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Edmonton, Alberta, 19 December 2017 – In its investigation report (P17H0019) released today, the Transportation Safety Board of Canada (TSB) determined that the lack of detailed inspection procedures contributed to the March 2017 crude oil leak from a storage tank at the Enbridge Pipelines Inc. Edmonton Terminal in Sherwood Park, Alberta. There were no injuries and no evacuation was required.

During a routine verification on 20 March 2017, Enbridge employees discovered traces of crude oil on the water surface in a creek that runs through the company's Edmonton Terminal. The source of the leak was a three-inch ball valve from an on-site storage tank. An estimated 10 cubic metres of product was released into the tank's secondary containment berm. Three cubic metres of the product were then released from the berm through its storm water drainage system into the creek.

Emergency response resources, which were available on site, were deployed within a few minutes to identify the origin of the leak and mitigate the impacts of the release. As a result, all released product was recovered from the containment berm and from the creek before the product reached the nearby North Saskatchewan River.

The investigation determined that the leak occurred when a gasket between the two halves of the ball valve was displaced out of its original position, likely due to volume expansion of frozen water within the valve. The product that was released into the creek flowed from a sluice gate valve at the end of the berm's storm water drain pipe. The sluice gate valve could not achieve a liquid-tight seal due to corrosion.

Although Enbridge conducts inspections at regular intervals, detailed procedures had not been implemented to assist inspectors with evaluating the condition of tank or berm components and with determining whether the components were suitable for continued service.

Following the occurrence, Enbridge initiated actions to ensure that all tank and containment berm components are thoroughly inspected. The company also reviewed its maintenance procedures as well as its hazard assessment and emergency response plans. The National Energy Board, which is responsible for regulating pipelines under federal jurisdiction, monitored the clean-up process and initiated a review of the occurrence to verify Enbridge's compliance with regulatory requirements, ensuring that the company took adequate corrective, preventive and safety actions.

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Richmond Hill, Ontario, 15 December 2017 – The Transportation Safety Board of Canada (TSB) will hold a news briefing on its investigation (A17O0264) into the helicopter Aerospatiale AS 350 B-2, registered to Hydro One Networks Inc, that crashed near Tweed, Ontario on 14 December 2017

When:
15 December 2017
2:30 p.m. Eastern Time
Who:
Peter Rowntree, Investigator-in-Charge
Jean-Pierre Regnier, TSB Investigator
Where:
10 Industrial Park (off Hwy 37, North of town centre)
Tweed, Ontario

See investigation page A17O0264.

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, 11 December 2017 – In its investigation report (R16D0092) released today, the Transportation Safety Board of Canada (TSB) found that the distance from which eastbound traffic on Highway 348 could see the crossing warning system in Sainte-Ursule, Quebec, was a key factor in the September 2016 collision between a VIA Rail passenger train and a tractor-trailer.

In the afternoon of 20 September 2016, a VIA Rail passenger train was travelling southward on the Joliette Subdivision. The train was struck by a tractor-trailer loaded with sand at the Highway 348 crossing in Sainte-Ursule, Quebec. The first coach of the train derailed, and the other rail cars as well as the locomotives were damaged. The tractor-trailer's fuel tanks ruptured and spilled approximately 60 gallons of fuel and approximately 1800 gallons of fuel spilled from the damaged locomotives. The track and the crossing warning system were damaged and the tractor-trailer was destroyed. The driver sustained serious injuries and two passengers on the train sustained minor injuries.

The investigation determined that the view of the crossing warning system was hindered by the left-hand curve that vehicles approaching from the west on Highway 348 must negotiate. While there was a sign at the curve indicating a railway crossing ahead, this sign was not equipped with lights to provide active warning of an approaching train. In this occurrence, when the driver of the tractor-trailer was negotiating the curve, visual attention was likely focused more on the outside of the curve, rather than further ahead. By the time the driver noticed that the warning system was active and applied the brakes, there was insufficient distance to stop the tractor-trailer before the crossing.

The investigation also determined that there had been several other motor vehicle accidents in the vicinity of the Highway 348 crossing. However, road accidents that do not involve railway equipment are not specifically considered by Transport Canada (TC), when assessing the risk at a crossing. Consequently, when crossing risk assessments are based only on rail accidents, the real risks to the public can be underestimated. The TSB issued Rail Safety Advisory (RSA) 10/17 suggesting that TC consider including accidents that occurred in the vicinity of railway crossings to assess their impact on safety. TC did not indicate that it would take any action on this issue.

Following the accident, the Ministère des Transports, de la Mobilité durable et de l'Électrification des transports evaluated the Highway 348 crossing in Sainte-Ursule and committed to installing an advance warning sign with flashing lights on the approach to this crossing in 2018.

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Edmonton, Alberta, 5 December 2017 – In its investigation report (R16E0051) released today, the Transportation Safety Board of Canada (TSB) found that proceeding past a restricted speed signal led to two trains colliding near Carvel, Alberta, in June 2016. The report highlights a number of safety risks, including the absence of physical fail-safe defences to ensure that signals are consistently recognized and followed.

On 4 June 2016, CN train 112 was proceeding eastward from Edson to Edmonton, Alberta, when it collided with the tail end of eastbound train 302, which had stopped near Carvel to allow a westbound train to pass. No cars derailed as result of the collision. The crew of train 302 did not feel the impact as their train was in a stretched state with the brakes released. After the collision, the crew of train 112 conducted a visual inspection of the tail end of train 302, but did not see that one empty hopper car had sustained minor damage, and did not report the incident. The collision was subsequently confirmed by remotely downloading information from the locomotive event recorder and a forward-facing video camera.

