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Transportation Safety Board of Canada (327)
Vancouver, British Columbia, 23 October 2014 – The Transportation Safety Board of Canada today released its investigation report (M14P0014) into the grounding of container vessel Cap Blanche on the Fraser River, British Columbia in January 2014. The report identified fog and reliance on predicted vessel positions based on inaccurate information as factors contributing to the grounding.
On 25 January 2014, the container vessel Cap Blanche was on its way to the Fraser Surrey Docks on the Fraser River, British Columbia. The vessel was under conduct of a pilot and visibility was reduced due to fog. The pilot used a function on his portable pilotage unit to assess the rate of turn to transit through the Steveston Bend. The information given by the equipment was inaccurate because it was subject to an unidentified GPS smoothing interval. The Cap Blanche grounded within the buoyed channel in the Stevenson Bend. The vessel was refloated approximately 30 minutes after the groundingwith minimal damage. No injuries or pollution were reported.
The investigation found that if a navigator primarily relies on a single piece of navigational equipment or information, there is a risk of potential errors going undetected. It further identified that the bridge team was unaware of the silting on the south side of Steveston Bend so they were unable to assist the pilot or identify the developing unsafe condition. The investigation also found decisions based on imprecise information can be made if pilots do not make use of the most accurate navigational equipment available to them.
Since the occurrence, the TSB issued a Marine Safety Advisory letter to the Pacific Pilotage Authority, providing information about the discrepancy between inputs from a vessel’s automatic identification system (AIS) and the pilots’ wide area augmentation system (WAAS)-based differential global positioning system antennas. The Pacific Pilotage Authority distributed the safety advisory to all pilots.
Québec, Quebec, 9 October 2014 – The Transportation Safety Board of Canada today released its investigation report (M13L0123) into the collision between bulk carrier Heloise and tug Ocean Georgie Bain in the Port of Montreal, Quebec. The investigation determined that language barriers on board the Heloise, and the failure to use available navigation resources on board both vessels contributed to the collision.
On 03 August 2013, the Heloise entered the main channel of the St. Lawrence River, where it met with two upbound vessels and numerous pleasure craft. At about the same time, the Ocean Georgie Bain had left its base to assist another vessel with berthing and was also entering the main channel. The pilot on the Heloise, concerned by the presence of pleasure craft, altered its course. Once the Heloise was clear of the craft, the pilot steadied the course of the vessel in the direction of the Ocean Georgie Bain and the 2 vessels collided. The pilot on the Heloise was not monitoring the Ocean Georgie Bain at the time of the collision, and the bridge crew on the Heloise was not assisting the pilot by maintaining a lookout or using navigational equipment to advise the pilot of relevant traffic.There was considerable damage to the Ocean Georgie Bain but no damage to the Heloise other than traces on the hull.
The investigation identified numerous risks including that operations on the bridge can be affected when language barriers inhibit communication. In addition, vessels in close proximity might not be detected and a collision may occur if available resources for safe navigation, such as radars and an electronic chart system, are not used. The investigation also found that companies and vessel masters must understand and apply all of the safe manning requirements for a vessel to be manned adequately.
Montreal, Quebec, 6 October 2014 – In its investigation report (R13Q0012) released today, the Transportation Safety Board of Canada (TSB) determined that the May 2013 collision between a VIA Rail Canada Inc. passenger train and a tractor-trailer at a private level crossing in Québec occurred when the train was proceeding through the crossing while the manual gate protecting the crossing was up. There were no injuries.
On 2 May 2013, a VIA Rail Canada passenger train, after disembarking the passengers and refuelling, was travelling in reverse between Gare du Palais and the Limoilou Yard in Quebec, Quebec. There were two crew members – the operating locomotive engineer in the lead locomotive, and the in-charge locomotive engineer on the ground, who was supervising the reverse movement. Instructions were being communicated to the locomotive engineer by radio. The collision occurred at the private level crossing leading to the Papiers White Birch paper mill. The last passenger car was damaged and the tractor-trailer was destroyed. About 300 litres of diesel fuel from the tractor-trailer's fuel tank spilled on the ground.
The investigation found that when the occurrence tractor-trailer started the turn to enter the paper mill, the manual gates at the crossing were up, and the traffic light controlling access to the plant was indicating that traffic could proceed. Noting that another truck had stopped on the paper mill side, the in-charge locomotive engineer concluded that the manual gate was down, and then informed the operating locomotive engineer that the crossing was protected while it was not. The guard who operates the crossing gates did not immediately recognize the need to lower the gates to protect the crossing, as the view of the train was partially obstructed and the refueling operation had taken less time than usual.
