MacMillan Yard facility to repair stabilized trucks. CN also ensured that the importance of the condition of coupler and truck components when performing safety inspections is being discussed with mechanical staff during daily job briefings.

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Richmond Hill, Ontario, 21 September 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A17O0209) on the September 2017 collision of a privately operated Cessna 150J aircraft that occurred with Lake Huron near Goderich, Ontario.

The TSB conducted a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues.

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Richmond Hill, Ontario, 11 September 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (R18T0032) on the February 2018 crossing accident in Breslau, Ontario.

The TSB conducted a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues.

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