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Dartmouth, Nova Scotia, 14 September 2017 – In its investigation report (M16A0141) published today, the Transportation Safety Board of Canada (TSB) identified that misinterpretation of radar information, a lack of situational awareness, and resulting decisions made in conditions of poor visibility led to the June 2016 close-quarters crossing in Halifax Harbour, Nova Scotia.

On the morning of 29 June 2016, the passenger vessel Summer Bay departed Halifax Harbour under thick fog conditions with 39 people on board. While the Summer Bay was outbound, the cruise ship Grandeur of the Seas with about 2770 people on board was making its way into the harbour. The pilot of the Grandeur of the Seas contacted the master of the Summer Bay in order to make passage arrangements. The master informed the pilot that the Summer Bay would keep well clear by staying to the west of the cruise ship. Shortly after making this arrangement and continuing as agreed, the Summer Bay suddenly altered course and crossed the bow of the cruise ship at a distance of about 25 metres.

The investigation determined that, after making the passage arrangements, the master of the Summer Bay, with limited experience operating under conditions of poor visibility in Halifax Harbour, misinterpreted radar information. The master also had an inaccurate mental model of the situation, which included the erroneous belief that there was a shoal on his starboard side. Based on the misinterpreted radar data and his limited knowledge of Halifax Harbour, the master decided to make a last-minute course alteration with insufficient information to determine whether it could be done safely. This decision placed the Summer Bay in a close-quarters situation with the Grandeur of the Seas. If vessel operators do not have standard operating policies, practices, and procedures in place, there is a risk that vessels will not operate safely. Although not required by regulation, the Summer Bay did have a safety management system (SMS) in place but it had not been audited by an outside entity. Further, the SMS on board the Summer Bay provided no guidance for navigation in restricted visibility or guidance on operating in Halifax Harbour when vessel traffic is present.

Safety management and oversight is a Watchlist 2016 issue. An operator's SMS must be thorough in accounting for all operating conditions that pose a risk to operators, such as operating in low visibility conditions, as in this occurrence. It is also important for an SMS to be audited by an external party.

Since this occurrence, the operator of the Summer Bay has developed standard operating procedures for its vessel masters operating in reduced visibility conditions and commissioned an external audit of its safety management system.

Published in Transportation Safety Board of Canada
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Richmond, British Columbia, 12 September 2017 – In its investigation report (M16P0241) released today, the Transportation Safety Board of Canada (TSB) found that an inadequate fuel hose connection for the generator caused the July 2016 fuel leak and fire on board the tug Ken Mackenzie in British Columbia.

On 11 July 2016, at approximately 2230 Pacific Daylight Time, the tug Ken Mackenzie, with two people aboard, reported a fire in the engine room while towing logs on the Fraser River, British Columbia. The two crew members abandoned the vessel by jumping on the log tow and were picked up by the assist tug Harken No. 5. The fire was extinguished with the assistance of vessels in the vicinity. There were no injuries.

The investigation determined that around 1900, during a scheduled crew change, the day shift crew informed the relieving crew that they had detected a smell of diesel fuel in the engine room. However, despite conducting safety rounds in the engine room, both crews were unable to find the source of fuel leakage, and so the vessel continued its voyage on the Fraser River.

Post-occurrence examination found that a connection between a copper tube and a flexible fuel hose for the generator was held together with a single hose clamp, and that the copper tube did not have serrations or a bead that would have helped keep the flexible hose connected. When this connection separated, diesel fuel sprayed onto components of the vessel's generator and ignited, causing the fire. Furthermore, the cables used for the fuel tanks' emergency shut-off valves, which were not designed to withstand elevated temperatures prevalent during a fire, seized in the conduit, thus making it impossible for the crew to shut off the fuel system.

If components for emergency equipment and machinery are installed or replaced by personnel without adequate guidance or knowledge of industry standards and are not inspected by a competent person before being put into service, there is a risk that the installation will be unsafe. Unsafe equipment and operating conditions may continue to occur if adequate regulatory oversight is not conducted for tugs less than 15 gross tons, putting people, property and the environment at risk.

Following the occurrence, the TSB issued a Marine Safety Advisory Letter to Transport Canada and a Marine Safety Information Letter to the vessel owners to provide information about the shortcomings concerning the control cables that were used on the vessel to operate emergency shut-offs for the fuel tanks.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
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Richmond Hill, Ontario, 11 September 2017 – In the release of its investigation report (A16O0066) today into a May 2016 in-flight avionics compartment fire, the Transportation Safety Board of Canada found that a fluid contaminant caused the fire that disabled electrical power distribution to several systems of the aircraft.