Following the occurrence, VIA Rail Canada Inc. amended its procedures so that trains no longer stop upon exiting Gare du Palaisand changed its refuelling point to move it away from the level crossing. Transport Canada has entered into discussions with the City of Quebec, the Papiers White Birch paper mill and Canadian National to improve the traffic light and crossing protection systems at this location.
The risk of passenger trains colliding with vehicles is a TSB Watchlist issue. Watch the TSB video!
Québec, Quebec, 2 October 2014 – The Transportation Safety Board of Canada (TSB) investigation into the grounding of the passenger vessel Louis Jolliet highlights the need for comprehensive emergency procedures, training, and drills according to its investigation report (M13L0067) released today.
On 16 May 2013, the passenger vessel Louis Jolliet ran aground off Sainte-Pétronille, Île d’Orléans, Quebec, while on a cruise with 57 passengers on board. The passengers and some crew were evacuated, the vessel sustained minor damage, and was refloated at high tide. There were no injuries or pollution reported.
The investigation found that, although present on the bridge at the time of the grounding, the master was not participating in or supervising the navigation of the vessel, leaving navigation to the recently-hired chief mate, who initiated a course alteration, and went aground.
In examining the events following the grounding, the investigation determined that key crew members were not familiar with their emergency duties. The investigation also determined that the emergency procedures in place for the vessel had shortcomings with respect to passenger safety management, and crew members had not practiced such procedures in a realistic way. Although the task of securing the safety of the passengers was accomplished on the day of the occurrence, the Louis Jolliet may carry up to 1000 passengers, highlighting the need for comprehensive and detailed procedures, training, and drills in passenger safety management. The investigation also highlighted the need for effective oversight of passenger safety by Transport Canada (TC).
Since the occurrence, Croisières AML, the owner/operator of the vessel, has implemented many safety actions addressing the issues outlined by the TSB investigation including new procedures to familiarize the crew with the route and new training and drills related to passenger safety. TC subsequently issued a notice to their inspectors on their requirements under the current regulations and made improvements to their reporting system.
Dorval, Quebec, 1 October 2014 – In its investigation report (A12Q0182) released today, the Transportation Safety Board of Canada (TSB) determined that the October 2012 forced landing of a Piper PA-34 in Victoriaville, Quebec, was the result of a fatigue crack in the right engine’s crankcase and an improperly maintained cabin ventilation system. The two pilots aboard the aircraft were seriously injured.
On 15 October 2012, a Piper PA-34-200 operated by Nadeau Air Service Inc. left Trois-Rivières, Quebec on a training flight with two pilots aboard. During a missed approach to the Victoriaville airport, the right engine failed and caught fire. The crew followed the appropriate procedures; however, smoke and fire entered the cockpit because one of the cabin heater duct control cables was disconnected. Soon after, dense smoke spread into the cockpit, and the crew quickly descended to attempt a landing in a field near the airport. The aircraft struck the ground and came to rest inverted.
The investigation found that there was a fatigue crack in a weld-repaired area of the right engine's crankcase. This repair did not meet the engine manufacturer's standards. The crack spread and eventually led to the engine failure. Engine oil then spread in the engine compartment and caught fire. Additionally, because one of the cables for the heater ducts was disconnected, it was impossible to prevent smoke and fire from entering into the cockpit.
Although the risks associated with weld-repaired crankcases have been documented, certain repair shops are approved to make such repairs. The report notes that there is an increased risk of engine failure if an aircraft has a weld-repaired crankcase. The report also notes a risk that crews will not have information critical to flight safety if aircraft anomalies are not systematically recorded in the aircraft's journey log.
Richmond, British Columbia, 30 September 2014 – In its investigation report (A13P0165) released today, the Transportation Safety Board of Canada (TSB) found the pilot of a Cessna 172 was not able to recover from a flight condition that led to a high-speed descent prior to colliding with terrain near Kamloops, British Columbia. The pilot and sole occupant of the aircraft suffered fatal injuries and the aircraft was destroyed.
On 6 August 2013, a student pilot was flying a Cessna 172 operated by TyLair Aviation Ltd. on a 2-hour training flight. The pilot and instructor discussed the training plan before the flight, and exercises were to be conducted in the company's training area 15 nautical miles west of the Kamloops Airport, as per normal practice. Following manoeuvres in the training area, the aircraft moved north of the practice area to an area of higher terrain and was climbing. Shortly after climbing to 9000 feet, the aircraft disappeared from radar and did not reappear. When the aircraft became overdue, the instructor notified search and rescue. The aircraft and the pilot were found the next day.
