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Richmond Hill, Ontario, 21 September 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A17O0209) on the September 2017 collision of a privately operated Cessna 150J aircraft that occurred with Lake Huron near Goderich, Ontario.

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

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Richmond Hill, Ontario, 11 September 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (R18T0032) on the February 2018 crossing accident in Breslau, Ontario.

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

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Dorval, Quebec, 10 September 2018 – In its investigation report (R17Q0061) released today, the Transportation Safety Board of Canada (TSB) determined that bottling of the air in the brake pipe during switching operations led to the July 2017 uncontrolled movement of rail cars in Mai, located 128 miles north of Sept-Îles, Quebec.

On 25 July 2017, a southbound Quebec North Shore and Labrador Railway (QNS&L) train, consisting of 159 loaded iron ore cars and 2 locomotives, stopped in Mai to add a locomotive and to relieve the locomotive engineer. The two locomotives were uncoupled from the cars to make room for the additional locomotive. A few minutes after the locomotives were uncoupled, the cars began to roll uncontrolled and passed a signal. The relief locomotive engineer, who was working nearby, took action to stop the movement. There were no injuries and no damage.

The investigation found that, while securing the train, the locomotive engineer closed the brake pipe angle cocks (valves at each end of a rail car or a locomotive used to open or close the brake pipe) between the locomotive and the first car before the air had fully exhausted from the brake pipe. With the angle cocks closed, the air became bottled in the brake pipe, leading to an undesired release of the air brakes. When the air brakes on the cars released, the hand brakes that were applied did not keep the cars in place. Consequently, the cars rolled uncontrolled for about 400 feet past a signal before being stopped when the relief locomotive engineer fully opened the angle cock.

The locomotive engineer was not used to following the procedures that consisted of leaving cars with only their service brakes applied during switching operations. He and other company employees often used the emergency brakes, which was contrary to company procedures. If railway companies do not ensure that employees are completely familiar with operating procedures they must follow, some procedures may not be well understood or applied, increasing the risk of accidents.

Following the occurrence, QNS&L clarified its operating procedures regarding brake pipe uncoupling and the minimum number of hand brakes to be applied. Training regarding these changes was also developed and delivered to all QNS&L locomotive engineers.

See the investigation page for more information.

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Edmonton, Alberta, 4 September 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18W0025) on the collision with terrain of an Airbus Helicopters AS 350 B2, operated by Sahtu Helicopters, near Tulita, Northwest Territories.

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

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Dorval, Quebec, 5 September 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A17Q0030) on a collision between two flying school aircraft that occurred over St-Bruno-de-Montarville, Quebec, in March 2017. The investigation determined that both pilots, who were flying solo under visual flight rules in controlled airspace, had deviated from the altitude restrictions provided by air traffic control before colliding in mid-air.

In the early afternoon of 17 March 2017, a Cessna 152 (C-GPNP), operated by a licenced pilot undergoing commercial training at Cargair Ltd., was returning to the Montréal/St-Hubert airport from a training flight in a local training area. At the same time, another Cessna 152 (C-FGOI), operated by a Cargair Ltd. student pilot, was departing the airport for a training flight in a local training area. At 12:38 Eastern Daylight Time, the two aircraft collided at 1500 feet above the Promenades St-Bruno shopping mall, less than two nautical miles from the airport. Substantially damaged, the C-GPNP aircraft subsequently struck the roof of the mall, seriously injuring its pilot. The C-FGOI aircraft, which fell in a parking lot, was destroyed and its student pilot was fatally injured. Both pilots were international students enrolled in flight training whose first language was neither English nor French, although both had their English-language proficiency assessed as operational, meaning they met the minimum international proficiency level acceptable for radiotelephony communication.

The investigation determined that the pilot of C-GPNP inadvertently descended 100 feet below his altitude restriction of 1600 feet while attempting to troubleshoot a radiocommunication issue. Meanwhile, for unknown reasons, the student pilot of C-FGOI  climbed 400 feet above his altitude restriction of 1100 feet, and then collided with the other aircraft from below. Neither pilot saw the other aircraft in time to prevent the collision, partly owing to the limitations of the see-and-avoid principle, which is the basic collision avoidance method under visual flight rules. A pilot’s ability to visually detect another aircraft and avoid collision is affected by many factors, such as: proximity, reaction time, obstructions to field of view, pilot scanning techniques, in-flight monitoring of instruments, and radiocommunications.

The investigation also found that the density and variety of operations conducted at the St-Hubert Airport increase the complexity of air traffic control. The varying levels of flying skills and language proficiency among the student pilots of the four local flying schools add to this complexity. In this regard, the investigation found that Transport Canada’s oversight of aviation language proficiency testing (ALPT) is limited to administrative verifications. Therefore, it is not possible to assess whether and to what extent designated examiners administer the ALPT program in a manner that ensures validity, reliability, and standardization nationally.

After the occurrence, Transport Canada published a Civil Aviation Safety Alert recommending that flight-training units ensure that student pilots have been awarded an operational level of language proficiency in accordance with the language proficiency scale set out in the personnel licensing standards prior to their first solo flight.

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Québec, Quebec, 6 September 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (M17C0292) on the December 2017 incident involving a person who fell overboard from the bulk carrier Federal Champlain at the Thunder Bay terminal, Ontario.

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

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Dorval, Quebec, 14 August 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (R18D0020) on the February 2018 crossing collision in Beaconsfield, Quebec.

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

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Edmonton, Alberta, 9 August 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18W0054) on the engine power loss and forced landing of a Super T Aviation Piper PA-31 Navajo on 36 Street N.E. in Calgary, Alberta on 25 April 2018.

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

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Québec, Quebec, 1 August 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (M17C0205) on the August 2017 loss of power and subsequent grounding of the chemical product carrier Bro Anna in Beauharnois, Quebec.

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

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Winnipeg, Manitoba, 24 July 2018 – In its investigation report (R17W0175) released today, the Transportation Safety Board of Canada (TSB) found that a thermite weld failure resulted in a Canadian Pacific Railway (CP) freight train derailment near Dominion City, Manitoba.

In the afternoon of 11 August 2017, a CP unit freight train was proceeding northward on the Emerson Subdivision when 22 covered hopper cars loaded with corn derailed while exiting a bridge over the Roseau River, near Dominion City, Manitoba. There were no injuries, and no product or rolling stock entered the waterway.

The investigation determined that the train derailed when a thermite weld, which joins two pieces of rail, failed under the train. The thermite weld fracture displayed "finning", which occurred when molten metal leaked from the casting mould and did not fully fuse with the rail. The thermite welding process had been completed in 2008. Also, due to the presence of multiple persistent and recurring geometry defects and track conditions, the rail in the vicinity of the thermite weld had been experiencing higher stresses during normal train operations. With the repeated tensile forces due to normal passing of each wheel of a train, the finning became the origin site of the fracture that led to the brittle failure of the thermite weld.

Although CP had been monitoring the priority surface defects in accordance with the federal Track Safety Rules and its Red Book requirements, the thermite weld failed before the priority defects reached a level that required immediate repair. If track geometry priority defects are not identified, monitored, and mitigated in a timely manner, further track structure degradation can occur, increasing the risk of derailments.

Following the accident, CP completed a rail replacement program on the Emerson Subdivision, installing about 5000 feet of continuous welded rail.

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