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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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Québec, Quebec, 25 October 2017 – In its investigation report (A16A0084) released today, the Transportation Safety Board of Canada (TSB) found that low altitude and the speed at which a private helicopter was flown caused it to crash into the Restigouche River after colliding with transmission cables in September 2016 near Flatlands, New Brunswick.

On the afternoon of 4 September 2016, a privately operated Bell 206B helicopter departed Charlo Airport, New Brunswick, for Rivière-du-Loup Airport, Quebec, with a pilot and two passengers on board. While flying along the Restigouche River, the helicopter collided with and severed power transmission cables that spanned the river at a height of 58 feet above the water. The aircraft was catastrophically damaged and subsequently fell into the river. The pilot and front-seat passenger were fatally injured. The rear-seat passenger survived the accident and bystanders helped him to shore.

The investigation concluded that the low altitude and the speed at which the helicopter was flown made the unmarked transmission cables difficult to see and avoid. It is likely that the pilot was unaware of the power transmission lines spanning the river, and that he did not see them before the helicopter struck them. Intentional low-altitude flying is risky, particularly without pre-flight planning and reconnaissance, and may result in a collision with wires or other obstacles, increasing the risk of injury or death. After the accident, Transport Canada determined that the power transmission lines spanning Restigouche River at Flatlands–Long Island did not require lighting or marking.

In addition, there were physiological factors that had the potential to degrade the pilot's decision making and performance, although their specific effects on the pilot could not be determined. The investigation found that the pilot had limited opportunities to sleep prior to the flight and was likely experiencing acute fatigue at the time of the accident. If pilots do not take advantage of opportunities to sleep between duty periods, there is an increased risk of degraded performance due to fatigue. A post-mortem toxicological exam performed on the pilot also revealed the presence of cannabinoids in his system. Conclusions regarding impairment, or the time at which the cannabinoids were used, could not be made. Flight crew members who use cannabinoids risk impaired performance and decision making, jeopardizing the safety of the flight.

The helicopter was equipped with an emergency locator transmitter (ELT). However, the search-and-rescue satellite system did not receive a signal from the helicopter's ELT. The investigation determined that the ELT activated but that its antenna broke off and the ELT sank into the river, which made its detection impossible. The Board issued four recommendations in 2016 (recommendations A16-02, A16-03, A16-04 and A16-05) to address deficiencies in ELT design standards that  may delay search-and-rescue operations after an accident. International collaboration is now underway to improve ELT specifications.

See the investigation page for more information.

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Québec, Quebec, 24 October 2017 – Tomorrow, the Transportation Safety Board of Canada (TSB) will release its investigation report (A16A0084) on the September 2016 fatal helicopter accident near Flatlands, New Brunswick.

Publication of report: October 25, 2017 at 10:00 am Eastern Time

Spokesperson: Mr. Jean-Marc Ledoux, Regional Manager, Air Investigations, will be available for interviews on October 25, 2017 from 10 am to 3 pm.

To book an interview with our spokesperson, please contact:
Transportation Safety Board of Canada
Media Relations
819-994-8053
This email address is being protected from spambots. You need JavaScript enabled to view it.


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, 16 October 2017 – In its investigation report (A16W0126) released today, the Transportation Safety Board of Canada (TSB) indicates that the absence of a company policy on landing with a specified minimum quantity of fuel was a key factor in a survey helicopter’s loss of power and collision with trees near Whitecourt, Alberta, in 2016.

On 5 September 2016, a Ridge Rotors Bell 206B Jet Ranger helicopter was operating a daylight flight to survey mountain pine beetle with the pilot and two surveyors on board. While flying 160 feet above ground, the helicopter suddenly lost engine power and, within seconds, descended and collided with trees. The surveyor sitting in the front was fatally injured when trees penetrated the cockpit, while the other surveyor seated in the back sustained minor injuries. The pilot received serious injuries. The helicopter was substantially damaged.

The investigation established that, during a short rest break on a sand bar prior to the accident, the pilot decided to continue with the flight instead of refueling at a nearby fuel cache. The remaining fuel was close to the minimum recommended quantities to ensure appropriate safety margins against temporarily uncovering boost pump inlets, exposing them to air. Ridge Rotors' practice of regularly operating helicopters with low fuel levels likely influenced the pilot's decision to continue the flight.

