Aviation.ca - Your Number One Source for Canadian Aviation News, Jobs and Information!

Canadian News

Richmond Hill, Ontario, 22 June 2018 - The Transportation Safety Board of Canada (TSB) will hold a news conference on 27 June 2018 to release its investigation report (R16T0111) on the uncontrolled movement of 2 locomotives and 74 railway cars that occurred in June 2016 at MacMillan Yard, located in Vaughan, north of Toronto, Ontario. The group of cars rolled uncontrolled for about 3 miles, reaching 30 mph before coming to a stop.

When:

27 June 2018
10:00 a.m. Eastern Time

Spokespersons:

Faye Ackermans, Board Member
Rob Johnston, Manager, Railway Investigations, Central Region & Headquarters
Nathalie Lepage, Senior Investigator

Where:

Transportation Safety Board of Canada
Richmond Hill Regional Office
23 East Wilmot Street, Richmond Hill, Ontario

The news conference will be broadcast live on Ustream at the following address: http://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
Media Relations
Telephone: 819-994-8053
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

Published in Transportation Safety Board of Canada
Written by
Read more...

Richmond, British Columbia, 18 June 2018 – In its investigation report (M17P0052) released today, the Transportation Safety Board of Canada (TSB) determined that inadequate vessel stability information led to the capsizing and sinking of the fishing vessel Miss Cory in the Strait of Georgia, British Columbia, in March 2017. One of the vessel's crewmembers was reported missing.

On 6 March 2017, the fishing vessel Miss Cory was purse seining for herring with 5 people on board. After a successful catch, the crew lifted the net using the vessel's boom to transfer the fish from the net into a packing vessel. While waiting for additional packing vessels to arrive, the vessel leaned to starboard to the point where the vessel's rubbing strake was submerged. Water likely entered the vessel from behind the rubbing strake, making its way into the aft hold and causing further leaning to starboard. The crew unsuccessfully attempted to dewater the vessel, unaware that a capsizing situation was developing. The crew on deck abandoned the vessel in the final seconds before it capsized and sank. The engineer, who was below deck, was possibly unaware of the situation and was unable to escape the sinking vessel.

The investigation determined that the combined effects of the weight of the fish in the net and the progressive downflooding of the compartments in the Miss Cory caused it to heel over and capsize. The attention on the task of dewatering the vessel likely affected the master's ability to maintain situational awareness and make use of alternate strategies to manage the vessel's stability or initiate procedures to safely abandon ship.

The vessel had not undergone a stability assessment for operations using its boom. As such, there were no means for the master to recognize that the vessel would rapidly capsize with a boom load of 5-7 long tons. Fishing vessel stability information is a key concern in the TSB Watchlist issue of Commercial Fishing Safety. There are also two outstanding Board recommendations (M94-33 and M16-02) regarding the adequacy of fishing vessel stability information.

The investigation also found that there were no procedures for the safe operation of the vessel or for dealing with emergencies. The crew did not practice emergency drills on board the vessel, though they discussed the muster list and associated emergency duties. The

uncoordinated abandonment of the vessel led to one crewmember remaining in the engine room when the vessel capsized, who was subsequently reported missing. If formalized emergency procedures are not practiced in drills, there is a risk that an emergency response will be delayed or uncoordinated, potentially endangering the safety of the crew and the vessel.

Following the occurrence, Fish Safe facilitated the development of a code of best practices for the roe herring fishery to address unsafe work practices that continue to put fishermen and vessels at risk. WorkSafeBC will enhance inspections in the commercial fishing industry, focusing on vessel stability documentation, emergency drills and procedures.

Published in Transportation Safety Board of Canada
Written by
Read more...

Québec, Quebec, 11 June 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (M17C0220) on the September 2017 mechanical failure and subsequent fire on board the tug Brochu in Port-Cartier, Quebec. No injuries or pollution were reported, but the fire caused extensive damage to the tug.

Early on, TSB investigators discovered a number of unsafe conditions that could potentially affect the crews and machinery operations of hundreds of other vessels worldwide having similar arrangements. Therefore in December 2017 the TSB issued a safety advisory to a wide range of Canadian and international stakeholders to inform them of the issue and encourage them to take appropriate action.

Published in Transportation Safety Board of Canada
Written by
Read more...

