Aviation.ca - Your Number One Source for Canadian Aviation News, Jobs and Information!

Transportation Safety Board of Canada

Transportation Safety Board of Canada (467)

Dartmouth, Nova Scotia, 19 January 2017 – Drawing attention to the wide range of safety risks that persist in the fishing industry, the Transportation Safety Board of Canada (TSB) today released its investigation report (M15A0348) into the November 2015 person overboard fatality near Clark’s Harbour, Nova Scotia.

On 30 November 2015, the opening day of lobster season, at about 0600 Atlantic Standard Time, the fishing vessel Cock-a-Wit Lady departed Shag Harbour, Nova Scotia, with five crew members on board. At 0911, the vessel reported that a deckhand had gone overboard while setting a first string of lobster traps. The crew recovered the deckhand and attempted resuscitation. After being airlifted to hospital, the crew member was pronounced deceased.

The investigation determined that while the crew was setting lobster traps, one of the traps got caught on the port guard rail. A deckhand attempted to free the caught trap with his feet, and while doing so, he stepped into the coils of rope attached to the traps. When he managed to free the trap, it quickly went over the stern, and the deckhand was hauled overboard and carried under water by the weight and momentum of the traps. The vessel's overhead block, which is mounted on top of the wheelhouse and used in conjunction with the trap hauler to pull traps aboard, was in stowed position as the crew was not planning on using it that day. In an attempt to save time, the crew tried to recover the deckhand using only the trap hauler but, given the angle of the line and additional strain of the submerged traps, the line parted. The crew then lowered the overhead block and was able to recover the deckhand. By that time, approximately 10 minutes had passed and the crew was unable to resuscitate the deckhand.

The investigation identified a number of risks related to emergency preparedness. These risks were also identified in a TSB Safety Issues Investigation (SII) into fishing safety that was published in 2012. If fishing vessel operations do not have a system for on-board risk management, such as safety meetings, there is a risk that crew members may not effectively mitigate on-board hazards. Furthermore, if vessel operators do not conduct drills that provide an opportunity for the crew to identify shortcomings in emergency response situations, such as a person overboard, there is a risk that fishermen will not be able to respond to an emergency effectively.

Commercial fishing safety is a TSB Watchlist issue as it is recognized nationwide that the loss of life on fishing vessels is simply too great. Although regulations have been published and will likely lower some of the risks associated with outstanding safety deficiencies, gaps remain with respect to, among other things, unsafe operating practices and crew training.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Winnipeg, Manitoba, 17 January 2017 – In its investigation report (A15C0130) released today, the Transportation Safety Board of Canada (TSB) found that deteriorating weather and departure under conditions of near darkness led to the fatal September 2015 crash of a Robinson R44 helicopter near Foleyet, Ontario.

On 8 September 2015, at approximately 2015 Eastern Daylight Time, an Apex Helicopters Inc. Robinson R44 departed a camp on Horwood Lake, Ontario, for the Foleyet Timber Camp with one pilot and one passenger on board. Sometime after liftoff, northwest of the Foleyet Timber Camp, the helicopter struck trees on elevated terrain and was destroyed by impact forces. There was no post-impact fire, and the occupants sustained fatal injuries.

The investigation determined that the flight was conducted in deteriorating weather and departed under conditions of near darkness. The helicopter was not equipped for flying at night or in instrument conditions, and the pilot was not certified for conducting such operations. It is likely that the pilot was unable to determine the helicopter’s height above the forest canopy and to notice the rising terrain ahead before striking trees. Because a number of hazards are associated with night flights, the TSB issued Recommendation A16-08, calling for regulations to clearly define the visual references required to reduce the risks associated with flying at night.

The helicopter was equipped with an emergency locator transmitter (ELT) that activated upon impact; however, it did not transmit its position because the antenna had broken off during the accident. The aircraft was not reported missing until the following day at approximately 1500, which resulted in search and rescue operations being delayed by approximately 20 hours. In 2016, the TSB issued four safety recommendations (A16‑02, A16‑03, A16‑04, and A16‑05) related to ELT crash survivability. If existing ELT design and certification standards do not ensure that the currently manufactured systems provide a reasonable degree of survivability from fire or impact forces, there is a risk that potentially life-saving search-and-rescue services may be delayed.

The investigation also found that the helicopter was not equipped with a flight data recorder or a cockpit voice recorder, nor was either required by regulation. In 2013, the TSB issued Recommendation A13-01, pushing for the installation of lightweight flight recording systems by all commercial operators. This occurrence demonstrates once more that if cockpit and flight data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.

