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Dorval, Quebec, 15 November 2017 – In its investigation report (A16Q0119) into a September 2016 fatal collision with terrain near the Manicouagan Reservoir, Quebec, the Transportation Safety Board of Canada (TSB) found that a fuel pump malfunction caused the engine to shut down during takeoff, leaving the pilot with not enough time to take appropriate action to attempt to restore engine power. The report also highlights the risks of attempting a 180° turn at low altitude during a takeoff emergency.

On the afternoon of 25 September 2016, a privately operated Cessna U206F floatplane left Kuashkuapishiu Lake, Quebec, for Ra-Ma Lake, Quebec, near the Manicouagan Reservoir, with the pilot and two passengers aboard. After takeoff, the floatplane began a climbing turn to the left when it reached the north end of the lake. A few moments later, it quickly banked to the right, lost altitude, struck the ground, and immediately caught fire. The fire consumed almost the entire cabin. The pilot sustained serious injuries, and the two passengers were fatally injured. No emergency locator transmitter (ELT) signal was received.

The investigation determined that soon after takeoff, the coupling shaft of the engine-driven fuel pump sheared, which cut off the engine's fuel supply and caused it to stop suddenly. The cause of the coupling shaft failure could not be determined. The procedure for engine failure after takeoff requires prompt lowering of the nose of the aircraft to establish a glide to a landing site straight ahead. Faced with the prospect of having to make a forced landing in the forest ahead, the pilot made a 180° turn in order to perform a water landing on Kuashkuapishiu Lake. During this turn, an aerodynamic stall ensued, resulting in a steep descending right turn at an altitude too low to regain control before impact with the ground.

The aircraft's ELT could not be found in the debris. However, the investigation established that it may have contained parts that no longer complied with approved design standards as indicated in Transport Canada Civil Aviation Safety Alert 2016-05. If ELTs contain unapproved parts, there is an increased risk that they will not work as intended in an accident, potentially delaying the arrival of search and rescue personnel.

Post-impact fires have been documented as a risk to aviation safety in previous TSB investigation reports. In 2006, the TSB issued Recommendation A06-10 to reduce the number of post-impact fires in impact-survivable accidents. The aircraft in this occurrence did not have, and was not required to have, any of the technologies, materials, or components identified in recommendation A06-10. There has been no direct action taken or proposed by Transport Canada in response to Recommendation A06-10 and the Board believes the risks remain significant. The response was therefore assessed as unsatisfactory.

See the investigation page for more information.

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Richmond, British Columbia, 2 November 2017 – The Transportation Safety Board of Canada (TSB) is recommending that Transport Canada work with the aviation industry and employee representatives to develop and implement requirements for a comprehensive substance abuse program to reduce the risk of impairment of persons while engaged in safety-sensitive functions. The details are in the investigation report (A15P0081) released today into the fatal 2015 in-flight breakup of a cargo aircraft operated by Carson Air Ltd.

On 13 April 2015, the Carson Air Swearingen SA-226-TC Metro II was carrying freight from Vancouver International Airport to Prince George Airport, British Columbia, with a crew of two pilots on board. About six minutes after departure, the aircraft disappeared from radar. Its last known position was approximately 15 nautical miles north of the airport at an altitude of about 7500 feet. Ground searchers found aircraft wreckage on steep, mountainous, snow-covered terrain later in the day. The aircraft had experienced a catastrophic in-flight breakup. Both the captain and first officer were fatally injured, and the aircraft was destroyed.

The investigation determined that the aircraft entered a steep dive, then accelerated to a high speed which exceeded the aircraft's structural limits and led to an in-flight breakup. Subsequent toxicology testing indicated that the captain had consumed a significant amount of alcohol on the day of the occurrence. As a result, alcohol intoxication almost certainly played a role in the events leading up to the accident.

"In Canada, regulations and company rules prohibit flying while impaired, but they rely heavily on self-policing," said Kathy Fox, Chair of the TSB. "What is needed is a comprehensive substance abuse program that would include mandatory testing as well as complementary initiatives such as education, employee assistance, rehabilitation and peer support."