Gatineau, Quebec, 11 June 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A17P0149) on the October 2017 loss of control and collision with terrain of a Robinson R44 helicopter at the Campbell River Airport, British Columbia. One pilot was fatally injured and the second pilot was seriously injured. There was no post-impact fire and no dangerous goods were on board.

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

Published in Transportation Safety Board of Canada
Written by
Read more...

Gatineau, Quebec, 4 June 2018 – In its investigation report (A17F0052) released today, the Transportation Safety Board of Canada (TSB) found that unexpected weather conditions on final approach, reduced runway conspicuity, and inadequate flight path monitoring led to a risk of collision with terrain.

On 7 March 2017, a WestJet Boeing 737-800 was operating as flight 2652 from Toronto/Lester B. Pearson International Airport (CYYZ), Ontario, to Princess Juliana International Airport (TNCM) in Sint Maarten with 158 passengers and six crew members on board. It entered a significant rain shower shortly after crossing the MAPON (missed approach point) waypoint. The crew initiated a missed approach 0.30 nautical miles from the runway threshold at an altitude of 40 feet above water. Once visibility improved, the crew conducted a second approach and landed without incident.

The investigation determined that the runway lights and the visual guidance system (PAPI) had been set at a low intensity during the rain shower that had obscured the view of the airport environment. Both the shower and the low lighting limited the visual references available to the crew to identify the runway properly until the aircraft had exited the rain shower and visibility sharply improved.

The sudden and unexpected poor visibility during the final approach increased the flight crew's visual workload and led to inadequate altitude monitoring. The crew did not notice that the aircraft had descended below the normal angle of descent to the runway threshold until the enhanced ground proximity warning system issued an alert.

After the occurrence, WestJet developed a corrective action plan, including information for pilots regarding possible challenges and threats on approaching and landing at Princess Juliana International Airport. WestJet also revised its Route & Aerodrome Qualification for TNCM with additional information. In addition, guidance on airport lighting system management will be added to the Air Traffic Services operations manual in TNCM by September 2018.

Published in Transportation Safety Board of Canada
Written by
Read more...

Vancouver, British Columbia, 31 May 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (M16P0378) into the causes and contributing factors that led to the October 2016 grounding and sinking of the U.S.-registered tug Nathan E. Stewart in British Columbia. The report underlines the need to effectively and reliably manage the risk of fatigue in the marine industry.

On 13 October 2016, shortly after 1 a.m. Pacific Daylight Time, the articulated tug-barge composed of the tug Nathan E. Stewart and a tank barge went aground on Edge Reef near Athlone Island, at the entrance to Seaforth Channel, approximately 10 nautical miles west of Bella Bella, British Columbia, within the Heiltsuk First Nation territory. The tug's hull was eventually breached and approximately 110 000 litres of diesel fuel were released into the environment. The tug subsequently sank and separated from the barge.

The investigation determined that the second mate who, contrary to Canadian regulations, was keeping watch alone on the bridge at the time of the accident, had fallen asleep and missed a planned course change. For more than two days, he had been working a 6-on, 6-off shift schedule, alternating six hours of duty and six hours of rest. This schedule presents a number of challenges which have been well documented by various studies and experts internationally, notably the difficulty in obtaining sufficient restorative rest during the off-duty periods. There was no prior discussion with the master on the second mate's preparedness for the watch, and the watchkeeper wasn't aware of the sleep-conducive conditions he was facing on the bridge that night.

The TSB has identified fatigue as a causal or contributory factor in numerous marine investigations. "There is a compelling need for vessel operators and watchkeepers to recognize and to address the factors that contribute to fatigue," said Kathy Fox, Chair of the TSB. "If watchkeepers have a better understanding of those factors, and the actions they can take to reduce the risks, then we should see a reduction in the number of fatigue-related occurrences in the marine industry."

The Board has made two recommendations following this investigation. Firstly, it is recommending that Transport Canada require that watchkeepers receive mandatory education and awareness training to help identify and prevent the risks of fatigue. Secondly, it is recommending that vessel owners implement comprehensive fatigue-management plans, tailored specifically for their individual operations.

The investigation also determined that the spill response and the recovery efforts of both the Western Canada Marine Response Corporation and the Canadian Coast Guard were in accordance with the prescribed time standards. However, because other responding agencies and some Canadian Coast Guard personnel were not familiar with the incident command system in use, there was confusion about roles and responsibilities and who had final authority. A coordinated and comprehensive evaluation of the response involving all organizations may have provided more insight to identify deficiencies and improve Canada's spill response regime.