Moments before the accident, the helicopter entered a left turn, and the resulting acceleration forces likely resulted in air entering the fuel pumps, interrupting fuel flow to the combustion chamber, which led to the engine power loss. The company used automatic ignition systems only in snow conditions. Consequently, the system had not been turned on in the occurrence aircraft. The investigation concluded that low altitude survey work in combination with low fuel levels and the inactive automatic ignition system contributed to the inability to recover from the engine power loss.

It is important for operators to understand the limitations of the Bell 206B helicopter fuel system and the risks associated with flights conducted with less than 20 US gallons of fuel. If operators do not observe the minimum fuel quantities recommended in the flight manual, there is a risk that the helicopter will be operated at fuel levels conducive to engine power loss.

As this occurrence demonstrates, some operators are not managing safety risks effectively. This operator and many others are not required to have a formal safety management system (SMS) in place. The TSB has repeatedly emphasized the advantages of an SMS, recommending that Transport Canada require all commercial aviation operators in Canada to implement a formal SMS (A16-12). To date, the Board has been unable to assess Transport Canada's response to this recommendation because Transport Canada has not specified the actions that will be taken to implement a formal SMS. Safety management and oversight is on the TSB Watchlist.

Transport Canada conducted a process inspection of Ridge Rotors after the accident, and the company subsequently implemented corrective action plans to address TC's minor findings of non-compliance. The company has also incorporated changes in its standard operating procedures and trained pilots accordingly.

See the investigation page for more information.

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Gatineau, Quebec, 12 October 2017 – In its investigation report (M16C0036) released today, the Transportation Safety Board of Canada (TSB) found that the capsizing and sinking of the Ocean Uannaq tug off Montreal, Quebec in 2016 was due to a lack of formalized operating procedures and inadequate assessment of the safety risks associated with complex marine operations.

On 1 April 2016, three tugs, including the Ocean Uannaq, were involved in repositioning an excavation barge on the St. Lawrence River as part of the new Champlain Bridge construction project. The Ocean Uannaq and another tug were assisting the Ocean Catatug 1, which was attached to the barge. In preparation for the move, the barge's upstream spuds, used for mooring, were raised before the downstream spuds. When one of the downstream spuds jammed as it was being raised, the barge and attached tug pivoted with the strong current around the jammed spud. The Catatug 1's port wire made contact with the Ocean Uannaq, which combined with the opposing current, created a hydrodynamic effect that led to the rapid capsizing of the tug. The two crew members managed to board the attached tug, and the Ocean Uannaq later sank at 1850. There were no injuries or pollution.

The investigation found that neither the tug's owner nor the operator had assessed the risks of the complex marine operations. Therefore, no operating procedures had been developed to guide masters in the best practices for directing operations, and masters were left to make ad hoc decisions. Safety management and oversight is a TSB Watchlist issue. The need for effective safety management has been demonstrated in a number of other occurrences.

Following the occurrence, the operator invited those involved in the occurrence, along with other key individuals from the construction site, the tug and barge owners, to conduct an internal accident investigation. Following that investigation, the existing shore side procedures were extended to the marine construction operations and the operator implemented procedures to help workers identify and mitigate risks on the work site. The operator also hired an assistant marine superintendent to specifically oversee the marine safety aspects of its operations.

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Winnipeg, Manitoba, 28 September 2017 – In its investigation report (A15C0163) released today, the Transportation Safety Board of Canada (TSB) found that ice accumulation and the company practice to operate in icing conditions led to the December 2015 crash of a cargo plane near Pickle Lake, Ontario.

At 0900 on 11 December 2015, a Cessna 208B Caravan, operating as Wasaya Airways Limited flight 127, left Pickle Lake Airport, Ontario, for Angling Lake / Wapekeka Airport, Ontario, with the pilot and a load of cargo on board. Less than 10 minutes into the flight, the aircraft began descending, made a sharp right turn, climbed again before starting another descent, then collided with trees and terrain at at an elevation of 1460 feet above sea level. The pilot was fatally injured, and the aircraft was destroyed. No signal was received from the emergency locator transmitter (ELT), which was damaged during the crash, and there were no flight recording devices aboard.