"We realize that employees within Canada's aviation industry will have concerns under any possible testing regime," added Chair Fox. "This is why we recommend that the substance abuse program consider and balance the need to incorporate human rights principles enshrined in the Canadian Human Rights Act with the responsibility to protect public safety."

Pilot incapacitation is one of three scenarios which the TSB has not ruled out to explain the possible events that led to the accident. It is also possible that the heaters of the pitot system, which provides airspeed information, were off or malfunctioned. The third scenario involves a number of flight-specific factors that are consistent with an intentional act.

However, without objective data from a cockpit voice recorder or flight data recorder, it is impossible to determine with certainty which scenario played out during the occurrence flight. The TSB has previously recommended (A13-01) the installation of lightweight flight recording systems aboard smaller commercial aircraft and flight data monitoring by smaller commercial operators, both to advance transportation safety and to provide data to investigators following an occurrence.

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Richmond, British Columbia, 31 October 2017 – The Transportation Safety Board of Canada (TSB) will hold a news conference on 2 November 2017 to make public its investigation report (A15P0081) into the 13 April 2015 in-flight breakup of a Carson Air Swearingen Metro II cargo aircraft near Vancouver, British Columbia.

When:
2 November 2017
10:00 a.m. Pacific Time
Who:
Kathy Fox, Chair of the TSB
Jason Kobi, Investigator-in-charge
Jean-Marc Ledoux, Manager, Quebec Region Air Investigations
Where:
Pinnacle Hotel Vancouver Waterfront
Tuscany Room
1133 W Hastings Street
Vancouver, British Columbia

The event will be broadcast live on 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.

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Dorval, Quebec, 31 October 2017 – In its investigation report (R16D0076) released today, the Transportation Safety Board of Canada (TSB) found that a lack of compliance with hand-signalling procedures and insufficient signalling equipment contributed to the August 2016 collision between a Canadian National Railway (CN) track unit and a tractor-trailer near Saint-Norbert, Quebec.

On 18 August 2016 at approximately 3:30 a.m. Eastern Daylight Time, a CN hi-rail track unit (TU) was travelling northward on the CN Joliette Subdivision when it approached a public crossing on Highway 347 near Saint-Norbert, Quebec. Because the track unit could not activate the crossing warning system, the crossing was manually protected. The CN flag-person positioned at the crossing signalled the TU operator to proceed. When the TU was approximately 400 feet (122 m) from the crossing, the flag-person saw the headlights of a road vehicle approaching from the west. The flag-person attempted to signal the driver of the vehicle to stop by waving a white headlamp while continuing to indicate to the TU operator to advance. However, the driver of the vehicle was unable to stop before the TU entered the crossing. The TU struck the vehicle (a tractor-trailer) and derailed. The two employees on board the TU and both occupants of the tractor-trailer sustained minor injuries. Approximately 600 litres of petroleum products were released from the TU and the tractor trailer.

The investigation found that CN's General Engineering Instructions (GEI) instruct TU operators to give the right of way to road vehicles, except when the crossing is protected by an activated warning device or by a flag‑person. However, the GEI do not specify that a flag-person must give the right of way to road vehicles. In this occurrence, the right of way was given to the TU rather than to the road vehicle. If instructions are not clear, there might be confusion on the appropriate actions to take. The investigation also determined that the personal protective equipment and the white headlamp that the flag-person was using were not sufficiently compelling to alert the driver of the tractor-trailer to make him aware of the unusual situation at the crossing. Nor did the flag-person have a key to activate the warning system for the crossing. If the equipment necessary for signalling at crossings is not used, procedures cannot be carried out as intended, which increases the risk of accidents.

Following the accident, CN published a safety bulletin on flagging procedures for track units passing through crossings. The bulletin dictates a number of items that flag-persons must have, including a tool to access crossing warning devices. CN also distributed a Safety Flash to all of its Engineering Services personnel. The document describes the facts of the accident and specifies the guidelines to prevent such an accident from recurring.

