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Toronto, Ontario, 25 April 2018 – The Transportation Safety Board of Canada (TSB) released its investigation report (A17O0025) into the runway excursion of Air Canada flight 623 at Toronto/Lester B. Pearson International Airport, Ontario. The investigation determined that weather conditions and lack of runway centreline lighting reduced the cues available to recognize the aircraft's drift in time to correct the trajectory or to execute a safe go-around.
On 25 February 2017, the Airbus A320 was completing an evening flight to Toronto from Halifax/Stanfield International Airport, Nova Scotia, with six crew members and 119 passengers on board. Just before touchdown, the aircraft began to deviate to the right of the runway centreline. It deviated further to the right after touchdown and entered the grassy area to the west of the runway. It then travelled approximately 2390 feet through the grass parallel to the runway before returning to the pavement. During the excursion, the aircraft struck five runway edge lights, causing minor damage to the left outboard wheel and the left engine cowling. There were no reported injuries.
The investigation found that during the final approach phase, while the aircraft was less than 30 feet above ground and on the runway centreline, a right roll command input caused the aircraft to enter a shallow right bank and start drifting to the right. The crew had limited visual cues to accurately judge the aircraft's lateral position because of rain, reduced windshield wiper capability and lack of runway centreline lighting. The severity of the drift was not recognized until the aircraft was less than 10 feet above ground and rapidly approaching the runway edge, which left limited time to correct the aircraft's trajectory before contacting the surface. Given the risks involved in executing a go-around from a low level in response to significant drift, the pilot continued the landing sequence while attempting to minimize the extent of the excursion.
Following the accident, Air Canada instituted a program for inspections of windshield wiper tension, developed a drift training scenario for the simulator, and issued further flight crew guidance on lateral drifts and lateral runway excursions.
Calgary, ALberta, 24 April 2018 – The Transportation Safety Board of Canada (TSB) will hold a news conference on 26 April 2018 to make public its investigation report (A16P0186) into the October 2016 fatal collision with terrain of a Cessna Citation 500 aircraft near Kelowna, British Columbia.
26 April 2018
10 a.m. Mountain Time
10 a.m. Mountain Time
Kathy Fox, TSB Chair
Beverley Harvey, Investigator-in-charge
Beverley Harvey, Investigator-in-charge
Metropolitan Conference Centre
Grand Lecture Theatre
333 4th Avenue SW, Calgary, Alberta
Paid parking available
Grand Lecture Theatre
333 4th Avenue SW, Calgary, Alberta
Paid parking available
The event will be broadcast live on www.ustream.tv/channel/transportation-safety-board-of-canada
This event is for media only. Media representatives will need to show their outlet identification.
The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
For more information, contact:
Transportation Safety Board of Canada
Winnipeg, Manitoba, 23 April 2018 – Today, the Transportation Safety Board of Canada (TSB) released a factual update on its investigation (A17C0146) into the fatal aircraft accident that occurred in Fond-du-Lac, Saskatchewan, on 13 December 2017. The update provides additional information on the sequence of events that led to the accident, the progress of the investigation activities to date, and the work planned for the next steps ahead.
As part of the investigation, the TSB will be conducting a data gathering exercise regarding aircraft operations at remote airports in Canada. "We count on the widest collaboration possible to better understand the challenges and requirements involved in ensuring safe flying conditions to and from remote communities," said Natacha Van Themsche, TSB Director of investigations, Air.
Québec, Quebec, 18 April 2018 – The Transportation Safety Board of Canada (TSB) today released its report (M17C0060) into the May 2017 fatal mooring accident that occurred on board the bulk carrier Nord Quebec at the Port of Trois-Rivières, Quebec. The report highlights the safety hazards and prevalence of occurrences related to mooring operations on board merchant vessels and describes the actions that have been taken internationally to improve guidance and raise awareness of the risks involved.
On 22 May 2017, while the bulk carrier Nord Quebec was berthing at section 16 of the Port of Trois-Rivières, the second officer and the bosun were tasked to deploy two forward mooring ropes, being used as forward spring lines, while a team of linesmen on the dock put these on the dock bollards. After the spring lines became caught under one of the dock's rubber fenders, the second officer leaned over the vessel handrail on the main deck to visually assess the situation. He briefly stepped back upon hearing a warning from a linesman, but leaned over the handrail again shortly after. As the vessel's hull moved away from the rubber fender and the spring lines were freed, the energy stored in their synthetic fibers caused them to snap upward in a slingshot motion along the vessel's side shell plating. The first spring line went above the main deck handrail, fatally injuring the second officer.
From 2007 to 2017, 24 occurrences (including this one) involving mooring operations in Canada on domestic and foreign-flagged vessels were reported to the TSB. In these occurrences, 24 persons sustained serious injuries and two were fatally injured. Several other occurrences due to mooring have also been reported internationally.