On 25 May 2016, an Air Canada Embraer ERJ 190-100 was operating as flight ACA361 from Boston/General Edward Lawrence Logan International Airport, Massachusetts, to Toronto/Lester B. Pearson International Airport, Ontario. While en route, warning lights illuminated and associated alarms sounded, alerting the crew that the aircraft was in an electrical emergency condition, and that the main sources of electrical power were offline. The flight crew followed the electrical emergency checklist and after a period of ten minutes, most electrical systems were restored. With main power restored, the aircraft continued to destination and landed uneventfully. No emergency was declared, and no injuries were reported. Air Canada maintenance personnel inspected the aircraft following arrival and noticed extensive fire and smoke damage to the right integrated control center.

The investigation determined that a fluid contaminant had come into contact with the integrated control center and caused arcing, which led to the fire. The fire eventually disabled the main electrical system. As a result of the electrical failure, the smoke detector in the recirculation bay remained unpowered during the period of time when smoke was likely detectable. Due to the lack of smoke or fire warning, the flight crew was unaware of the severity of the situation when it elected to continue to destination. If flight crews are not fully aware of the severity of an emergency situation and exercise their discretion not to land at the nearest suitable airport, then there is an increased risk that a flight may be continued to destination when safer options exist.

Following this occurrence, the manufacturer has proposed changes to its electrical emergency procedure and checklist.

See the investigation page for more information.

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Montréal, Quebec, 7 September 2017 – Following its investigation (A15Q0120) into the fatal floatplane crash that occurred in August 2015 near Tadoussac, Quebec, the Transportation Safety Board of Canada (TSB) is recommending today that Transport Canada require all commercially operated de Havilland DHC-2 (Beaver) aircraft be equipped with a stall warning system.

On the morning of 23 August 2015, a Beaver floatplane, carrying a pilot and five passengers, took off from the waters of Lac Long, near Tadoussac, Quebec, to conduct a sightseeing flight. At the end of the flight, the pilot made a low-altitude turn, likely to give the passengers a better view of some wildlife. The aircraft stalled in a steep turn, descended vertically and struck the ground. The aircraft was destroyed, and the six occupants were fatally injured.

The investigation determined that while the pilot was making a low-altitude turn, an aerodynamic stall occurred, causing the aircraft to enter a spin. An aerodynamic stall occurs when the wings of an aircraft fail to generate enough lift, and—if one wing stalls before the other—a spin ensues. In a spin, the aircraft is rotating and descending vertically. A spin in itself does not necessarily result in an accident, if it happens at sufficient altitude for the pilot to be able to regain control of the aircraft. In this case, although the pilot managed to stop the spin, there was insufficient altitude to prevent the aircraft from hitting the ground.

"In this accident, the aircraft had no stall warning system. Despite the pilot's considerable experience, and even though he was an instructor on this aircraft type, he did not perceive that a stall was imminent when he made the turn," said Kathy Fox, Chair of the TSB. "That is why today the TSB is issuing a recommendation intended to prevent accidents like this one from happening again. We are calling on Transport Canada to require that all commercially operated Beavers be equipped with a stall warning system to alert pilots before their aircraft stalls." There are currently 382 DHC-2s registered in Canada, 223 of which are used in commercial operations. "A stall warning system on board all commercially operated de Havilland DHC-2 aircraft will give pilots and passengers a last defence against this type of loss of control," emphasized Chair Fox.

The investigation also found that the pilot had been regularly performing low-altitude manoeuvres during his sightseeing flights. However, such manoeuvres are not necessary for this type of flight. Given that the aircraft was not equipped with a flight data recorder, the company was not aware of these practices. In 2013, the Board recommended that Transport Canada facilitate the installation of lightweight flight data recorders to help companies monitor how their aircraft are being flown. In addition, following an accident, access to this data would give investigators a better understanding of what happened.

Following the occurrence, the operator, Air Saguenay, has increased oversight of its sightseeing flights and made adjustments to its training.

See the investigation page for more information.

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Montréal, Quebec, 5 September 2017 – The Transportation Safety Board of Canada (TSB) will hold a news conference on 7 September 2017 to make public its investigation report (A15Q0120) into the 23 August 2015 loss of control and collision with terrain of a de Havilland DHC-2 aircraft near Tadoussac, Quebec.

