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Dartmouth, Nova Scotia, 29 January 2015 – In its report (M13M0287) released today, the Transportation Safety Board of Canada (TSB) found that maintenance deficiencies and lack of adequate emergency procedures led to the 7 November 2013 loss of electrical power and grounding of the passenger ferry Princess of Acadia in Digby, Nova Scotia. There were no injuries or pollution reported.

The Princess of Acadia was approaching the ferry terminal at Digby, Nova Scotia, with 87 passengers and crew aboard. In preparation for docking, as the bow thruster was started, the main generator blacked out causing a loss of electrical power and disabling the main propeller pitch control pumps. Once the pitch control pumps stopped, the propeller thrust defaulted toward full astern while the engines were still running, causing the vessel to slow down, stop and travel backwards towards the nearby shoreline until running aground.

The investigation found that a deteriorated generator component caused the failure of two main generators and the blackout of the main electrical switchboards, among other system failures. The investigation also identified that neither the bridge nor the engine room had effective procedures in place to respond to the blackout of the main switchboard. Because of this, the master was not informed that engine room personnel were having difficulty restoring power, and the engine room was not aware of the urgency of the situation. This impeded an effective response to the emergency. The vessel had voluntarily implemented a safety management system (SMS), but it did not provide the master with guidance to proactively identify risks or investigate hazardous occurrences.

There were also deficiencies with passenger-related duties in written evacuation procedures and with Transport Canada’s oversight to ensure compliance with regulations regarding passenger safety emergency procedures. As such, there is a risk that these procedures will not achieve their intended purpose. Previous marine investigations (M12C0058 and M13L0067) have found deficiencies in the oversight of passenger safety regulations.

Following the occurrence, Bay Ferries Ltd., the vessel operator, instituted improved operating procedures for when the vessel prepares to arrive at Digby. They have also installed a simplified voyage data recorder, which records bridge audio and information navigation equipment and other available sensors. Llloyd’s Register, the vessel classification society, has increased the frequency for generator breaker testing.

Safety management and oversight is a TSB Watchlist issue. The TSB is calling on Transport Canada to implement regulations requiring all operators in the air and marine industries to have formal safety management processes and for effective oversight of these processes. When companies are unable to effectively manage safety, the regulator must not only intervene, but do so in a manner that succeeds in changing unsafe operating practices.

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Gatineau, Quebec, 28 January 2015 – While recognizing significant positive action taken by the regulator, the Transportation Safety Board of Canada (TSB) remains concerned about Transport Canada’s (TC) response to outstanding recommendations stemming from its investigation into the Montreal, Maine & Atlantic Railway (MMA) train that derailed on 6 July 2013 in Lac-Mégantic, Quebec.

“Transport Canada continues to take important steps to address the rail safety deficiencies we identified in our Lac-Mégantic investigation,” said Kathy Fox, Chair of the TSB. “With respect to preventing runaway trains, TC has introduced multiple layers of defences that, if fully implemented, will significantly reduce risks. But with respect to TC auditing and oversight activities, we are concerned that the department has not yet put in place an effective oversight regime that guarantees all railways will be audited in sufficient breadth and frequency to ensure safety issues are addressed in a timely manner.”

Prevention of runaway trains: Unattended equipment (R14-04)

The investigation determined that more robust defences are required to prevent runaways. Even if they have a low probability of occurrence, these events can have extreme consequences, particularly if they involve dangerous goods—as was seen in Lac-Mégantic. For this reason, the Board recommended that TC require Canadian railways to implement additional physical defences to prevent runaway equipment.

In October 2014, TC issued an Emergency Directive (which expires 29 April 2015) that addresses many of the weaknesses in the Canadian Rail Operating Rules pertaining to the securement of equipment. Along with a standardized hand brake chart and explicit instructions for hand brake effectiveness testing, additional physical securement measures must be used. TC also said it will hire additional specialized staff to strengthen oversight related to train securement and to monitor compliance with these additional levels of defence to prevent runaways. If the proposed measures are fully implemented on a permanent basis, the risk of runaway equipment will be significantly reduced; therefore, the Board assesses the response as having Satisfactory Intent.

Safety management systems audits and essential follow-up (R14-05)

Until Canada's railways make the cultural shift to safety management systems (SMS), and TC makes sure they have effectively implemented SMS, the safety benefits will not be fully realized. For this reason, the Board recommended that TC audit the SMS of railways in sufficient depth and frequency to confirm that the required processes are effective, and that corrective actions are implemented to improve safety.

TC has committed to bringing into force additional regulations and enforcement capabilities, hiring more auditors and strengthening its training programs. While significant progress has been made, TC has not yet demonstrated that it has implemented an effective oversight regime to ensure all railways will be adequately audited. Furthermore, TC has not committed to auditing every SMS component within a given time period. As a result, deficiencies within a railway's SMS may not be identified and addressed in a timely manner; therefore, the Board assesses the response as being Satisfactory in Part.

