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Gatineau, Quebec, 20 July 2017 – Tabled in Parliament yesterday, the Transportation Safety Board of Canada's (TSB) 2016-17 Annual Report highlights the TSB's major achievements and the work it has done to advance transportation safety on Canada's waterways, along its pipelines and railways, and in the sky in the last year.

In 2016-17, the TSB published 44 investigation reports and issued a total of 20 recommendations in the Marine, Rail, and Aviation sectors. Watchlist 2016 was released with two new safety issues and was featured prominently through a proactive outreach campaign. The annual report provides a substantive update on Watchlist issues and related activities.

Initiatives of particular interest are the first-ever multi-modal TSB Transportation Safety Summit and the completion of the Railway Safety Issues Investigation Report: Expanding the use of locomotive voice and video recorders in Canada. The Safety Summit, held in April 2016, brought together senior Canadian transportation executives from government and the transportation industry, along with some of their labour organizations, to share best practices—notably for capturing and using safety data in a proactive, non-punitive way—and to identify ways of strengthening organizational safety culture and safety management. The railway safety report, released in September 2016, also involved the participation of key railway stakeholders. It reviewed some best practices, identified and evaluated implementation issues, examined potential safety benefits of the expanded use of on-board recorders, and collected background information for the development of an action plan to implement locomotive voice and video recorders. It also served as a foundation for legislative changes recently tabled in Parliament.

On a less positive note, the reassessment of 69 outstanding recommendations still requiring government and industry action showed little progress. The response to only one of these outstanding recommendations has been upgraded to Fully Satisfactory, the TSB's highest rating. Of the other 68 recommendations, nine were reassessed with a higher rating because of positive information received from the change agents, five received a lower rating due to a lack of progress, and the status the other 54 has not changed at all.

"We remain determined to continue to push for action where we feel more can be done to make the transportation system, and by extension all Canadians, safer still," says Chair Fox. "Our activities build on over a quarter-century of cutting edge investigative work, solid reporting, and advocating for safety. It may be hard to quantify in concrete terms the impact that our work has. That is because the effect is cumulative. But year after year, we see a steady trend in declining accident rates and we are heartened by that," she added.

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Richmond, British Columbia, 13 July 2017 – Citing the complex design of the Crush Crescent–Glover Road railway crossing and driver distraction as contributing factors, the Transportation Safety Board of Canada (TSB) today released its investigation report (R15V0191) into the 2015 fatal crossing accident in Langley, British Columbia.

On the morning of 11 September 2015, a Canadian National (CN) train struck an ambulance at a railway crossing in Langley. The two paramedics inside the ambulance, including the one who was driving, were injured. The patient who was being transported in the back of the ambulance later succumbed to injuries sustained in this accident.

The investigation determined that the ambulance entered the intersection when the grade crossing warning system (GCWS) had been activated. The crossing bell was ringing, the flashing lights were activated, and the gates were descending. The driver, whose cell phone was active at the time, was intending to make a left-hand turn, but stopped on the tracks when a lowered crossing gate for the opposite lane appeared to be blocking the way forward. In an attempt to fit the ambulance between the main track and that lowered gate, the ambulance was edged forward, but not enough to move it clear of the approaching train. It was later found that the lowered gate was not an impediment to the ambulance moving forward.

The investigation identified the complex design of the crossing—with multiple lanes, two distinct rail tracks close together, and many different visual cues, some of them harder to see or appearing to be contradictory—as a contributing factor in this accident. Also, the distraction by cell phone use likely decreased the driver's ability to detect warning stimuli in the environment while traversing the crossing.

"Technology has done much to make the interactions of road vehicles and trains safer. It can also do more. But drivers too must do their part," said Peter Hickli, TSB investigator-in-charge.

The TSB issued two rail safety advisories (RSA) as a result of this investigation. The first advisory (RSA 07-16) relates to safety issues arising from conflicting information given by the railway crossing and road traffic signals at the Crush Crescent–Glover Road crossing in Langley. The second advisory (RSA 06-17) indicates that Transport Canada, the BC Ministry of Transportation and Infrastructure, Canadian Pacific (the railway owner), and the Township of Langley should resolve jurisdictional responsibility for roadway markings at this crossing, and for other crossings in the province of BC where this responsibility is unclear.

Since the accident, a number of steps have been taken to improve safety at this railway crossing, by making the interaction between drivers and their environment as unambiguous as possible. These improvements include relocating the warning system and upgrading its equipment, installing flashing lights overhead for better visibility, repainting some pavement markings, and adding an LED sign warning of an approaching train.

See the investigation page for more information.