When:
7 September 2017
11:00 a.m. Eastern Time
Who:
Kathy Fox, Chair of the TSB
Pierre Gavillet, Investigator-in-charge
Where:
Hôtels Gouverneur Montréal
Chicoutimi Room
1415 Saint-Hubert Street
Montréal, Quebec

The event will be broadcast live on our YouTube channel.

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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Gatineau, Quebec, 30 August 2017 – The Transportation Safety Board of Canada (TSB) today released its report (R16H0024) into the March 2016 collision between a Canadian Pacific Railway (CP) train and a CP hi-rail vehicle near Nemegos, about 25 km east of Chapleau, Ontario. There were no injuries and no derailment.

On 6 March 2016, a CP foreman and a machine operator were performing snow-clearing duties in a siding near Nemegos, Ontario. After completing their duties at approximately 1520 local time, the two maintenance-of-way employees boarded a hi-rail vehicle and entered the main track to proceed westward, intending to exit the track at a nearby crossing. About 21 minutes later, a CP train travelling eastward saw the vehicle and made an emergency brake application. When they saw the oncoming train, the two maintenance-of-way employees stopped and quickly got out of the hi-rail vehicle. Soon after, the train struck the vehicle at 35 mph. The vehicle was destroyed and the locomotive sustained minor damage.

The investigation determined that the crew was operating the hi-rail vehicle without having obtained a track occupancy permit (TOP) to protect it from trains. Further administrative defences were nullified when the crew did not follow other procedures designed to identify errors and enhance situational awareness. Consequently, the hi-rail vehicle was operated undetected for about 8 miles. The foreman was likely fatigued when the crew boarded the vehicle and left the siding. It was also found that the hi-rail vehicle in this occurrence was not equipped to be detectable by rail traffic control when it was on the track. If physical safety defences to warn or to intervene when a vehicle has exceeded its TOP limits are not implemented, unsafe situations can remain undetected, increasing the risk of collisions between trains and track vehicles.

As part of CP's safety management system, safety data are collected and analyzed to identify emerging trends. There was no indication that CP had specifically identified the upward trend in track vehicles being operated outside their limits of authority. There is an increased risk of accidents if railways do not regularly review safety data to identify trends, emerging trends or recurring situations. Safety management and oversight is a TSB Watchlist issue.

Following the occurrence, CP responded to a Transport Canada letter of non-compliance, indicating that a safety bulletin reviewing the occurrence and applicable rules was issued to all CP engineering employees. Over 2,500 employees were tested on track protection procedures. CP is also exploring methods for electronically requesting TOPs.

See the investigation page for more information.

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Richmond, British Columbia, 28 August 2017 – According to the Transportation Safety Board of Canada's (TSB) investigation report (A16P0069) published today, loss of tail-rotor effectiveness (LTE) at low altitude led to the May 2016 helicopter crash near Prince George, British Columbia.

On 04 May 2016, a Highland Helicopters Bell 206B Jet Ranger-III was conducting infrared scanning over a logged area about 112 nautical miles northwest of Prince George, British Columbia, with three people on board. Approximately 7 minutes after starting scanning operations, the helicopter spun uncommanded to the right several times and hit the ground. The helicopter was destroyed on impact, and all the occupants were seriously injured. There was no post-impact fire.

The investigation determined that the combination of high gross weight and high power setting while the pilot was manoeuvring at low speed, downwind, and out of ground effect (an altitude greater than half of the helicopter's rotor diameter) put the helicopter in a flight condition that resulted in LTE. Loss of tail-rotor effectiveness is an uncommanded yaw rate that does not subside of its own accord, which if not corrected can result in the loss of control of the helicopter. It occurs when the tail rotor is not capable of providing adequate thrust to maintain directional control. It was found that in this occurrence, the LTE occurred at a height above ground that did not give the pilot enough time to recover before the helicopter struck the ground.

See the investigation page for more information.

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Montréal, Quebec, 21 August 2017 – The Transportation Safety Board of Canada (TSB) will hold a news conference in Montréal, Quebec, on 7 September 2017 to release its investigation report (A15Q0120) into the fatal loss of control and collision with ground of a De Havilland DHC-2 aircraft that occurred on 23 August 2015 near Tadoussac, Quebec.