Published in Transportation Safety Board of Canada
Written by
Read more...

Vancouver, British Columbia, 29 May 2018 - The Transportation Safety Board of Canada (TSB) will hold a news conference on 31 May 2018 to make public its investigation report (M16P0378) into the October 2016 grounding and subsequent sinking of the tug Nathan E. Stewart in the Seaforth Channel, 10 nm west of Bella Bella, British Columbia.

When: 31 May 2018, 10:00 a.m. Pacific Daylight Time

Who: Kathy Fox, Chair of the TSB and Glenn Budden, Investigator-in-charge

Where: Vancouver Maritime Museum, T.K. Gallery, 1905 Ogden Avenue, Vancouver, British Columbia

The event will be broadcast live on Ustream at the following address: http://www.ustream.tv/channel/ZK7R3XaGbPP

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
Media Relations
Telephone: 819-994-8053
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

Published in Transportation Safety Board of Canada
Written by
Read more...

Edmonton, Alberta, 29 May 2018 – The Transportation Safety Board of Canada (TSB) investigation (A16W0092) into an occurrence where the nose wheel failed to extend on an Air Georgian flight found several maintenance-related deficiencies that went undetected by the company's safety management system (SMS). These issues also went undetected by Transport Canada oversight activities.

On 12 July 2016, an Air Georgian Ltd. Beechcraft 1900D turboprop aircraft was operating as Air Canada Express flight 7212 from Lethbridge, Alberta, to Calgary, Alberta, with 2 flight crew members and 15 passengers on board. When the flight crew lowered the landing gear for the approach into Calgary, they noticed that there was no gear-safe indication for the nose landing gear. The flight circled for about one hour while the flight crew attempted to fix the problem. An emergency was declared and the aircraft landed with the nose gear partially extended. There was minimal damage to the aircraft, no fire, and there were no injuries.

The investigation found that the nose landing gear did not fully extend because of a lack of lubrication to certain landing gear components. These components were not properly lubricated because maintenance personnel were not adequately trained on lubrication techniques and the use of lubrication equipment. The company's quality control program also contributed to ineffective lubrication activities going undetected for an extended period of time prior to the occurrence.

Safety management and oversight is a TSB Watchlist issue. This investigation found that Air Georgian's SMS was ineffective at identifying and correcting improper and unsafe practices related to nose landing gear lubrication tasks.

Transport Canada's (TC) surveillance of Air Georgian focused primarily on its SMS rather than on regulatory compliance. As a result, ineffective lubrication processes went undetected during three TC inspections prior to the occurrence. If TC does not adopt a balanced approach to oversight that combines inspections for compliance with SMS audits, there is a risk that improper maintenance practices will not be identified, which may lead to incidents and accidents.

Following the occurrence, Air Georgian carried out a fleet campaign to address the greasing issue and reduced the inspection interval for the affected component. The company also hired a manager for maintenance training, and provided human factors training to its staff on distraction, including the need to track and document steps in the workflow.

Published in Transportation Safety Board of Canada
Written by
Read more...

Richmond, British Columbia, 15 May 2018 – The Transportation Safety Board of Canada (TSB) released today its investigation report (M17P0098) into the April 2017 fatal accident involving the commercial sports fishing vessel Catatonic, near Tofino, British Columbia. The report highlights the risks posed by vessel modifications, which may compromise the safety features of the original design and increase the risk that the vessel will not be adequate for the intended voyage.

On 30 April 2017, at approximately 9:30 a.m. PDT, the sports fishing vessel Catatonic left Tofino, for nearby fishing grounds with one operator and four passengers on board. During the next few hours as the vessel anchored at various fishing spots, it was observed to take on water from the stern due to shipping seas. By 1303 PDT, as the vessel was preparing to return to the dock, the operator was unable to re-start the starboard engine. Subsequently the port engine stopped and bilge pumps, navigation equipment, and communications equipment also ceased functioning. Using a personal cellphone, the operator called the Canadian Coast Guard to report the emergency and give their approximate location. Eventually, the vessel could not maintain its upright aspect, and everyone on board abandoned the vessel into the water. Search and Rescue (SAR) vessels recovered the operator and passengers from the water and took them to a local hospital where two of the passengers were pronounced dead.