Following the Nord Quebec occurrence, the TSB sent a Marine Safety Information Letter to various stakeholders, demonstrating the international profile of safety issues related to mooring operations. The letter served to inform the work of the International Maritime Organization's subcommittee responsible for amending the mooring provisions of the International Convention for the Safety of Life at Sea (SOLAS) and for drafting new guidelines for safe mooring operations. The management company of the occurrence vessel launched a campaign to raise awareness and promote mooring operations risk assessments. The Transport Safety Investigation Bureau of Singapore, where the vessel is registered, has also issued safety information on mooring-related risks.
Richmond Hill, Ontario, 23 April 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (R17T0170) into a July 2017 occurrence in London, Ontario, during which a Canadian Pacific Railway employee was injured after falling from a train in the Quebec St. Yard.
The TSB is releasing this limited-scope investigation report to highlight the importance of completing timely vegetation control along the railway right-of-way so that vegetation obstructions do not compromise safe railway operations.
Winnipeg, Manitoba, 29 March 2018 – The Transportation Safety Board of Canada (TSB) released today its investigation report (R16W0242) into a November 2016 uncontrolled train movement, collision and derailment in Estevan, Saskatchewan.
On 29 November 2016, at about 0515 Central Standard Time, a southbound Canadian Pacific Railway (CP) ballast train rolled uncontrolled in the siding at Estevan, Saskatchewan, and struck the side of a northbound CP freight train that had just stopped on the main track. The ballast train locomotive sustained damage and a freight car on the northbound train derailed and sustained minor damage. No dangerous goods were involved and there were no injuries.
The investigation determined that, while the two crew members from the ballast train were performing a passing train inspection of the northbound train, the locomotive engineer (LE) left his position on the ground and entered the locomotive cab of his train. While in the cab, the LE inadvertently moved the automatic brake handle to the release position. Without realizing that the automatic air brakes were releasing, the LE returned outside to complete the passing train inspection.
The investigation also found that, due to a build up of ice and snow on the locomotive brakes of the ballast train, the effectiveness of these brakes alone had been reduced, resulting in a retarding force that was insufficient to hold the train. Upon recognizing that the train was moving, the LE immediately boarded the locomotive, entered the cab and initiated an emergency brake application. However, the ballast train continued to move at a speed of less than 1 mph until the locomotive struck the side of the northbound train, which had by then stopped on the main track.
In accordance with Rule 112 of the Canadian Rail Operating Rules, railways are permitted to use the reset safety control (RSC) system with roll-away protection as a secondary method of train securement for an unattended train. However, the roll-away protection feature on the ballast train did not activate to stop the train, as the uncontrolled train did not reach the pre-set activation speed of 2.5 mph. This occurrence highlights the risk that using the locomotive's RSC system equipped with roll-away protection as a secondary method of train securement may not always prevent an uncontrolled movement.
From 2008 to 2017, 541 occurrences related to unplanned/uncontrolled movements were reported to the TSB. Over this 10 year period, there were 21 occurrences involving loss of control, of which 14 affected the main track. Uncontrolled movements are low frequency–high-risk events that can occur due to loss of control, switching without air, or insufficient securement. Uncontrolled movements that affect the main track will typically present the greatest risk of adverse outcomes, particularly if dangerous goods are involved.
This investigation has also raised three TSB Watchlist issues:
- Safety management and oversight: a railway must have processes for ensuring compliance with regulations and rules. Because crew members of the ballast train had been on duty for about 13 hours by the time the train was secured after the incident, which exceeded the maximum on-duty time of 12 hours as specified in the work/rest rules, CP should have filed a report in order to meet regulatory requirements.
- On-board voice and video recorders: valuable data are going unrecorded, hindering the progress of TSB safety investigations and affecting the capability of railways to improve safety management systems.
- Fatigue management systems for train crews: although both crew members were fatigued at the time of the occurrence, it could not be determined if any significant performance decrements had occurred. Fatigue continues to pose a risk to the safe operation of trains, particularly freight trains, which move 70% of the country's surface goods.
Following this occurrence, the TSB issued a Rail Safety Advisory (RSA) relating to the roll-away protection activation of the RSC device on some CP locomotives. In December 2016 and January 2017, CP issued two System Bulletins indicating that the RSC with roll-away protection is not to be used as a physical securement or mechanical device when operating certain series of locomotives.
Calgary, Alberta, 28 March 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (R17C0074) into the October 2017 main-track derailment of a Canadian Pacific Railway train near Antelope, Saskatchewan. There were no injuries, but 37 covered hopper cars loaded with potash derailed.
The TSB is releasing this limited-scope investigation report to raise awareness about rail surface defects and to encourage the implementation of corrective measures as required.
Richmond, British Columbia, 28 March 2018 – In its investigation report released today (A16P0045), the Transportation Safety Board of Canada (TSB) found that design limitations of the helicopter's hydraulic system, combined with how control inputs were applied, led to the March 2016 loss of control and collision with terrain involving a helicopter near Smithers, British Columbia.
