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Dartmouth, Nova Scotia, 13 February 2018 - The Transportation Safety Board of Canada (TSB) will hold a news conference on 15 February 2018 to make public its investigation report (R16M0026) into the July 2016 crossing accident at a public railway crossing on Robinson Street in Moncton, New Brunswick.

When:

15 February 2018
10:00 a.m. Atlantic Time

Who:

Faye Ackermans, Member of the Transportation Safety Board
Don Ross, Investigator-in-charge
Ian Perkins, Senior Investigator

Where:

Crown Plaza Moncton Downtown
Kent Room
1005 Main Street, Moncton, New Brunswick

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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Edmonton, Alberta, 5 February 2018 – In its investigation report (A16W0170) released today, the Transportation Safety Board of Canada found that the common practice of clearing aircraft and vehicle movements across an infrequently used runway without prior coordination contributed to a runway incursion at the Calgary International Airport, Alberta, in December 2016. The risk of collisions on runways is on the TSB's Watchlist of issues that must be addressed to make Canada's transportation system even safer.

In the late afternoon of 2 December 2016, the Calgary airport switched operations from using parallel north/south runways to the infrequently used Runway 29 due to strong westerly winds. Consequently, Air Canada flight 221 was cleared for takeoff on Runway 29 by the tower controller. However, during the takeoff roll, the flight crew saw a Sunwest Aviation cargo aircraft crossing Runway 29 on Taxiway A. Because the Sunwest aircraft was more than halfway across Runway 29 at that time, the Air Canada crew elected to continue with the takeoff, which was completed without further incident.

The investigation determined that the runway incursion occurred after the ground controller cleared the Sunwest aircraft to cross Runway 29 while the Air Canada flight was departing. The ground controller, who was simultaneously overseeing the movement of two other aircraft, inadvertently applied the usual practice of clearing aircraft to cross Runway 29 without coordinating with the tower controller. Since the construction of parallel runways in 2014, Runway 29 was mostly used at night – when ground and tower control responsibilities are combined and coordination is not required – and during strong westerly winds during the day. As a result, there was little opportunity to maintain proficiency in Runway 29 operations during the day, and no training to practice those operations, including the need to coordinate before crossing Runway 29. Additionally, the runway jurisdiction system on the controllers' displays, a tool to remind them of which controller is responsible for which runways, did not provide a sufficiently compelling cue to ensure coordination with tower control before clearing an aircraft to cross Runway 29.

There have been four other runway incursions involving Runway 29 at the Calgary airport since parallel runway operations began in 2014. Issues of declining proficiency with Runway 29 operations were identified through NAV CANADA's safety management system (SMS). Although some corrective measures were taken, further safety action that had been identified was not pursued. If proposed safety actions are not tracked to completion, there is an increased likelihood that identified safety risks will not be effectively mitigated. Safety management and oversight is an issue on the TSB Watchlist.

Following this occurrence, NAV CANADA took a number of steps to improve procedures for Runway 29 operations at the Calgary airport. It has created a new "monitor" control position to provide more effective surveillance when using Runway 29. It has also improved the display systems used by controllers as memory aids when coordination is required.

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Richmond, British Columbia, 24 January 2018 – In its investigation report (A16P0180) released today, the Transportation Safety Board of Canada (TSB) found that an out-of-limit weight-and-balance condition and optical illusions associated with low-altitude flight in snow-covered, sloping terrain likely contributed to the aerodynamic stall and loss of control of a de Havilland DHC-2 Beaver aircraft near Laidman Lake, British Columbia. As a result, the pilot was fatally injured, and two passengers sustained serious injuries. The other two passengers sustained minor injuries. There was no post-impact fire, but the aircraft was substantially damaged.

On 10 October 2016, at approximately 0820 Pacific Daylight Time a privately operated de Havilland DHC-2 Beaver aircraft on amphibious floats left Vanderhoof Airport for Laidman Lake, both in British Columbia, for a hunting expedition. At about 12 nautical miles (nm) away from the destination, the pilot turned the aircraft to fly over a mining exploration site located on higher terrain east of the lake. The aircraft continued to fly at a constant altitude over the rising terrain for about four minutes until it was just about 100 feet above the trees. As the aircraft was now too low and too slow to climb further, the pilot banked it steeply to the left toward lower terrain. The aircraft rolled abruptly from side to side, then struck the trees and ground. The emergency locator transmitter (ELT) on-board activated on impact, the signal was detected, and a search and rescue operation was initiated.