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Richmond Hill, Ontario, 12 July 2017 – The Transportation Safety Board of Canada (TSB) today released its investigation report (A15O0188) into a fatal collision with terrain involving a privately operated Cessna 182 near Parry Sound, Ontario. This investigation emphasizes the risks of flying at night in areas with limited cultural and ambient lighting, as well as without adequate instrument flying proficiency.

On 9 November 2015, a privately operated Cessna 182 with one pilot and one passenger aboard, departed from the Parry Sound Area Municipal Airport, Ontario, for a night visual flight rules (VFR) flight to Tillsonburg, Ontario. Once airborne, the aircraft immediately started a right climbing turn, which then became a descending turn before colliding with terrain. The two occupants were fatally injured and a post-impact fire destroyed the aircraft.

The investigation determined that it is likely that the pilot did not adequately assess the hazards associated with a night VFR departure from an airport with limited cultural and ambient lighting. In heavily populated areas, it may be easy for pilots to maintain visual reference to the surface using cultural lighting, such as street and building lights. However, flights are often conducted in remote locations of Canada, where there may be little to no cultural lighting available to help pilots maintain visual reference to the surface. The pilot, who was likely not proficient at flying with reference to instruments, may have become disoriented after losing visual reference to the ground and lost control of the aircraft.

The report highlights several risk factors related to VFR night flying. If current regulations do not clearly define what is meant by visual reference to the surface, night flights may be conducted with inadequate visual references, increasing the risk of accidents. The Board previously made a recommendation (A16-08) calling for Transport Canada (TC) to amend the regulations to clearly define the visual references required for night VFR flying. TC has responded that it will conduct safety promotion/education activities, which will be followed in 2017 by a regulatory amendment project. The Board has assessed TC's response to this recommendation as Satisfactory Intent.

See the investigation page for more information.

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Richmond Hill, Ontario, 21 June 2017 – The Transportation Safety Board of Canada (TSB) today released its investigation report (M16C0014) on the capsizing and sinking of the fishing vessel Bessie E. in Mamainse Harbour, near Sault Ste. Marie, Ontario. This report highlights gaps in federal, Ontario provincial and Batchewana First Nation Band oversight and gaps in efforts to promote safety in the commercial fishing vessel industry.

On 16 February 2016, the fishing vessel Bessie E., with the master and four crew members on board, sustained an engine failure while returning to Mamainse Harbour, Lake Superior, Ontario, after a day of fishing. The investigation found that the vessel's engine shut down as the rolling of the vessel in the prevailing seas most likely disturbed sediment in the fuel tanks. The sediment then clogged the fuel filters, restricting fuel supply to the engine. If vessel fuel system repairs are not done correctly and are not performed by a qualified person, the safety of the crew, vessel, and environment may be at risk.

While work was being carried out to restart the engine, the vessel drifted outside of the harbour and closer to shore. The vessel then touched bottom and the wind pushed it until it was parallel to the rocky shore. Everyone on board jumped ashore, and the vessel capsized and sank shortly afterwards. There were no injuries, though the vessel was a total loss.

The investigation highlights several factors as to risk in the areas of safety oversight and promotion in the commercial fishing vessel industry. It could not be determined whether the master held any marine certificates required by regulation, and there were several regulatory safety deficiencies found on the vessel. If there is no oversight for all commercial fishing operations to ensure regulatory compliance, there is a risk that safety deficiencies will not be detected within those fishing operations.

Furthermore, it was determined that if governments and leaders in the fishing community do not work collaboratively to ensure that fishermen can and do work safely, then fishermen may not employ safe working practices. The TSB has previously issued a recommendation (M99-02) calling for the provinces to review their workplace legislation with a view to presenting it in a manner that will be readily understood by those to whom it applies. Federal and provincial courts have indicated that the provinces have the responsibility of regulatory oversight of the "business of fishing." The investigation raised doubts as to whether the Ontario Occupational Health and Safety Act is beingapplied to commercial freshwater fishing vessels. The Ontario Ministry of Labour defines fishermen as workers engaged in commercial aquaculture; therefore, other commercial freshwater fishermen in Ontario, who do not meet this definition, may not fall under its jurisdiction. The Ministry of Labour regulates only fishing vessels that are registered with the Workplace Safety Insurance Board and where crew members meet the definition of a "worker".

Numerous other deficiencies, as revealed in the TSB's Safety Issues Investigation into Fishing Safety in Canada, were also found. In particular, fishing safety will be compromised until the complex relationship and interdependency among safety issues is recognized and addressed by the fishing community. Commercial fishing safety is on the TSB Watchlist.

See the investigation page for more information.

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Vancouver, British Columbia, 14 June 2017 – Today the Transportation Safety Board of Canada (TSB) is issuing three recommendations to improve passenger vessel safety resulting from its investigation (M15P0347) into the fatal October 2015 capsizing of the passenger vessel Leviathan II in Clayoquot Sound, British Columbia.