The investigation found that the aircraft collided with terrain 30 nautical miles west of Kamloops at about 4500 feet above sea level. The collision occurred at a high speed and a nose-down attitude. The manoeuvres the pilot was conducting were not known, but a nose-drop during some training manoeuvres could lead to a spiral dive if not corrected in time. It is possible that the pilot had begun recovery from a spiral dive and achieved a wings-level attitude, but did not have enough altitude to fully recover. During impact, the aircraft's cabin was severely compromised, making this accident unsurvivable.
Investigators also found that the aircraft was not carrying an emergency locator transmitter (ELT). An ELT was not required since the flight was not intended to travel beyond 25 nautical miles from Kamloops, but its removal should have been documented and placarded. The lack of an ELT resulted in a delay in locating the aircraft.
Ottawa, Ontario, 24 September 2014
At 0832 EDT on 18 September 2013, VIA Rail passenger train No. 51 departed Ottawa Station and proceeded westward en route to Toronto. At 0847, OC Transpo double decker Bus No. 8017 (the bus) departed OC Transpo Fallowfield Station on the OC Transpo Bus Transitway (Transitway). At 0848, while proceeding at about 47 mph, the train entered the Transitway crossing located at Mile 3.30 of VIA Rail's Smiths Falls Subdivision (the crossing) and was struck by the northbound bus. As a result of the collision, the front of the bus was sheared off. The train, comprised of 1 locomotive and 4 passenger coaches, derailed but remained upright. No VIA crew members or passengers were injured. Among the bus occupants, there were 6 fatalities, 8 serious injuries and approximately 25 minor injuries.
The accident bus is an Enviro 500 (E500) double decker model designed and manufactured by Alexander Dennis Limited (ADL) in the United Kingdom. It was delivered to OC Transpo in September 2012.
Work completed to date
On the day of the accident, investigators obtained downloads from the crossing signal bungalow and the locomotive event recorder (LER) to evaluate the operation of the crossing protection and the train. The bus tires and brakes were visually examined and documented in place. The bus did not have a single event recorder to store vehicle performance and operation data (i.e. black box). However, there were a number of electronic units which contained non-volatile-memory (NVM).Footnote 1 The bus battery was disconnected and the engine compartment was sealed to preserve any recorded data. The bus was then transported to a secure location for further examination.
On 28 September 2013, the TSB conducted an accident re-enactment on the Transitway. The re-enactment was photo and video documented from the bus driver's station. It was conducted at approximately the same time as the accident and under similar environmental conditions. A few days later, additional testing was conducted at the crossing to record the time it took for various bus types to travel over the crossing after stopping at the north approach.
Sequence of events
A detailed sequence of events was compiled from various sources including the train, the crossing signals, the bus and video cameras at the OC Transpo Fallowfield Station. Some event times for activities that occurred onboard the bus were approximated based on multiple witness accounts of what transpired.
All available data from the electronic units recovered from the bus and containing NVM was downloaded and examined at the TSB Engineering Laboratory. This work was completed by May 2014. Only the Engine Control Module (ECM) contained any information relevant to the operation of the bus just prior to the accident. However, the information lacked sufficient detail to conduct a meaningful analysis and further work was required to calculate speed at the time of the collision, braking force and the related stopping distances.
Bus braking system
A detailed teardown and examination of the bus braking system was completed in June 2014. A braking analysis was performed to determine event timing, speed at the time of impact, braking distance and amount of brake force applied to a loaded bus during the accident scenario. The analysis incorporated measurements and observations made on-site and detailed engineering calculations based on ECM data, brake system reaction time and brake performance charts from both the bus certification tests and manufacturer tests. This work was completed in August 2014.
Traffic studies and speed testing
Traffic studies were conducted on Woodroffe Avenue, the Transitway and Fallowfield Road. The TSB conducted speed testing in the vicinity of the crossing for vehicles using the Transitway.
TSB Human Performance staff conducted an ergonomic study of the driver's station for each of the bus designs operated by OC Transpo.
As part of data collection and information sharing, the following activities have been ongoing:
- In accordance with an existing Memorandum of Understanding (MOU), the TSB and the Coroner have been sharing information in support of each other's ongoing investigations.
- Numerous interviews have been conducted with survivors, witnesses, OC Transpo staff and City of Ottawa personnel. The TSB continues to conduct interviews as necessary.
- TSB specialists have remained in contact with the next of kin of the victims and have provided them with updates on progress.
What we know
The following is a summary of facts as determined by the investigation so far.
- The bell was activated, but no train horn was sounded due to an existing municipal ban.
- The crew applied the emergency brakes 2 seconds prior to the accident.
- The train was travelling at 47 mph when it was struck by the bus.