The investigation determined that at the time of the occurrence, the aircraft was 682 pounds over its maximum weight, its cargo was not secured, and its centre of gravity exceeded the aft limit by 3.1 inches. This out-of-limit weight-and-balance condition increased the aircraft's stall speed and degraded its climb performance, stability, and slow-flight characteristics. During impact, the forward shifting of the unsecured cargo and the partial detachment of the rear seats resulted in injuries to the passengers.

The investigation also determined that, as the aircraft approached the mountain ridge, the high overcast ceiling and uniform snow-covered vegetation were conducive to optical illusions associated with flight in mountainous terrain. These illusions likely contributed to the pilot misjudging the proximity of the terrain and inadvertently adopting an increasingly nose-up attitude, without detecting the declining airspeed, before banking the aircraft to turn away from the hillside. As the angle of bank increased during the turn, the stall speed also increased and the aircraft entered an accelerated stall. These conditions, coupled with the low altitude, likely prevented the pilot from regaining control of the aircraft before it struck the ground.

The absence of a stall warning system deprived the pilot of the last line of defence against an aerodynamic stall and the subsequent loss of control of the aircraft. In 2017, the Board recommended that all commercially operated DHC-2 aircraft in Canada be equipped with a stall warning system. Although the response to Recommendation A17-01 has not been assessed yet, today's report underscores the benefits of equipping all DHC-2s with a stall warning system to reduce the risk of injuries or death from a stall at low altitude.

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Richmond Hill, Ontario, 23 January 2018 – In its investigation report (A16O0149) released today, the Transportation Safety Board of Canada (TSB) determined that a lack of coordination and planning by air traffic control led to a risk of collision between two de Havilland DHC-8 aircraft near Sudbury, Ontario, in October 2016.

On 14 October 2016, Porter Airlines Flight 533 was on an instrument flight rules (IFR) flight to the Sudbury Airport (CYSB), Ontario. It was to arrive from the south with an estimated time of arrival at 1005 Eastern Daylight Time. Soon after the North Bay controller cleared Flight 533 for a visual approach to Runway 04, Jazz Aviation LP Flight 604 took off under visual flight rules (VFR) on Runway 22, heading south towards its destination. Runway 22 was the active runway at Sudbury and reciprocal to Runway 04. Approximately three minutes later, when both aircraft were 9.5 nautical miles southwest of the Sudbury Airport, the traffic alert and collision avoidance systems (TCAS) in the flight crews' respective aircraft issued a resolution advisory to take specific action to avoid a collision. Both flight crews took evasive action. Radar data indicated that the two aircraft came within 0.4 nautical miles of each other at the same altitude.

The investigation found that the North Bay controllers' practice of clearing incoming IFR aircraft for an approach without regard for the active runway at the Sudbury Airport created a situation wherein IFR traffic was counter to the flow of, and therefore more likely to come into conflict with, VFR traffic operating at the airport. Further, air traffic control approved the VFR departure of Flight 604 without a coordinated plan to prevent conflict between the aircraft and incoming IFR traffic. Flight 604 was not fully aware of the traffic situation at the airport when it taxied to Runway 22, as the Sudbury flight service station's taxi departure advisory did not include information about inbound opposite direction traffic.

The risk of collision occurred after Flight 604 made its left turn to fly away from the airport towards its destination. This turn was not apparent to North Bay air traffic control, as the display was set at a scale that was too large to detect heading changes right after they occur. Unaware of Flight 604's exact position, the controller suggested that it turn right, essentially bringing it back toward the approach path of Runway 04 and in conflict with Flight 533.

Following the TCAS resolution advisory, the flight crew from both Flight 604 and 533 initially maneuvered their respective aircraft contrary to the TCAS commands. As result, the vertical separation between the two aircraft was reduced.