Following the accident, Apex Helicopters Inc. has reviewed and emphasized the importance of timely reporting of overdue aircraft with all newly hired pilots and ground crew.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Richmond Hill, Ontario, 10 January 2017 – In the release of its investigation report (A14O0218) today, the Transportation Safety Board of Canada (TSB) determined that flight crew deviation from standard landing procedures led to the October 2014 risk of a runway excursion, and that the aircraft was not stabilized during a portion of the approach phase.

On 3 October 2014, the Bombardier DHC-8-400, operating as Sky Regional Airlines flight 7519, departed Montréal/Pierre Elliott Trudeau International Airport, Quebec, for a regularly scheduled flight to Billy Bishop Toronto City Airport, Ontario. During the landing, the aircraft touched down approximately 800 feet from the threshold of runway 26 but did not slow down in a timely manner. As the aircraft approached the end of the runway, the flight crew steered the aircraft toward the last taxiway to prevent an overrun. The aircraft came to a stop on the taxiway, shortly after exiting the runway. There were no injuries and no damage to the aircraft.

During the landing roll, likely in an attempt to make a smooth landing, the flight crew did not adhere to standard landing technique, and only light braking was initially applied, leading to the risk of overrun. It was also determined that during a portion of the approach phase, the aircraft did not meet stabilized approach criteria as a result of being well above the desired approach path. The investigation also highlights deficiencies in training for flight crews in recognizing unstable approaches, as well as the lack of mandatory company reporting of unstable approaches, as risk factors.

Unstable approaches are one of the key safety issues on the 2016 TSB Watchlist. When continued to a landing, unstable approaches are known to increase the likelihood of a landing accident. There is also an outstanding Board recommendation (A14-01) calling for Transport Canada to require airlines to monitor and reduce unstable approaches that continue to a landing.

Following this occurrence, Sky Regional Airlines conducted an internal Safety Management System (SMS) investigation. It identified and took steps to mitigate the risks associated with portions of its flight operations. This included updating initial and recurrent training of landing procedures and equipping its DHC-8-400 fleet with enhanced quick access flight recorders for accurate flight data analysis.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Richmond Hill, Ontario, 9 January 2017 – In its investigation report (A14F0065) released today, the Transportation Safety Board of Canada (TSB) determined that an unstable approach led to the 10 May 2014 hard landing of an Air Canada Rouge Airbus 319 at the Sangster International Airport in Montego Bay, Jamaica. There were no injuries and no structural damage to the aircraft.

The Air Canada Rouge Airbus A319 was operating as flight AC1804 from Toronto, Ontario, to Montego Bay, Jamaica, with 131 passengers and 6 crew members on board. At approximately 14 minutes before touchdown, the aircraft was cleared for a non-precision approach to Runway 07 at the Montego Bay airport. The approach became unstable and the aircraft touched down hard. The landing subjected the main landing gear to very high loading. The aircraft was subsequently inspected and the main landing gear shock absorbers were replaced as a precaution.

The investigation determined that the approach became unstable as a result of inconsistent airspeed management and delayed configuration of the aircraft for landing. The flight crew did not adhere to standard operating procedures, which required the monitoring of all available parameters during approach and landing.  The investigation also found that simulator training to recognize an unstable approach leading to a missed approach had not been provided. As such, the flight crew did not recognize the instability of the approach and continued it well beyond the point at which a missed approach and go-around should have been initiated.

If flight crews do not follow standard procedures and best practices that facilitate the monitoring of stabilized approach criteria and excessive parameter deviations, there is a risk that undesired aircraft states will be mismanaged. Unstable approaches are one of the key safety issues on the 2016 TSB Watchlist. There is also an outstanding Board recommendation (A14-01) calling for Transport Canada to require airlines to monitor and reduce unstable approaches that continue to a landing.

Following the occurrence, Air Canada Rouge refined its stable-approach policy, modified its training to include more manual flying scenarios and incorporated simulator training for unstable approaches leading to a missed approach.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Richmond, British Columbia, 14 December 2016 – Another fatal commercial fishing accident that occurred in September 2015 off the West Coast of Vancouver Island, British Columbia (M15P0286), has led the Transportation Safety Board of Canada (TSB) to issue five new recommendations.