See the investigation page for more information.

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Richmond Hill, Ontario, 26 October 2017 – The Transportation Safety Board of Canada (TSB) today released its investigation report (R15T0173) into the July 2015 uncontrolled movement of 91 cars which subsequently collided with and caused the derailment of an inbound train in the Canadian National Railway (CN) MacMillan Yard in Toronto, Ontario.

On 29 July 2015, a cut of 91 cars, led by 24 tank cars loaded with petroleum crude oil, separated from a yard locomotive as it was being pulled out of a pullback track. The cut of cars rolled uncontrolled back into the receiving yard, reaching a speed of about 13 mph before it collided with inbound CN freight train 422. The head-end locomotives of train 422 were shoved back about 350 feet, resulting in the derailment of 10 of the train's cars, and one car on an adjacent track. Approximately 585 feet of track was damaged. There was no release of product and there were no injuries.

The investigation found that the cars separated when a worn component in the first car's coupler assembly only partially engaged the coupler knuckle connected to the locomotive. When it reached peak load near the top of the pullback track, the partially engaged component yielded, releasing the 91 cars. It is likely that the conductor of the remotely operated yard locomotive had not confirmed that the coupler knuckle was fully engaged before moving the cut of cars out of the receiving yard. Furthermore, the receiving yard was not equipped with any means to slow the cars, and the authorization that allowed train 422 to follow behind the assignment into the receiving yard put it in a vulnerable position once the cut of cars separated and rolled uncontrolled back into the receiving yard.

Following the occurrence, CN issued guidance to its employees on how to ensure that couplers are properly locked. Transport Canada conducted a follow-up regulatory inspection at CN's MacMillan Yard to verify compliance against data for all hard coupling events. It is also developing a tank car monitoring project with the National Research Council of Canada, which should provide a better understanding of the operating environment that tank cars and their commodities experience while in transit.

See the investigation page for more information.

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Québec, Quebec, 25 October 2017 – In its investigation report (A16A0084) released today, the Transportation Safety Board of Canada (TSB) found that low altitude and the speed at which a private helicopter was flown caused it to crash into the Restigouche River after colliding with transmission cables in September 2016 near Flatlands, New Brunswick.

On the afternoon of 4 September 2016, a privately operated Bell 206B helicopter departed Charlo Airport, New Brunswick, for Rivière-du-Loup Airport, Quebec, with a pilot and two passengers on board. While flying along the Restigouche River, the helicopter collided with and severed power transmission cables that spanned the river at a height of 58 feet above the water. The aircraft was catastrophically damaged and subsequently fell into the river. The pilot and front-seat passenger were fatally injured. The rear-seat passenger survived the accident and bystanders helped him to shore.

The investigation concluded that the low altitude and the speed at which the helicopter was flown made the unmarked transmission cables difficult to see and avoid. It is likely that the pilot was unaware of the power transmission lines spanning the river, and that he did not see them before the helicopter struck them. Intentional low-altitude flying is risky, particularly without pre-flight planning and reconnaissance, and may result in a collision with wires or other obstacles, increasing the risk of injury or death. After the accident, Transport Canada determined that the power transmission lines spanning Restigouche River at Flatlands–Long Island did not require lighting or marking.

In addition, there were physiological factors that had the potential to degrade the pilot's decision making and performance, although their specific effects on the pilot could not be determined. The investigation found that the pilot had limited opportunities to sleep prior to the flight and was likely experiencing acute fatigue at the time of the accident. If pilots do not take advantage of opportunities to sleep between duty periods, there is an increased risk of degraded performance due to fatigue. A post-mortem toxicological exam performed on the pilot also revealed the presence of cannabinoids in his system. Conclusions regarding impairment, or the time at which the cannabinoids were used, could not be made. Flight crew members who use cannabinoids risk impaired performance and decision making, jeopardizing the safety of the flight.