The investigation established that the aircraft performance was consistent with operation in icing conditions that exceeded the capabilities of the aircraft. The high takeoff weight also exacerbated the problem. As the aircraft continued its flight in icing conditions, rather than returning to base, it experienced substantially degraded aircraft performance as a result of ice accumulation, which led to an aerodynamic stall, loss of control, and collision with terrain.

The investigation also determined that company practices did not ensure that operational risks were assessed and managed appropriately. Flying into forecast icing conditions was a company norm although four of the five Cessna 208B aircraft were prohibited from operating in these conditions. At the time of the accident, the operator had not implemented all of the mitigation strategies from its January 2015 risk assessment of Cessna 208B operations in known or forecast icing, and remained exposed to some unmitigated hazards that had been identified in the risk assessment. Consequently, pilots lacked important information and tools for sound decision-making and for safe, efficient operations.

The presence of flight recording devices can help identify safety deficiencies, which is why the Board previously recommended (Recommendation A13-01) that Transport Canada work with industry to remove obstacles to the implementation of flight data monitoring and the installation of lightweight flight recording systems by commercial operators not currently required to carry them. The Board also issued four other recommendations in 2016 (Recommendations A16-02, A16-03, A16-04 and A16-05) to address deficiencies in ELT design standards which may delay search and rescue operations after an accident. International collaboration is now underway to improve ELT specifications.

Following the accident, Wasaya conducted two safety management system investigations. As a result, the company increased minimum weather requirements for visual flight rules flights and improved operational flight plan procedures. It also increased the time allocated for technical training on the Cessna, tested a reporting system for icing encounters, and revised the maintenance schedule for the application of anti-icing treatments.

See the investigation page for more information.

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Dartmouth, Nova Scotia, 27 September 2017 – In its investigation report (A16A0041) released today, the Transportation Safety Board of Canada found that the lack of consideration of a combination of risks during a winter storm contributed to the April 2016 landing accident at Gander International Airport, Newfoundland and Labrador.

On the evening of 20 April 2016, Air Canada Express flight 7804, operated by Exploits Valley Air Services (EVAS), departed Goose Bay International Airport, Newfoundland and Labrador, for Gander International Airport with 14 passengers and two crew members on board. The weather forecast for the time of arrival in Gander was wind gusting to 55 knots, reduced visibility, and heavy blowing snow. At 2130, the aircraft touched down right of the runway centreline and almost immediately veered to the right. The nose wheel struck a compacted snow windrow on the runway, causing the nose landing gear to collapse.  As the aircraft's nose dropped, the propeller blades struck the snow and runway surface. Most of the propeller blades separated at the root, and a portion of a blade penetrated the cabin wall. The aircraft slid further down the runway before coming to a stop. Three passengers sustained minor injuries.

The investigation found that the blowing snow made it difficult to identify the runway centreline markings, and that the situation was exacerbated by the absence of centreline lighting and a possible visual illusion caused by the blowing snow. Neither pilot had considered that the combination of landing at night, in reduced visibility, with a crosswind and blowing snow, on a runway with no centreline lighting, was a hazard that may create additional risks. The crew also did not recognize that the gusty crosswind conditions had caused the aircraft to drift to the right during landing. The operator did not have defined crosswind limits that would have restricted the maximum crosswind allowed for take-off and landing, nor was it required to do so. Rather, it relied on aircraft captains to determine their own personal limits for crosswind landings. If operators do not have defined crosswind limits, there is a risk that pilots may land in crosswinds that exceed their abilities, which could jeopardize the safety of flight.

While there is no requirement for this operator to have a safety management system, it did have a flight safety program. Safety management and oversight is on the TSB Watchlist. The TSB has repeatedly emphasized the advantages of a safety management system to allow companies to effectively manage risk and make operations safer.

The investigation also found that neither pilot had received crew resource management (CRM) training at EVAS, nor was it required by regulation. CRM training is specifically designed to address interactions between crew members and fully prepare them to recognize and mitigate risks encountered during flights. Transport Canada intends to move ahead with implementation of the outstanding TSB Recommendation A09-02 and impose a mandatory requirement for operator CRM training.

See the investigation page for more information.

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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.

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