On 05 September 2015, at approximately 15:30 Pacific Time, the Caledonian, a large, 100-foot fishing vessel with four crew members on board, capsized 20 nautical miles off the west coast of Vancouver Island. The crew had been fishing for two days. After the final catch was hauled aboard, and as the crew prepared to stow it, the vessel began to list. Within a couple of minutes, water covered the deck and the vessel rolled over. No distress call was sent and none of the vessel's emergency signaling devices activated. The vessel sank about six hours later. Only one crew member was wearing a personal flotation device (PFD), and this crew member was the only one who survived.

"At the TSB, we have seen similar circumstances occur far too often. In fact, on average, 10 fishermen die each year somewhere in Canada's commercial fishing industry. These deaths are nearly all preventable, and this why this issue is still on our Watchlist," said Kathy Fox, Chair of the TSB. "We are asking that all commercial fishing vessels have a stability assessment appropriate for their size and operation, that this assessment information be kept current, and that it be used to determine safe vessel operating limits."

The investigation determined that the capsizing of the Caledonian was caused by a combination of factors. The most significant ones were the operating practices, such as where the fuel was stored and the way fish and seawater were loaded, and the tendency of vessels to grow heavier with time. These factors caused the vessel to float lower in the water and reduced its stability, which changed its safe operating limits. The crew, however, did not recognize that the vessel had grown heavier over the years or that their operating practices were putting them and the vessel at risk.

"Here in British Columbia, roughly 70 percent of all fishing-related fatalities in the past decade came while not wearing a PFD. Yet many fishermen still don't wear them," said Chair Fox. "It's no longer acceptable to think of fishing as just a dangerous job and that nothing can be done about it. There are steps that we can take; there are steps that we must take.”

Including this occurrence, the TSB has investigated 28 occurrences in the past 10 years resulting in 26 fatalities in commercial fishing in Canada. This investigation is similar to many other investigations and that is why the TSB is recommending that:

All commercial fishing vessels, large and small, have their stability assessed; and that this stability information be kept up to date and be presented in a way that is clear and useful for the crew.
(Recommendations M16-01, M16-02, and M16-03)
Both regulators, WorkSafeBC and Transport Canada, require crews on fishing vessels to wear suitable PFDs at all times on deck and develop ways to confirm that they are complying.
(Recommendations M16-04 and M16-05)

See the investigation page for more information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Québec, Quebec, 7 December 2016 – Following its assessment of the collapse of the platform and gangway at the wharf in Sainte-Rose-du-Nord, Quebec, in September (occurrence number M16C0146), the Transportation Safety Board of Canada (TSB) is publishing a Marine Safety Information Letter today.

On 7 September 2016, at about 1130 Eastern Daylight Time, the passenger vessel Fjord Saguenay II docked at the marina in Sainte-Rose-du-Nord, Quebec, to board passengers for a cruise on the river. The vessel’s chief officer authorized the passengers, who were waiting on the dock, to begin boarding by using the platform and the gangway. At around 1140, the platform came away from the dock, taking the gangway with it and falling approximately eight metres. Several passengers who were standing on the gangway at the time of the occurrence sustained injuries.

The investigation revealed that the platform connecting the gangway to the dock had been fastened with lag screws to a piece of treated lumber, which was affixed to the dock with bolts. The piece of treated lumber holding the lag screws was in poor condition and, as a result, the screws were torn from their footings. No periodic maintenance or inspection of the platform or fastening system had been performed since it was first installed in 2011.

The assessment of the occurrence was unable to identify any existing municipal or provincial regulations referring to the periodic maintenance or inspection of this type of installation during its life cycle. The TSB has sent a Marine Safety Information Letter about this occurrence to the mayor of the municipality of Sainte-Rose-du-Nord. A copy of this letter has been sent to the Fédération québécoise des municipalités, the Union des municipalités du Québec, the Ordre des ingénieurs du Québec and the Federation of Canadian Municipalities to raise their awareness of the risks of such installations.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Dartmouth, Nova Scotia, 30 November 2016 – In its investigation report (A15A0045) released today, the Transportation Safety Board of Canada (TSB) determined that a degraded level of situational awareness contributed to the fatal helicopter accident near Rigolet, Newfoundland and Labrador, in July 2015. One passenger sustained fatal injuries, the pilot sustained serious injuries, and the other passenger sustained minor injuries.