The helicopter was equipped with an emergency locator transmitter (ELT). However, the search-and-rescue satellite system did not receive a signal from the helicopter's ELT. The investigation determined that the ELT activated but that its antenna broke off and the ELT sank into the river, which made its detection impossible. The Board issued four recommendations in 2016 (recommendations A16-02, A16-03, A16-04 and A16-05) to address deficiencies in ELT design standards that  may delay search-and-rescue operations after an accident. International collaboration is now underway to improve ELT specifications.

See the investigation page for more information.

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Québec, Quebec, 24 October 2017 – Tomorrow, the Transportation Safety Board of Canada (TSB) will release its investigation report (A16A0084) on the September 2016 fatal helicopter accident near Flatlands, New Brunswick.

Publication of report: October 25, 2017 at 10:00 am Eastern Time

Spokesperson: Mr. Jean-Marc Ledoux, Regional Manager, Air Investigations, will be available for interviews on October 25, 2017 from 10 am to 3 pm.

To book an interview with our spokesperson, please contact:
Transportation Safety Board of Canada
Media Relations
819-994-8053
This email address is being protected from spambots. You need JavaScript enabled to view it.


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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Edmonton, Alberta, 16 October 2017 – In its investigation report (A16W0126) released today, the Transportation Safety Board of Canada (TSB) indicates that the absence of a company policy on landing with a specified minimum quantity of fuel was a key factor in a survey helicopter’s loss of power and collision with trees near Whitecourt, Alberta, in 2016.

On 5 September 2016, a Ridge Rotors Bell 206B Jet Ranger helicopter was operating a daylight flight to survey mountain pine beetle with the pilot and two surveyors on board. While flying 160 feet above ground, the helicopter suddenly lost engine power and, within seconds, descended and collided with trees. The surveyor sitting in the front was fatally injured when trees penetrated the cockpit, while the other surveyor seated in the back sustained minor injuries. The pilot received serious injuries. The helicopter was substantially damaged.

The investigation established that, during a short rest break on a sand bar prior to the accident, the pilot decided to continue with the flight instead of refueling at a nearby fuel cache. The remaining fuel was close to the minimum recommended quantities to ensure appropriate safety margins against temporarily uncovering boost pump inlets, exposing them to air. Ridge Rotors' practice of regularly operating helicopters with low fuel levels likely influenced the pilot's decision to continue the flight.

Moments before the accident, the helicopter entered a left turn, and the resulting acceleration forces likely resulted in air entering the fuel pumps, interrupting fuel flow to the combustion chamber, which led to the engine power loss. The company used automatic ignition systems only in snow conditions. Consequently, the system had not been turned on in the occurrence aircraft. The investigation concluded that low altitude survey work in combination with low fuel levels and the inactive automatic ignition system contributed to the inability to recover from the engine power loss.

It is important for operators to understand the limitations of the Bell 206B helicopter fuel system and the risks associated with flights conducted with less than 20 US gallons of fuel. If operators do not observe the minimum fuel quantities recommended in the flight manual, there is a risk that the helicopter will be operated at fuel levels conducive to engine power loss.

As this occurrence demonstrates, some operators are not managing safety risks effectively. This operator and many others are not required to have a formal safety management system (SMS) in place. The TSB has repeatedly emphasized the advantages of an SMS, recommending that Transport Canada require all commercial aviation operators in Canada to implement a formal SMS (A16-12). To date, the Board has been unable to assess Transport Canada's response to this recommendation because Transport Canada has not specified the actions that will be taken to implement a formal SMS. Safety management and oversight is on the TSB Watchlist.

Transport Canada conducted a process inspection of Ridge Rotors after the accident, and the company subsequently implemented corrective action plans to address TC's minor findings of non-compliance. The company has also incorporated changes in its standard operating procedures and trained pilots accordingly.

See the investigation page for more information.

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Gatineau, Quebec, 12 October 2017 – In its investigation report (M16C0036) released today, the Transportation Safety Board of Canada (TSB) found that the capsizing and sinking of the Ocean Uannaq tug off Montreal, Quebec in 2016 was due to a lack of formalized operating procedures and inadequate assessment of the safety risks associated with complex marine operations.