"It's time for Transport Canada to work with whale-watching companies and other passenger vessel operators to ensure the experience they offer is not just thrilling, but as safe as it can be," said Kathy Fox, Chair of the TSB. "When people find themselves in cold water, every second counts. Our recommendations today are aimed at putting in place measures to avoid accidents in the first place, and to expedite rescue efforts if an accident occurs."

On 25 October 2015, the Leviathan II was on a whale-watching excursion in the Plover Reefs area near Tofino, British Columbia, with 27 people on board. As the vessel was about to leave the area, a large breaking wave approached and impacted the vessel on the starboard quarter. The vessel broached and rapidly capsized, throwing all 24 passengers and 3 crew into the cold seawater without flotation aids. The subsequent rescue operation recovered 21 survivors. Six passengers died.

The investigation determined that the sea conditions in the area were favourable to the formation of breaking waves. However, none had been seen when the vessel first approached the area to observe sea lions. Moments after the master became aware of the large wave approaching the starboard quarter, he tried to turn the vessel to minimize the impact, but the wave struck the vessel before these actions could be effective. The crew did not have time to transmit a distress call before the capsizing, nor did the vessel have a means to automatically send a distress call. It was only by chance that the crew retrieved and activated a parachute flare, alerting nearby Ahousaht First Nation fishermen who arrived on the scene first, alerted search-and-rescue (SAR) authorities, and began recovering survivors from the water.

The Board's first recommendation is that Transport Canada (TC) require commercial passenger vessel operators on the west coast of Vancouver Island to identify those areas and conditions conducive to the formation of hazardous waves, and adopt practical strategies to reduce the likelihood of an encounter (M17-01). The Board is also recommending that TC require passenger

vessel operators across Canada to adopt explicit risk-management processes that identify hazards and then implement proactive strategies to reduce these risks. These risk management processes should also be accompanied by comprehensive guidelines so that vessel operators and TC inspectors can implement and oversee them effectively (M17-02).

The TSB's third recommendation is aimed at reducing response time in the event of an accident. It took 45 minutes after the capsizing before SAR authorities became aware of the capsizing. The TSB wants TC to require all commercial passenger vessels operating beyond sheltered waters to carry emergency position-indicating radio beacons (EPIRBs) or other similar equipment. These are designed to float free in the event of a capsizing or sinking and automatically transmit a continuous distress signal to SAR authorities (M17-03).

See the investigation page, investigation findings backgrounder and recommendations backgrounder for more information.

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Vancouver, British Columbia, 12 June 2017 - The Transportation Safety Board of Canada (TSB) will hold a news conference on 14 June 2017 to make public its investigation report (M15P0347) into the October 2015 capsizing and sinking of the passenger vessel Leviathan II off Plover Reefs in Clayoquot Sound, British Columbia.

When:

14 June 2017
10:00 a.m. Pacific Daylight Time

Who:

Kathy Fox, Chair of the TSB
Clinton Reberio, Investigator-in-Charge
Pierre Murray, Regional Manager of Marine Investigations

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.

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Dorval, Quebec, 8 June 2017 – In its investigation report (R16D0073) released today, the Transportation Safety Board of Canada (TSB) found that a main-track switch inadvertently left in the reverse position led to the August 2016 derailment of a Canadian National Railway (CN) train in Acton Vale, Quebec.

On 11 August 2016, a CN freight train was travelling eastward on the Sherbrooke Subdivision of the St. Lawrence & Atlantic Railroad. When the train crew noticed that a main-track switch at Acton Vale, Quebec was lined for the siding, the train's emergency brakes were applied. The train was unable to stop before the switch and was diverted into the siding where the lead locomotive struck a derail and derailed. Derails are devices designed to stop runaway equipment by derailing it. The track was slightly damaged and the derail was destroyed. There were no injuries.

The investigation determined that the main-track switch was inadvertently left in the reverse position, leading to the train being diverted into the siding. A worker tasked with handling the switch had not moved it back to the normal position after completing another task and mistakenly recorded it as being in the normal position. Because the emergency brakes were not applied at a distance that allowed the train to stop before entering the siding, the train entered the siding, struck the derail and derailed. The investigation found that there is an increased risk of accidents occurring on non-signaled tracks if there are no physical defences to alert train crews of a misaligned switch and if the control system is unable to detect a switch left in the reverse position.

Following the occurrence, St. Lawrence & Atlantic Railroad engineering employees received refresher training on the Canadian Rail Operating Rules, including the company's special instructions that apply when a main-track switch is handled.

See the investigation page for more information.