This issue has been identified as one of the key risks to the transportation system and it is included on the TSB's 2014 Watchlist.

“The Minister of Transport and the department have taken strong action to improve rail safety in the wake of the Lac-Mégantic tragedy, but more work needs to be done,” added Ms Fox. “We will continue to monitor the department and rail industry's progress in implementing new regulations and procedures introduced by TC. Canadians deserve no less than the safest transportation system.”

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Gatineau, Quebec, 21 January 2015 – The Transportation Safety Board of Canada today released its investigation report (R13D0077) into the derailment of a Canadian National Railway (CN) freight train in Taschereau Yard, Montréal, Quebec.

On 6 November 2013, at approximately 05:05 Eastern Standard Time, a CN freight train derailed 10 empty cars while travelling through a tight curve at Taschereau Yard in Montréal, Quebec. The derailed cars and the track were damaged. There were no injuries.

The investigation determined that, as the train began to accelerate from a stop, the empty cars occupying the curve were pulled over the lower (inside) rail and derailed. The first car to derail, the 29th car, was an empty, long car equipped with end-of-car cushioning devices. These cars are susceptible to high lateral/vertical (L/V) forces, especially in curves. With a block of empty cars marshalled ahead of a block of loaded cars, the empty cars experienced a significantly higher L/V force than the loaded cars.

In the weeks following the derailment, CN issued instructions aimed at minimizing in-train forces in the curve of track CX01. Yard and train personnel must ensure that the train brakes are fully released before initiating a movement and must limit the force applied to the train by the locomotive consist.

CN will continue to ensure compliance with these instructions by reviewing locomotive event recorder downloads.

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TDG Regulations TDG home pageTable of ContentsPDF versionThe TDG Regulations have been consolidated to include SOR/2014-159 (Part 4, Dangerous Goods Safety Marks) and SOR/2014-152 (Update of Standards). Disclaimer: These documents are
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Calgary, Alberta, 14 January 2015 – In its investigation report (R13C0087) released today, the Transportation Safety Board of Canada (TSB) determined that a Canadian Pacific train derailed when a wheel flange struck and climbed a switch point and then fell between the switch point and the rail.

On 11 September 2013, the freight train departed from Alyth Yard in Calgary enroute to Red Deer, Alberta. As the train crossed over the switch, it derailed seven tank cars loaded with natural gasoline condensate (a product commonly used to dilute bitumen so that it can flow through a pipeline). During the derailment, approximately 600 feet of track was destroyed and a natural gas line supplying a switch heater was severed, prompting an evacuation in the vicinity. There were no injuries or product loss from the tank cars.

The investigation determined that wheel flanges striking the switch point had caused overstress impacts on the tip of the switch point, creating a ramp for the wheels to climb up and derail the seven cars. Given the track layout, including a combination of curves, the transition from empty to loaded cars entering the crossover likely resulted in the wheels of the loaded cars tracking more towards the standard switch point.

Following the occurrence, Canadian Pacific made improvements to the track infrastructure, including removing the switch points involved in this occurrence, upgrading the rails and installing a new turnout.

The transportation of flammable liquids by rail is a Watchlist issue. The TSB is calling for railway companies to conduct route planning and analysis, and perform risk assessments to ensure that risk-control measures are effective. Additionally, flammable liquids must be shipped in more robust tank cars to reduce the likelihood of a dangerous goods release during accidents.

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Vancouver, British Columbia, 13 January 2015 – The Transportation Safety Board of Canada today released its investigation report (A13P0166) into the crash of an air taxi near Hesquiat Lake, British Columbia. The float plane, with 6 on board, crashed shortly after take-off. Everyone aboard survived the crash; however, the pilot and one passenger died when they were unable to exit the aircraft before it was consumed by flames in a post-crash fire.

At 1015 Pacific Daylight Time, a de Havilland Beaver floatplane, operated by Air Nootka Ltd., left Hesquiat Lake for Air Nootka Ltd.'s water aerodrome base near Gold River, B.C. with a pilot and 5 passengers on board. Visibility at Hesquiat Lake was about 2 ½ nautical miles in rain and the cloud ceiling was about 400 feet above lake and sea level. Approximately 3 nautical miles west of the lake, while over Hesquiat Peninsula, the aircraft struck a tree top at about 800 feet above sea level and crashed. Shortly after the aircraft came to rest, the fire started.