On 16 March 2016, an Airbus Helicopter AS 350 FX2 operated by TRK Helicopters Ltd., departed from the base of a ski run approximately 82 nautical miles northwest of Smithers, on a day visual flight rules flight to the base camp, with the pilot and six passengers onboard. Soon after takeoff, while operating at low altitude, the pilot initiated a descent into a ravine. During the descent, the helicopter's airspeed increased rapidly. Moments later, the helicopter abruptly rolled to the right, pitched up, and collided with terrain on a steep snow-covered slope. There were no injuries, and all seven occupants exited the helicopter, which was substantially damaged. There was no post-impact fire and the emergency locator transmitter did not activate.
The investigation highlighted a well-known design characteristic of the AS 350 hydraulic system, called servo transparency. This phenomenon occurs when the aerodynamic forces on the main-rotor system, due to a combination of environmental and operational factors, exceed the capability of the hydraulic system and cause the aircraft to pitch up and roll to the right. The investigation found that prior to the crash, the pilot placed the helicopter in a flight regime that resulted in servo transparency. Although the self-correcting tendency of the aircraft allowed the pilot to regain hydraulic system assistance, the altitude was too low for the pilot to recover before impact.
The helicopter was not equipped with a flight data recorder or a cockpit voice recorder, nor were these required by regulation. However, there was a Global Positioning System (GPS) onboard that incorporated a data recording capability. The flight was also captured on two personal in-flight videos. The GPS and videos provided investigators with vital information about airspeed and other key variables in the last seconds of the flight. The Board has recommended in the past that Transport Canada work with industry to implement flight data monitoring and lightweight flight recorders in commercial aircraft (Recommendation A13-01). Although the recommendation was supported by the regulator, few concrete actions have been taken to date.
The investigation also found that the emergency locator transmitter failed because of undetected wear over time. If manufacturers do not follow recommended inspection and/or replacement schedules provided by sub-component suppliers, there is an increased risk that the emergency locator transmitter will fail.
Following the occurrence, TRK Helicopters Ltd. amended its training curriculum to emphasize emergency procedures related to hydraulic system failures and the conditions that increase the risk of servo transparency. Airbus Helicopters has begun developing flight data monitoring systems and has undertaken to revise its training syllabus, with the possible inclusion of a video on servo transparency.
Québec, Quebec, 27 March 2018 – The Transportation Safety Board of Canada (TSB) today released its report (M16C0137) into the August 2016 collision between the passenger vessel C03097QC and an unidentified object near Les Bergeronnes, Quebec. The report identifies safety deficiencies in local whale-watching operations in the Saguenay–St. Lawrence Marine Park.
On 29 August 2016, the rigid-hull inflatable passenger vessel C03097QC, also known as Aventure 6, was transiting the Saguenay–St. Lawrence Marine Park during a marine mammal observation tour with nine people on board, when it collided with an unidentified object, possibly a whale. Two people, including the vessel operator, were thrown overboard and other passengers were injured during this accident. The vessel's outboard engines were damaged during the collision.
The investigation found that the attention necessary to carry out all of the tasks required of the operator, including conducting the tour and monitoring the vessel's speed and position, resulted in the operator not seeing a nearby whale. As the vessel reached the speed of 21.6 knots, it collided with an unidentified object. Due to its speed, the vessel kept moving ahead after the initial impact, and the skegs of both outboard engines also collided with the object. The impacts threw the two people overboard, and shut down the engine power. Since the passengers were unfamiliar with the use and operation of the vessel's equipment, they were unable to deploy the lifebuoy and pyrotechnics, and did not know how to broadcast a distress call. One passenger called 911 from a cell phone and another managed to restart one engine and manoeuver the vessel to retrieve the people overboard.
There is no regulatory requirement for the owning company of the Aventure 6 to have a formal safety management system. Safety management and oversigh is a Watchlist 2016 issue. As this occurrence demonstrates, some companies consider safety to be adequate as long as they are in compliance with minimum regulatory requirements. However, regulations alone cannot foresee and account for all of the risks unique to a particular operation or industry.
In June 2017, following the 2015 capsizing of the whale-watching vessel Leviathan II, the TSB recommended to Transport Canada (M17-02) that it require commercial passenger vessel operators to adopt explicit risk management processes, and that it develop comprehensive guidelines to assist with the implementation and oversight of those processes. The response to this recommendation has not yet been assessed.
Following the occurrence, the TSB sent a safety letter to the vessel owner concerning deficient and missing shipboard safety equipment and other safety issues. A copy was sent to federal and provincial regulators, and to five other companies operating in the local marine mammal observation industry. In response, the vessel owner made safety equipment upgrades, and updated its standard pre-departure passenger briefing to include information that was previously missing.
Dorval, Quebec, 26 March 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (R17Q0088) into the 25 October 2017 crossing collision involving a VIA Rail Canada Inc. passenger train and a tractor-trailer near Hervey-Jonction, Quebec. The truck driver sustained minor injuries, but none of the eight passengers on board the train were injured.
The TSB is releasing this limited-scope investigation report to raise awareness about crossing-related hazards and to encourage the implementation of corrective measures as required.