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Richmond, British Columbia, 22 January 2018 – In its investigation report (A16P0078) released today, the Transportation Safety Board of Canada (TSB) determined that the attempt to land in gusty crosswind conditions led to the hard landing of a floatplane in Kitkatla, British Columbia.

On 24 May 2016, a de Havilland DHC-2 Beaver seaplane operated by Inland Air Ltd. was conducting a crosswind landing at Kitkatla Water Aerodrome, British Columbia, with the pilot and six passengers on board. The aircraft landed on its left float with sufficient force to cause the aircraft to bounce back into the air. Its right float then struck the water, causing the float structure to collapse. The aircraft nosed over and came to rest inverted. All seven occupants evacuated the aircraft as it became submerged, and local boaters were able to rescue them immediately. One of the passengers was seriously injured.

The investigation found that the decision to carry out a water landing in gusty crosswind conditions, when lower-risk options were available, placed the aircraft occupants at an increased risk of a landing-related accident. In this occurrence, four of the ten most frequently cited factors contributing to seaplane accidents identified in the TSB's Safety Study of Piloting Skills, Abilities and Knowledge in Seaplane Operations (SSA93001), which pertain to the landing area selection, wind conditions and aircraft control, are applicable.

While Inland Air Ltd. had voluntarily implemented a safety management system (SMS), there were no formal processes for documenting and assessing hazards or risks such as those associated with this occurrence. Approximately 90% of all Canadian aviation certificate holders are currently not required by regulation to have a SMS. The TSB had previously issued a recommendation (A16-12) calling for Transport Canada to require all commercial air operators in Canada to implement a formal SMS. Safety management and oversight is also on the TSB Watchlist.

Numerous factors as to risk related to emergency preparedness and search-and-rescue were also identified in this investigation. Although the passengers received a briefing from the pilot, some critical information, such as the location of available exits, was not included in the briefing. The pilot also did not confirm that the occupants understood their role in the event of an emergency. These factors increased the risk of injury or death during the evacuation from the aircraft.

The passengers were not wearing personal flotation devices (PFDs), nor were they required to by regulation. If pilots and passengers are not required to wear suitable PFDs, as called for in the outstanding TSB Recommendation A11-06, they are at increased risk of drowning once they have escaped the aircraft.

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Calgary, Alberta, 17 January 2018 – In its investigation report (R16C0065) released today, the Transportation Safety Board of Canada (TSB) determined that train control decisions based upon inaccurate assumptions led to the September 2016 collision and derailment involving two Canadian Pacific Railway (CP) trains in Calgary, Alberta.

On 3 September 2016, westbound train 303 collided with the tail end of train 113, which was stopped on a non-main track near Alyth Yard in Calgary. Two locomotives on the head end of train 303 and two of its hopper cars derailed. The last car on train 113 also derailed. There were no injuries and no dangerous goods were released.

The investigation found that the collision occurred when train 303 was unable to stop despite applying emergency brakes when the tail end of train 113 came into view. Train 303 had been instructed to follow train 113 into the non-main track when arriving at Alyth Yard. The locomotive engineer overheard parts of a radio conversation that led him to believe that train 113 was undergoing a passing inspection three miles further west. This belief was reinforced when train 303 was not held at Glenmore, about a mile to the east of where the main track ends before entering Alyth Yard, which was normal practice when a preceding train was delayed.

The investigation also found that train 303 entered the non-main track at 36 mph, too fast for the heavy unit train to stop within half the range of vision, as required. The maximum track speed at this location was 45 mph, instead of the usual 15 mph for non-main tracks. Following a track reconfiguration in 2013, CP had changed the method of train control in the area from centralized traffic control to non-main track, but without reducing the maximum track speed. At the time of this operational change, a risk assessment was not mandatory. However, current regulations would require a risk assessment. If risk assessments are not conducted for changes to railway operations, potential hazards may not be identified and appropriately mitigated, increasing the risk of accidents. Safety management and oversight is on the TSB Watchlist of key issues to be addressed to make Canada's transportation system even more secure.

Following the occurrence, CP reduced track speeds in the occurrence area. By December 2016, it had reinstalled centralized traffic control in the area.