On 30 July 2015, an Airbus Helicopters AS 350 BA, operated by Canadian Helicopters Limited (CHL), was flying to a remote microwave tower site approximately five nautical miles west-southwest of Rigolet, Newfoundland and Labrador, with a pilot and two passengers on board. The pilot had flown with these passengers often and they had been working together at other tower sites on the previous three days. After the passengers carried out the site maintenance as planned, the pilot began preparing for the return flight. At about 1609 Atlantic Daylight Time, the helicopter lifted off from the helipad and, while flying forward, struck one of the tower's outer guy wires with the main rotor. The helicopter struck the ground and settled on its upper right side. The helicopter was destroyed.

The investigation determined that the pilot did not note the outer guy wires and did not include them in the departure plan. The pilot's lower level of attention while conducting a routine flight led to an ineffective visual scan resulting in degraded situational awareness.

Following this occurrence, the helipad at Moliak was moved outside of the circumference of the outer guy wire anchor points. Bell Aliant also collaborated with CHL to conduct reviews of all Labrador tower sites to identify hazards. CHL has also adopted the policy of conducting an overhead inspection flight prior to landing at any Bell Aliant site.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Saskatoon, Saskatchewan, 16 November 2016 – In its investigation report (R14W0256) released today, the Transportation Safety Board of Canada (TSB) determined that a broken rail, due to an undetected defect, led to the October 2014 derailment of a Canadian National Railway (CN) freight train near Clair, Saskatchewan. There were no injuries, although a flash fire during the emergency response put CN emergency responders at risk.

On 7 October 2014, a CN freight train proceeding westward from Winnipeg, Manitoba, destined to Edmonton, Alberta, derailed 26 cars, including six Class 111 tank cars loaded with dangerous goods, near Clair, Saskatchewan. Two of the tank cars, which were loaded with petroleum distillates, released product that subsequently caught fire. As a precaution, 50 residents within a five-mile (8 km) radius were evacuated and Provincial Highway 5 was closed. Approximately 650 feet of track was destroyed.

This investigation identified risk factors related to the transportation of flammable liquids by rail, and safety management and oversight as outlined in the TSB Watchlist. Two of the Class 111 tank cars released product, and the damage to these cars was consistent with failures noted by the TSB in other investigations. The TSB made recommendations (R14-01 and R14-02) to address these issues as part of the Lac-Mégantic investigation.

The investigation determined that the train derailed when a sudden and catastrophic failure of one of the rails occurred under the train, due to the presence of an undetected defect. Poor rail surface conditions had masked the presence of this defect and reduced the effectiveness of visual inspections and ultrasonic inspections. Including this occurrence, the TSB has investigated seven occurrences in the past 10 years involving a rail break due to a pre-existing rail defect that was not detected by ultrasonic testing.

During the emergency response, CN emergency responders were flaring (igniting) the contents of one of the breached tank cars that had overturned and released product which pooled on the soil below the tank car. A flash fire occurred when the vapors inside the tank car ignited, sending a large fireball towards the two emergency responders who were carrying out the flaring activity. Both emergency responders took immediate evasive action to avoid the flash fire, which quickly extinguished itself.

The investigation found that CN emergency responders, who were likely fatigued, did not consider all the risks associated with the flaring activity prior to igniting the pool of product released from the tank car. CN did not document the close-call during the flaring activity or proactively share the information with any outside agencies, highlighting gaps in CN's reporting and/or procedures.

The investigation also identified deficiencies in provincial incident commander training, emergency response activity monitoring and post-response follow-up.

“If company and industry guidance is not followed and close-calls during emergency response activities are not properly documented and openly shared among all responding agencies, similar circumstances could occur, putting emergency response personnel at risk,” said TSB manager and lead investigator Rob Johnston.

Following the occurrence, CN improved procedures for flaring tank cars and enhanced its documentation requirements for emergency response activities. The Saskatchewan Ministry of the Environment enhanced its procedures for ensuring that incident commanders are appropriately trained and site monitoring activities are established when responding to emergencies involving dangerous goods.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Richmond, British Columbia, 3 November 2016 – According to a Transportation Safety Board of Canada (TSB) investigation report (A15P0147) released today, the engine of a Beechcraft A36 Bonanza that force-landed on Highway 97 northeast of Osoyoos, British Columbia, in July 2015 lost power, likely because of fuel starvation due to vapour lock.