The venue will be announced on 5 September 2017, as well as details about the 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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Richmond, British Columbia, 17 August 2017 – The Transportation Safety Board of Canada (TSB) today released its investigation report (M16P0162) into the May 2016 collision between the tugs Albern and C.T. Titan in the Northumberland Channel near Nanaimo, British Columbia. The collision led to the sinking of the Albern and damage to the hull of the C.T. Titan. There were no injuries; minor pollution was reported.

On 24 May 2016, at approximately 1730 Pacific Daylight Time, the Albern, with two people on board, and the C.T. Titan, with a crew of three, departed a log yard, bound for Nanaimo Harbour for a crew change. The C.T. Titan was on a parallel course with the Albern and overtaking it.

The investigation determined that, while the vessel was overtaking the Albern at full speed, the master of the C.T. Titan left the flying bridge to navigate from the wheelhouse, leaving the navigational controls unattended for 6 to 8 seconds. During this time, the C.T. Titan veered to port, likely due to its misaligned rudders, and the master could not transfer propulsion control to the wheelhouse quickly enough to avoid the collision. The force of the impact pushed the Albern over, causing it to capsize and then sink. Both crew members of the Albern were trapped underwater as the vessel capsized, but managed to escape before it sank. They were rescued by the crew of the C.T. Titan.

The investigation also found risks related to unsafe work practices, the lack of company safety management processes, and insufficient regulatory inspections. If unsafe work practices, such as the procedure for unattended transfer of control aboard the C.T. Titan, are performed repeatedly without adverse consequences, there is a risk that operators will have a reduced perception of the hazards involved with unsafe work practices and will continue to perform them. The TSB also noted that if companies do not have a process for managing vessel safety, including the development of safe operating procedures, there is a risk that deficiencies in vessel equipment and practices may go unidentified or unaddressed.

Following the occurrence, the company, which owned both vessels, had a safety management system gap analysis performed and an action plan prepared based on the International Safety Management Code. As a result, company staff attended situational awareness and bridge resource management training. The company also corrected safety deficiencies related to life raft securement.

See the investigation page for more information.

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Dartmouth, Nova Scotia, 9 August 2017 – Today, the Transportation Safety Board of Canada (TSB) issued its investigation report (M16A0115) into the April 2016 crane failure and fatality aboard a small aquaculture vessel near Milligan's Wharf, Prince Edward Island.

On 29 April 2016, at approximately 1035 Atlantic Daylight Time, a small aquaculture vessel, with the operator and the deckhand on board, was performing spring maintenance of oyster growing cages one nautical mile east of Milligan's Wharf, Prince Edward Island. The operator was working over the side of the vessel, underneath the elevated boom of the crane, to untangle a securing line attached to a floating oyster cage. The crane failed when the piston rod fractured, and the boom and attached rigging struck and fatally injured the operator.

The investigation determined that the design of the crane was flawed, not allowing for full extension of the piston rod when the crane boom was fully raised. The piston rod was therefore making contact with the hose guards when extending, subjecting it to side loading and forcing it to bend. After bending on several occasions, the material was no longer able to sustain the bending stress, and the rod fractured.

The investigation determined that the crew and the company owners had not detected the design flaw within the few weeks that the crane was in service, nor was the crew conducting a thorough visual inspection of the crane before each voyage. If there are no standards for the design and construction of lifting appliances on small fishing vessels, there is an increased risk that unsafe lifting appliances will be constructed and installed. Also, if lifting appliances installed on fishing vessels are not inspected by either Transport Canada or an authorized representative, defects in those appliances that pose a hazard may go undetected.

The investigation also found that there were no lifejackets carried on board the vessel as required by regulation. If fishermen do not wear personal flotation devices (PFDs) or lifejackets while working on deck, despite industry awareness initiatives promoting their use, there is an increased risk that fishermen will not survive in the event that they fall overboard. Although the absence of PFDs did not play a direct role in this occurrence, this persistent risk has been identified in other TSB investigations. Consequently, the Board has recommended that Transport Canada, British Columbia, and New Brunswick require crews on fishing vessels to wear suitable PFDs at all times on deck and that they develop ways to confirm compliance (Recommendations M16-04, M16-05 and M17-04).

A number of risks related to onboard risk management, highlighted in the investigation, are also identified in a TSB safety issues investigation (SII) into fishing safety that was published in 2012.

Commercial fishing safety is a TSB Watchlist issue as it is recognized nationwide that the loss of life on fishing vessels is simply too great.

See the investigation page for more information.

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