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Calgary, Alberta, 31 May 2017 – Citing a combination of inadequate train handling and employee fatigue as contributing factors, the Transportation Safety Board of Canada (TSB) today released its investigation report (R16C0012) into the 2016 Canadian Pacific Railway (CP) derailment in Alyth Yard in Calgary, Alberta.

The accident occurred on 18 February 2016 in the early morning, when a CP freight train was performing a switching operation in Alyth Yard. While moving at approximately 2.5 mph over a short distance within the yard, a power increase in excess of the maximum throttle position for the area was applied. The investigation determined that excessive pulling force produced by the locomotives over-stretched the train as it was travelling through a curve. With the train brakes at the rear of the train not yet fully released, 13 cars derailed when several wheels came off the rail after climbing the inside rail. There were no injuries and no dangerous goods were released.

Specific train handling requirements relating to the maximum locomotive throttle for the occurrence location were not followed. In this occurrence, there was no requirement for the operating crew to review the relevant train handling material prior to initiating a train movement. Furthermore, there was nothing in the operating environment to remind the crew that there was a change in operating requirements at that location.

The investigation also raised fatigue management as a contributing factor, as a crew member was likely fatigued after having had poor quality sleep in the two weeks prior and having been awake for 23 hours  at the time of the occurrence.

Fatigue management is a shared responsibility. Employees have a responsibility to make every effort to report to work well rested while the company has a responsibility to provide a system that allows them to do so, including procedures to remove themselves from eligibility for duty without fear of discipline. Fatigue management systems for train crews are a Watchlist 2016 issue. As this occurrence demonstrates, fatigue continues to pose a risk to the safe operation of trains, particularly freight trains, which move 70% of the country's surface goods. The initiatives taken to date have been inadequate to fully address the issue. Fatigue management systems for train crews will remain on the TSB Watchlist until Transport Canada completes its review of railway fatigue management systems; and TC and the railways implement further actions to effectively mitigate the risk of fatigue for operating crew members on freight trains.

See the investigation page for more information.

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Richmond, British Columbia, 31 May 2017 - The Transportation Safety Board of Canada (TSB) will hold a news conference in Vancouver, British Columbia, Canada, on 14 June 2017 to make public its investigation report (M15P0347) into the October 2015 capsizing and sinking of the passenger vessel Leviathan II off Plover Reefs in Clayoquot Sound, British Columbia.

Information about the exact venue location will be announced on 12 June 2017, as well as details about an official webcast.

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.

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Québec, Quebec, 29 May 2017 – In its investigation report (M16C0005) released today, the Transportation Safety Board of Canada (TSB) found that ambiguous communications between the pilots and bridge crew, and incorrectly installed emergency backup steering controls, led to the January 2016 grounding of the container vessel MSC Monica in Deschaillons-sur-Saint-Laurent, Quebec.

On 22 January 2016, the MSC Monica was on a voyage from Montréal, Quebec, to Saint John, New Brunswick, with a helmsman, the officer of the watch, and two pilots on the bridge. The vessel ran aground on the St. Lawrence River 1 nautical mile north-northeast of Deschaillons-sur-Saint-Laurent, Quebec. It was refloated the following day with the assistance of three tugs, and proceeded to Québec, Quebec, to undergo the necessary inspections. The vessel sustained minor damage to its hull and major damage to the propeller. There were no injuries or pollution reported.

The investigation found that the MSC Monica unexpectedly veered to starboard, likely due to the helm being inadvertently placed to starboard. The subsequent communication between the helmsman and the pilot navigating the vessel was ambiguous, which led the pilots and the officer of the watch to conclude that there was a steering gear failure. The second pilot then switched to the backup steering system. However, its control was not installed consistently with international standards or with the manufacturer's specifications. The second pilot, who was unfamiliar with this particular installation, unintentionally applied a hard turn to starboard rather than a hard turn to port while attempting to maintain the vessel in the buoyed navigation channel. A delayed hard to port course correction was applied by the officer of the watch; however, the vessel eventually ran aground. Post-occurrence examinations revealed no malfunction with the vessel's steering gear system.

The investigation also determined that the installation of the backup steering control (non-follow-up mode) was such that it would contradict a user's expectations. If the ergonomics of critical shipboard equipment are designed in a way that is confusing or contradicts expectations, there is a risk that a user who is unfamiliar with their configuration will operate them incorrectly. Furthermore, it was found that there is a risk of premature, uncoordinated and ineffective actions if bridge team members do not share a complete and common understanding of a problem and continuously exchange information to solve problems.

Following the occurrence, the backup steering control was correctly reinstalled in accordance with the manufacturer's recommendations. Although no steering malfunction was identified, the owners of the MSC Monica preventively overhauled several steering gear system components and replaced various control and navigation equipment on the bridge during the periodic drydocking of the vessel, which took place in Turkey during the fall of 2016.

See the investigation page for more information.

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