On 7 July 2015, at approximately 1645 Pacific Daylight Time, the privately operated Beechcraft A36 Bonanza (C-GPDK) departed Oliver Municipal Airport, British Columbia, with only the pilot on board for a flight to the Boundary Bay Airport. Approximately six minutes after takeoff, the aircraft suffered an engine power loss, and the pilot carried out a forced landing on Highway 97. The aircraft struck a truck and a power pole, and came to rest on the edge of the road. A post-impact fire consumed most of the aircraft. The pilot was able to get out of the aircraft, but sustained serious burns.

The investigation determined that the aircraft's engine was likely starved of fuel due to vapour lock, and lost power as a result. Vapour lock occurs when fuel, normally in liquid form, changes to vapour while still in the fuel delivery system. This change causes a reduction in pressure to the fuel pump, disrupts fuel flow, and can result in temporary or complete loss of engine power. The pilot had experienced fuel-flow fluctuations and power losses on previous flights with C-GPDK, but was able on those occasions to successfully regain normal power and engine operation. Those previous successes in regaining full engine power may have delayed the pilot's selection of a forced landing area. The nearest airport was then not an option, and Highway 97 was chosen as the next best emergency landing area.

Post-impact fires have been documented as a risk to aviation safety in previous TSB investigation reports. In 2006, the TSB issued a recommendation to reduce the number of post-impact fires in impact-survivable accidents. C-GPDK did not have, and was not required to have, any of the technologies, materials, or components identified in Recommendation A06-10. If aircraft are not fitted with crashworthy fuel-system components that retain fuel or with systems that eliminate ignition sources, the risk of injury or death due to post-impact fire is increased.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Ottawa, Ontario, 31 October 2016 — The Transportation Safety Board of Canada (TSB) released its latest safety Watchlist today, at the same time announcing a more proactive approach to engage government and industry leaders in dialogue and action that leads to safety improvements across Canada’s transportation network.

“No longer is it enough to point out a problem and wait for others to take notice,” said TSB Chair Kathy Fox. “In the next few days and weeks, we'll meet with key stakeholders to push for concrete action, and then we'll report publically on the results.”

This year's edition of the Watchlist, which identifies the key safety issues that need to be addressed in the air, marine, and rail sectors, features the addition of two new issues. “Fatigue has been a factor in numerous railway investigations, most notably regarding freight train operations,” said Fox. “Too many train crews aren't getting the rest they need, whether its shifts that are too long or irregular scheduling that interferes with normal sleep times. It's time for the railway industry to start applying fatigue science to crew scheduling, instead of calling for more studies.”

Fox said the second new issue is Transport Canada's slow progress addressing previous TSB recommendations, something that affects all aspects of the transportation network, with potentially adverse outcomes. “There are currently 52 TSB recommendations that have been outstanding for ten years or more. Over three dozen of those have been outstanding for more than twenty years,” she said. “There is no reasonable excuse for taking that long—especially in cases where TC agrees that action is needed.”

Fox added that “good intentions” on the part of the government aren't enough to reduce the very real safety risks that must be addressed. “If that were enough, the same accidents wouldn't keep happening and we wouldn't need a Watchlist.”

Eight of the ten issues on this year's Watchlist are holdovers from previous years. One previous issue, railway crossing safety, was removed from the list thanks to significant action on the part of Transport Canada, the railways and road authorities —including new grade-crossing regulations and a decline in the number of crossing accidents.

Of the other issues on this year's Watchlist, Fox said safety management systems have not yet been mandated in all sectors of the transportation industry, and TC must oversee them effectively. The safety culture in the fishing industry needs to change to prevent needless loss of life and injuries. In spite of strong safety measures taken by TC regarding transportation of flammable liquids by rail, the risk will persist in the system until the new tank car standards and effective risk controls are fully implemented. There still isn't a plan in place to implement physical defenses against railway signal indications not being followed. The railway industry is not reaping the safety benefits of on-board voice and video recorders in locomotive cabs. Airlines need to better track unstable approaches that continue to a landing to prevent accidents. While some airports are making runway ends safer to reduce the risk of runway overruns, there is no requirement to do so for all major airports. Lastly, the number of runway incursions is too high, which could lead to a catastrophic accident.

Watchlist 2016 issues

Multi-modal

Marine

Rail

Air

Published in Transportation Safety Board of Canada
Written by
Read more...
         
Aviation.ca is not responsible for the content of external Internet sites. Copyright © 1997-2015 Skytech Dynamics Corporation, All rights reserved exogenous-blank
exogenous-blank
exogenous-blank
exogenous-blank

Login or Register