The investigation found that, after correctly identifying a signal calling for reduced speed, the crew of train 112 passed the signal at a speed that exceeded the limit. As such, they were unable to stop in time to avoid the collision with train 302. Upon entering a curve at 27 mph, they saw train 302 stopped about 840 feet ahead whereas they had assumed it was further away. The emergency brake was applied, slowing the train to about 18 mph prior to the collision.

This occurrence once again highlights the systemic risks of not following railway signal indications, a TSB Watchlist issue. If existing signal systems do not include physical fail-safe capabilities, signal recognition or application errors by crew members may not be detected, increasing the risk of train collisions and derailments. Since 1998, the TSB has investigated 13 other similar occurrences and issued two recommendations (R13-01 and R00-04) calling for implementation of physical train controls and additional backup safety defences to help ensure that signal indications are consistently followed. Despite significant work on research initiatives, there still remains no short-term plan to address the risk of train collision or derailment in the absence of additional backup safety defences. Transport Canada responses to both recommendations have been assessed as Satisfactory in Part.

In addition, the crew of train 112 did not follow the requirements for reporting contraventions and safety hazards. If relevant safety data, including incident or rule violation reports, are not available to help identify safety issues, emerging trends involving unsafe events may not be identified in a timely manner, increasing the risk of accidents. In this occurrence, the decision not to report the collision resulted in only a cursory inspection of both trains, rather than the required thorough inspections.

Although the crew of train 112 met established rest requirements, the unpredictability of train schedules and call times may lead to cumulative sleep deficit, which can increase the risk of fatigue. This is why fatigue management for freight train crews has been on the TSB Watchlist since 2016.

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Dartmouth, Nova Scotia, 27 November 2017 – In its investigation report (M16A0327) released today, the Transportation Safety Board of Canada (TSB) found that adverse weather conditions led to the sinking of the small open fishing vessel Pop's Pride and the loss of life of its four occupants in September 2016, off the coast of Newfoundland and Labrador. The report also highlights the continued need for focused and concerted action by all levels of government and industry members to fully address the safety risks and deficiencies that persist in Canada's fishing industry.

In the early morning of 6 September 2016, the Pop's Pride departed St. John's Harbour, Newfoundland and Labrador, with the master and three crew members on board to attend to the cod gillnets they had previously set approximately 0.65 nautical miles north of Cape Spear. On that day, the wind in the area rose to 25-30 knots, causing significant spray and waves up to two metres high, with water temperature at 12 °C. Once all gillnets were recovered, the load on board the small vessel, combined with the environmental conditions, likely caused the Pop's Pride to swamp and sink, leaving the four fishermen in the water. No distress signals were received and it wasn't until 1539 that family and community members reported the vessel overdue. Halifax search and rescue authorities initiated a search operation shortly thereafter and by early evening, two bodies wearing personal flotation devices (PFDs) were recovered. The submerged vessel was located the following day. The other two crew members were never found and are presumed drowned.

The investigation determined that the Pop's Pride proceeded in weather conditions beyond the normal operating conditions of an open fishing vessel. The crew's decision to sail in adverse weather and sea conditions was likely influenced by several factors related to fisheries resource management measures and economic pressures. One such factor was the licence requirement to attend to the fishing gear every 48 hours in order to ensure fresh product and minimize waste. Although the Newfoundland and Labrador Fishery Regulations provide for extensions under exceptional circumstances beyond the fisherman's control, like inclement weather, this information is not included in the licence conditions document for cod fishing issued by Fisheries and Oceans Canada (DFO). Another factor that may have influenced the crew's decision is the weekly fishing quota with no end-of-season date, which was introduced in 2016. Because the closing date was not predetermined, the season could close at any time and, as a result, the crew was likely highly motivated to meet their weekly quota. If fish harvesting measures do not take into account the safety impact on fishermen, there is a risk that they will fish in conditions they would otherwise avoid, thereby compromising the safety of the vessel and crew.

The investigation also determined that the Pop's Pride did not have an emergency position-indicating radio beacon (EPIRB), nor was it required by regulation to carry one. In 2001, the Board issued Recommendation M00-09 calling on Transport Canada (TC) to require that small fishing vessels carry an EPIRB or other appropriate emergency communications equipment. The new Fishing Vessel Safety Regulations (FVSR), which came into effect a year after this accident, do not extend this requirement to fishing vessels less than 12 metres in length. The TSB continues to record fatalities and occurrences on board small fishing vessels that were not equipped with an EPIRB, and that were either unable or did not use any other means of signalling distress. The measures in the FVSR do not mitigate the risk identified in Recommendation M00-09. Therefore, the Board has reassessed TC's response as unsatisfactory.

The TSB has made a number of other recommendations over time to address the safety risks highlighted in today's report. Two recommendations called on TC to work to enhance safety culture within the fishing industry through greater collaboration with DFO, the fishing community and training institutions. Actions taken in response to these recommendations were assessed as fully satisfactory (M03-02) and satisfactory in part (M03-07) due to the signing of a Memorandum of Understanding in 2006 among TC, DFO and the Canadian Coast Guard to ensure collaboration on commercial fishermen's safety at sea. More recently, Recommendation M16-03 called on TC to require that all small fishing vessels undergo a stability assessment and establish standards to ensure that the stability information is adequate and readily available to crew members. The response to that recommendation has not yet been assessed.

In 2012, the TSB released an in-depth Safety Issues Investigation into Fishing Safety in Canada, providing an overall national view of safety issues in the fishing industry. Commercial fishing safety has also been a Watchlist issue since 2010. As this tragic accident demonstrates, concerns remain about the use and availability of lifesaving appliances on board, such as EPIRBs, and about unsafe operating practices.

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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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