The investigation found that the Catatonic's stern sank primarily due to water ingress into the vessel's pontoons and stern buoyancy compartments. Modifications made to the vessel allowed the water shipped on deck to first enter the fish boxes and then drain into the pontoon bilges. Holes that had been made in the shipside and the bulkhead also allowed the water to enter the pontoons and into the stern buoyancy compartments and contributed to the stern's sinking.

Significant components of the vessel had also been modified, including its powering arrangement. The vessel's original design for two batteries operating separately was modified to allow both batteries to be charged and drained simultaneously, and act as the only power source to the entire vessel. When the battery unit drained, the vessel was without a power supply for critical equipment such as the engines, bilge pumps, and VHF radiotelephones. If vessel modifications compromise the safety features of the original design, then there is an increased risk that the vessel will not be adequate for its intended voyage.

The investigation also determined that, at the time of the occurrence, the vessel's manual emergency position indicating radio beacon (EPIRB) was not the approved type and was defective. The operator's personal locator beacon (PLB) was not activated since the operator was not familiar with its operation. Additionally, because the vessel's power supply was depleted, the very high frequency (VHF) radios and global positioning system were not functional; the operator was therefore unable to relay the vessel's exact location to the Joint Rescue Coordination Centre. Because the vessel's exact location could not be provided to SAR authorities, 1 hour and 40 minutes elapsed from the time the stern sank to the time everyone was recovered from the water. If accurate position information is not provided in an emergency, there is a risk that valuable time will be lost while SAR resources try to locate the vessel.

The TSB is not aware of any safety action taken as a result of this occurrence.

Published in Transportation Safety Board of Canada
Written by
Read more...

Richmond, British Columbia, 14 May 2018 – In its investigation report (R16V0195) released today, the Transportation Safety Board of Canada (TSB) determined that inadequate safety watch training contributed to an employee injury at the Roberts Bank Yard in Delta, British Columbia in December 2016.

On 18 December 2016, a Toronto Terminals Railway (TTR) locomotive engineer and a conductor were shoving 66 empty intermodal platforms onto the east leg track at the Roberts Bank Yard in Delta, BC. The conductor was driving a vehicle beside the lead platform while providing instructions to the locomotive engineer who was positioned at the opposite end of the movement. At the same time, two track workers employed by a track maintenance contractor (PNR RailWorks) were clearing snow from a switch on the same track. As the movement approached the switch, the conductor saw the workers and activated the oscillating beacon on top of the vehicle to alert them to the approaching movement. When no reaction was observed, the conductor attempted to sound the vehicle's horn, but it was inoperative. The conductor then instructed the locomotive engineer to stop the movement. However, the movement was unable to stop before the leading platform struck and seriously injured one of the track workers.

The investigation found that the conductor's instruction to the locomotive engineer to stop was not made in time to allow the movement to be stopped before reaching the switch. The attentional focus required to monitor the movement's progress while driving the vehicle, combined with the expectation that the track workers would clear the track, likely contributed to the late call to stop the movement.

Deficiencies with the use of safety watch protection by the track workers were also identified in the investigation. Safety watch is a form of track protection that requires one of the members of a track work crew to be assigned with the sole task of continuously monitoring the work site for oncoming trains or other on-track equipment. In this occurrence, neither of the track workers was solely performing the duties of safety watch. The track workers had not been adequately trained in its use and did not have an accurate understanding of how to apply such protection. In addition, as the use of safety watch and the associated processes were not specifically audited, the inadequate application of this form of track worker protection was not apparent.

Safety management and oversight is a TSB Watchlist issue. As demonstrated in this occurrence, gaps in training, supervision, and efficiency testing of employees can decrease the effectiveness of a company's safety management system (SMS).

Technical Safety BC (formerly BC Safety Authority) issued a Safety Advisory to notify all provincially certified railways operating in BC of the risks associated with shoving equipment. It recommended that railways review their processes to ensure compliance with all applicable rules and regulations regarding shoving equipment.

BCR Properties Ltd., the owner of the Roberts Bank Yard, completed a risk assessment and incorporated a number of protection measures into its SMS. BCR also followed up with the contractor to ensure its employees receive appropriate training and certifications.

Published in Transportation Safety Board of Canada
Written by
Read more...
         
Aviation.ca is not responsible for the content of external Internet sites. Copyright © 1997-2015 Skytech Dynamics Corporation, All rights reserved exogenous-blank
exogenous-blank
exogenous-blank
exogenous-blank

Login or Register