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Winnipeg, Manitoba, 11 January 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation brief (R17W0199) into the derailment of an eastbound Canadian Pacific Railway train carrying potash on 17 September 2017. During the occurrence, 37 cars derailed west of Blucher, Saskatchewan, at around 7:55 am. There were no dangerous goods involved, and no injuries.

See investigation page.

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Montréal, Quebec, 10 January 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A16A0032) into the March 2016 fatal collision with terrain of a Mitsubishi MU-2 twin-engine turboprop aircraft in Îles-de-la-Madeleine, Quebec. The report underlines the risks of continuing an unstable approach to a landing, which is on the TSB Watchlist of key safety issues that need to be addressed to make Canada's transportation system even safer.

On 29 March 2016, the MU-2 aircraft departed Montréal/Saint-Hubert Airport for Îles-de-la-Madeleine, Quebec, an approximate two-hour flight. On board were the pilot, a passenger-pilot, and five passengers. During the final approach, when the aircraft was 1.4 nautical miles west-southwest of the airport, it deviated south of the approach path. At approximately 1230 Atlantic Daylight Time, aircraft control was lost, resulting in the aircraft striking the ground in a near-level attitude. The aircraft was destroyed, and all occupants were fatally injured.

The MU-2 is a high-performance aircraft, which is especially challenging to fly at low airspeed, particularly during sudden applications of engine power. While in cruise flight, the pilot modified his approach plan by delaying the aircraft's initial descent. This placed the aircraft above the planned descent profile and compressed the time available for the pilot to complete the required checklist activities, while monitoring the aircraft's airspeed, altitude and rate of descent, thereby increasing the pilot's workload. Under these high workload conditions, the pilot likely did not recognize that a go-around was an option available to reduce his workload, and he continued with the unstable approach. During the final moments of the flight, a loss of control occurred when the pilot rapidly added full power, at low airspeed and low altitude, which caused an aircraft upset and resulted in the aircraft sharply rolling to the right and descending rapidly. Although the pilot managed to level the wings, the aircraft was too low to recover before striking the ground.

"We have seen too many of these unstable approaches in the past lead to tragic accidents," said Kathy Fox, TSB Chair. "It is important that pilots consider conducting a go-around when an approach is unstable. We will continue to highlight the risks of unstable approaches until there is a reduction in the number of accidents in which approach stability was a causal or contributory factor."

Regulators, operators and aircraft manufacturers have defined stable-approach criteria, which pilots are trained to follow. Stable approaches make landings more consistent and predictable—giving pilots time to monitor key elements such as airspeed, altitude, rate of descent, and to complete checklists—thereby improving the likelihood of a safe landing.

In this investigation, a crucial source of information was the lightweight recorder that the pilot had developed and installed on board the aircraft, even though it was not required by regulation. The device provided investigators with highly valuable acceleration and GPS data as well as cockpit audio, allowing them to piece together a detailed history of the flight.

"The benefits of lightweight recorders are obvious: knowing what happened is the first step to understanding why. Although the TSB does not endorse any single product, it would be fair to say that the lightweight recorder on this aircraft can be viewed as an indication of the way forward," added Chair Fox.

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Montréal, Quebec, 08 January 2018 – The Transportation Safety Board of Canada (TSB) will hold a news conference on 10 January 2018 to make public its investigation report (A16A0032) into the March 2016 fatal collision with terrain of a Mitsubishi MU-2B-60 aircraft in Îles-de-la-Madeleine, Quebec.

When:
10 January 2018 at 10 am Eastern time
Who:
Kathy Fox, TSB Chair
Natacha Van Themsche, Director of Air Investigations, TSB
Where:
Holiday Inn Montréal Centre-Ville
Room Hibiscus A&B
999 Saint-Urbain, Montréal, Quebec
Paid parking available

The event will be broadcast live on 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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Edmonton, Alberta, 5 January 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation brief (A16W0094) into the collision with terrain of a privately registered North American Aviation Inc. T28-B aircraft that occurred on 17 July 2016 while the aircraft was performing an aerobatic routine during an air show at Canadian Forces Base Cold Lake (CYOD), Alberta. The pilot was fatally injured. There were no injuries to air show personnel or spectators, and there was no post-impact fire. There was minor damage to airfield infrastructure.

See investigation page.

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