The accident investigation identified flight at low level in poor weather as causal. It also found that Air Nootka did not have effective methods to monitor its pilots' in-flight decision-making and associated practices. As a result, Air Nootka had no way to detect and correct unsafe behaviour or poor decision making. Further, the investigation found that risks still persist in the area of post-crash survivability. The lack of a requirement for shoulder harnesses on all passenger seats, the lack of technology to reduce fuel leakage or to eliminate ignition sources, and the lack of alternate means of escape such as push-out windows, all increase the risk of tragic results in the event of a crash. These issues have all been highlighted in previous TSB accident investigations.

In November of 2014, the TSB announced that it would conduct a Safety Issues Investigation into Canadian air taxi operations to understand the risks that persist in this important sector of the aviation industry. The study will engage industry, the regulator and other stakeholders to gain a full understanding of the issues affecting air taxi operations. The Board may make recommendations to address any identified systemic deficiencies.

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MONTREALandHALIFAX,Jan. 13, 2015/CNW Telbec/ - Air Canada (TSX: AC) and Jazz Aviation LP ('Jazz'), a wholly-owned subsidiary of Chorus Aviation Inc. (TSX:CHR.B CHR.A), have reached agreement on an amended and extended
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MONTREAL, Jan. 12, 2015 /CNW Telbec/ - Michael Rousseau, Executive Vice President and Chief Financial Officer, will present at the AltaCorp Capital / ATB Corporate Financial Services Institutional Investor Conference on
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Winnipeg, Manitoba, 8 January 2015 – The Transportation Safety Board of Canada today released its investigation report (A13C0105) into a float plane accident that occurred in the Northwest Territories (NWT). The pilot, the only person aboard, was fatally injured and the aircraft was destroyed.

On 22 August 2013, at approximately 18:50 Central Standard Time, a float-equipped Transwest Air DHC-3 turbine-powered Otter left Scott Lake, NWT, on a flight to Ivanhoe Lake, NWT. The aircraft did not arrive at the destination and was reported overdue at approximately 21:00. The company notified the Joint Rescue Coordination Centre, and a search and rescue aircraft was dispatched. The wreckage was located on 23 August 2013, in an un-named lake 10 nautical miles north of the last-reported position.

The Board made a number of findings as to causes and contributing factors. Among them were the facts that, during the approach to landing on the previous flight, the right wing was damaged by impact with several trees and that the damage was not evaluated or inspected by qualified personnel prior to the subsequent takeoff. The investigation also revealed that a number of stressors throughout the day disrupted the pilot's processing of safety-critical information, and likely contributed to an unsafe decision to depart and operate a damaged, uninspected aircraft. En route, the damaged aircraft departed controlled flight likely due to interference between parts of the failing wingtip acting under air loads, and the right aileron.

To enhance safety in its operations, Transwest Air Limited held discussions with its pilots concerning pilots' responsibilities to remove themselves from flight duty if they do not feel fit to fly. A Safety Directive was also issued outlining Transwest Air's expectation of compliance with the Canadian Aviation Regulations and action to be taken in the event that an aircraft is damaged.

In November of 2014, the TSB announced that it would conduct a Safety Issues Investigation into Canadian air taxi operations to understand the risks that persist in this important sector of the aviation industry. The study will engage industry, the regulator and other stakeholders to gain a full understanding of the issues affecting air taxi operations. The Board may make recommendations to address any identified systemic deficiencies.

Published in Transportation Safety Board of Canada
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Richmond, British Columbia, 7 January 2015 – In its investigation report (A13P0163) released today, the Transportation Safety Board of Canada (TSB) found that a Kamov Ka-32 helicopter operated by VIH Helicopters Ltd. suffered an engine power loss due to anomalies in engine components that were not detected by quality control during engine manufacture and assembly.

On 4 August 2013, a Kamov Ka-32 helicopter was carrying out forest fire suppression operations near Bella Coola, British Columbia using a water bucket on a long line. Just as the helicopter lifted a load of water out of a lake, there was a series of unusual sounds and the aircraft began to shake severely. The pilot not flying released the water bucket, and the pilot flying flew towards land for an emergency landing. The crew experienced difficulties controlling the aircraft on the way to the intended landing area. The helicopter touched down while drifting sideways to the right, and subsequently bounced and rolled onto its right side. The crew, who suffered minor injuries, shut down the engines and exited the helicopter without difficulties. There was no fire.

The investigation found that compressor turbine components failed due to manufacturing anomalies, causing the engine to lose power. Quality control during the manufacture and assembly of the engine's compressor turbine section did not identify the anomalies in the components, which were visible to the naked eye. If poor quality control is systemic, helicopters with these engines (Klimov TV3-117) are at risk of failure, which can have serious consequences for aircraft, crew, and passengers.

Following the occurrence, the Russian aviation regulator issued a revised airworthiness directive that increased maintenance requirements for engines installed in Kamov Ka-32 helicopters used for external load operations.

Published in Transportation Safety Board of Canada
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