On 1 April 2016, three tugs, including the Ocean Uannaq, were involved in repositioning an excavation barge on the St. Lawrence River as part of the new Champlain Bridge construction project. The Ocean Uannaq and another tug were assisting the Ocean Catatug 1, which was attached to the barge. In preparation for the move, the barge's upstream spuds, used for mooring, were raised before the downstream spuds. When one of the downstream spuds jammed as it was being raised, the barge and attached tug pivoted with the strong current around the jammed spud. The Catatug 1's port wire made contact with the Ocean Uannaq, which combined with the opposing current, created a hydrodynamic effect that led to the rapid capsizing of the tug. The two crew members managed to board the attached tug, and the Ocean Uannaq later sank at 1850. There were no injuries or pollution.

The investigation found that neither the tug's owner nor the operator had assessed the risks of the complex marine operations. Therefore, no operating procedures had been developed to guide masters in the best practices for directing operations, and masters were left to make ad hoc decisions. Safety management and oversight is a TSB Watchlist issue. The need for effective safety management has been demonstrated in a number of other occurrences.

Following the occurrence, the operator invited those involved in the occurrence, along with other key individuals from the construction site, the tug and barge owners, to conduct an internal accident investigation. Following that investigation, the existing shore side procedures were extended to the marine construction operations and the operator implemented procedures to help workers identify and mitigate risks on the work site. The operator also hired an assistant marine superintendent to specifically oversee the marine safety aspects of its operations.

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Winnipeg, Manitoba, 28 September 2017 – In its investigation report (A15C0163) released today, the Transportation Safety Board of Canada (TSB) found that ice accumulation and the company practice to operate in icing conditions led to the December 2015 crash of a cargo plane near Pickle Lake, Ontario.

At 0900 on 11 December 2015, a Cessna 208B Caravan, operating as Wasaya Airways Limited flight 127, left Pickle Lake Airport, Ontario, for Angling Lake / Wapekeka Airport, Ontario, with the pilot and a load of cargo on board. Less than 10 minutes into the flight, the aircraft began descending, made a sharp right turn, climbed again before starting another descent, then collided with trees and terrain at at an elevation of 1460 feet above sea level. The pilot was fatally injured, and the aircraft was destroyed. No signal was received from the emergency locator transmitter (ELT), which was damaged during the crash, and there were no flight recording devices aboard.

The investigation established that the aircraft performance was consistent with operation in icing conditions that exceeded the capabilities of the aircraft. The high takeoff weight also exacerbated the problem. As the aircraft continued its flight in icing conditions, rather than returning to base, it experienced substantially degraded aircraft performance as a result of ice accumulation, which led to an aerodynamic stall, loss of control, and collision with terrain.

The investigation also determined that company practices did not ensure that operational risks were assessed and managed appropriately. Flying into forecast icing conditions was a company norm although four of the five Cessna 208B aircraft were prohibited from operating in these conditions. At the time of the accident, the operator had not implemented all of the mitigation strategies from its January 2015 risk assessment of Cessna 208B operations in known or forecast icing, and remained exposed to some unmitigated hazards that had been identified in the risk assessment. Consequently, pilots lacked important information and tools for sound decision-making and for safe, efficient operations.

The presence of flight recording devices can help identify safety deficiencies, which is why the Board previously recommended (Recommendation A13-01) that Transport Canada work with industry to remove obstacles to the implementation of flight data monitoring and the installation of lightweight flight recording systems by commercial operators not currently required to carry them. The Board also issued four other recommendations in 2016 (Recommendations A16-02, A16-03, A16-04 and A16-05) to address deficiencies in ELT design standards which may delay search and rescue operations after an accident. International collaboration is now underway to improve ELT specifications.

Following the accident, Wasaya conducted two safety management system investigations. As a result, the company increased minimum weather requirements for visual flight rules flights and improved operational flight plan procedures. It also increased the time allocated for technical training on the Cessna, tested a reporting system for icing encounters, and revised the maintenance schedule for the application of anti-icing treatments.

See the investigation page for more information.

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