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Richmond Hill, Ontario, 29 September 2016 – The Transportation Safety Board of Canada (TSB) determined that a passenger’s unsafe behaviour and intoxication led to him falling overboard from the vessel Northern Spirit I in Toronto, Ontario, and subsequently drowning. The investigation also found that the crew’s emergency response efforts were not coordinated. The findings are in the investigation report (M15C0094) released today.

On 13 June 2015, the Northern Spirit I was on an evening cruise when security guards near the bow of the vessel observed that one of the passengers was behaving erratically and appeared to be intoxicated. When the passenger was seen leaning over the upper deck railing on the starboard side, two security guards rushed over to him and attempted to prevent him from falling, but he went overboard. A guard advised the master of the situation, search and rescue authorities were alerted, and the vessel was maneuvered to return on a reverse track in an attempt to locate the passenger. Numerous first-responder organizations joined the search effort as the evening progressed, but the search was unsuccessful. The passenger's body was recovered 18 days later.

The investigation found that the passenger was intoxicated, and that he had been drinking before boarding and while on board the vessel. Security guards and crew members had not detected this during pre-boarding screening or on board the vessel, and the passenger had not been denied alcoholic beverage service. The passenger's high blood alcohol concentration affected motor skills and increased the risk of hypothermia, which decreases the chance of survival in the water.

Because the signal to initiate the man-overboard procedure was not sounded, the crew's response to the emergency was not coordinated and did not align with the company emergency procedures. In addition, there were delays in launching the vessel's emergency boat owing to its position on the vessel's stern. The investigation also found that if emergency procedures in the safety management system or muster list lack key details and do not fully account for all contingencies, there is a risk that opportunities to recover a person who has fallen overboard may be missed.

Although the crew had performed some emergency drills, they had not performed any man-overboard drills, which may have prevented the crew from being able to easily recall the steps to take during a person-overboard situation. There is a risk of increased death or injuries during emergencies if crew members do not practise drills for emergency procedures.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
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Dartmouth, Nova Scotia, 27 September 2016 – Citing a combination of track conditions and rail wear as contributing factors, the Transportation Safety Board of Canada (TSB) today released its investigation report (R15M0034) into the April 2015 Canadian National Railway (CN) derailment near Saint-Basile, New Brunswick.

On 17 April 2015, a westbound CN freight train derailed 35 rail cars and one locomotive at Mile 212.8 on the Napadogan Subdivision. The derailment destroyed approximately 900 feet of main track. Twenty of the derailed cars were residue tank cars that had last contained crude oil.

The investigation determined that significant wear on the rail had resulted in the wheel contact shifting outward, which reduced the rail's lateral stability. In addition, as the train was negotiating the curve, track conditions and the curve elevation condition combined to increase lateral forces on the rail, leading to the train's derailment.

The investigation observed that if track gauge is close to maintenance tolerances, it is harder to protect against incremental gauge-widening forces, increasing the risk of derailments. It also highlighted the limited guidance available to track maintenance personnel faced with a combination of track conditions. The TSB notes that there are no clear criteria for addressing combination defects (more than one defect occurring within 100 feet of track) that can pose a threat to safe rail operations, increasing the risk that unsafe combinations of track conditions can be missed or remain unaddressed during track inspections.

In 2014, the transportation of flammable liquids by rail was added to the TSB Watchlist. Based on this investigation and previous ones, recommendations, and other safety communications, the TSB reiterates that flammable liquids must be shipped in more robust tank cars to reduce the likelihood of a dangerous goods release during accidents. Fortunately, in this accident, all the derailed tank cars were residue cars.

Following the occurrence, CN reduced the combined wear limit for 136-pound rail and initiated gauge restraint measurement to enhance its assessment of lateral strength of the track structure.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
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