- At the time of the accident, the crossing Active Warning Device (AWD) protection operated as intended with no malfunctions.The gates had been horizontal for 26 seconds prior to the accident.
- TSB has not identified any issues with the operation of the train, the operation of the crossing signals or the condition of the track.
- The Coroner's investigation determined that there was no medical illness involved in the driver's death and toxicology testing showed no evidence of drugs or alcohol.
- A series of mandatory certification tests had been conducted to verify compliance with the Canada Motor Vehicle Safety Standards (CMVSS). The bus met or exceeded all CMVSS criteria for operation in Canada.
- Upon delivery of the bus, an Ministry of Transportation of Ontario (MTO) inspection was performed on 21 September 2012, with no exceptions noted.
- The bus was maintained in accordance with the operator's approved maintenance program.
- There were no reported brake defects on the occurrence bus.
- There were no mechanical discrepancies identified that would preclude normal operation of the bus air brake system.
- The initial application of the bus brakes occurred when the bus was travelling at a speed of 67.6 km/h (42 mph ), which exceeded the posted speed limit of 60 km/h (37.3 mph).
- Full braking force was not initially applied.
- The bus was located 116.8 ft (35.6 m) south of the point of collision when braking was initiated.
- The bus was travelling between 6.4 - 7.7 km/h (4 and 4.8 mph ) when the collision occurred.
- TSB calculations indicated that, the stopping distance for a bus travelling at the posted speed limit (60 km/h) with all other factors remaining the same, would have been 29.5 m (96.8 ft) which would be 6.1 m (20 ft) before the point of collision.
- Within the driver workstation of the ADL double decker buses, a small video monitor (6” (15 cm) wide by 3 ¾” (10 cm) high) is located on the left side of a forward panel above the driver seat which creates a significant upwards viewing angle for the driver.
- OC Transpo drivers are instructed not to stare at the video monitor while driving.
- At station stops, OC Transpo drivers are required to view the monitor before departing to ensure that upper deck passengers are seated. If passengers are seen standing on the upper deck, drivers are required to announce that standing is not permitted on the upper deck.
- To find available seating after boarding a double decker bus, some passengers may be moving or standing on the upper deck after the bus is in motion. Under these conditions, to monitor the upper deck, a driver will need to periodically glance at the screen while the bus is in motion. This situation can lead to a driver being visually distracted from the driving task.
Communication of safety deficiencies
Today, the TSB issued two new safety advisory letters (RSA 10/14, RSA 12/14) to the City of Otttawa on: distracted driving, and bus speed on the Transitway at the VIA Rail level crossing.
With respect to distracted driving, given the importance of minimizing driver distraction, the City of Ottawa may wish to review the procedural/operational aspects related to the use of the video monitors on OC Transpo double decker buses to ensure that safe bus operation is always maintained.
With respect to bus speed on the Transitway, the City of Ottawa may wish to implement additional measures to monitor and control bus speed, particularly in the vicinity of railway crossings.
Following the identification of safety issues in the September 2013 TSB accident re-enactment, the City of Ottawa:
- Reduced the speed on the Transitway in the area of the crossing from 60 km/h to 50 km/h.
- Cleared the trees and brush that obscured the crossing.
- Removed the sign adjacent the Transitway which obscured the crossing lights.
- Installed an advance warning light for the northbound lane approaching the crossing.
For VIA Rail:
- Although still visible for northbound traffic, 2 of the crossing lights were slightly misaligned.
The misalignment was corrected and all 142 VIA public crossings were subsequently inspected (Alexandria, Beachburg, Smiths Falls and Chatham Subdivisions). A total of 20 lights were corrected at 12 crossings.
On 25 February 2014, the TSB issued 2 Rail Safety Advisory Letters (RSA 01/14, RSA 02/14) to the City of Ottawa, following a review of a number of reported incidents that occurred at the crossing. While such incidents are not normally reportable to the TSB, the team followed up on them as part of its ongoing investigation.
The TSB documented 4 incidents in which OC Transpo buses traversed the crossing while the lights were activated but the gates had not yet come down.The TSB advised that vehicle drivers should slow down when approaching a railway crossing, look both ways, be prepared to stop and yield the right of way to a train. It further suggested that the City of Ottawa ensure that buses can stop safely in advance of an activated railway crossing signal. On 28 February 2014, in response, OC Transpo issued Bulletin No. 050/14, entitled Safety at Railway Crossings to all operators (drivers), Transit Supervisors and Dispatchers. On 02 May 2014, OC Transpo and the Amalgamated Transit Union (ATU) jointly issued a handout, entitled Railroad Crossings, Important Information for all Operators, to all drivers.
Additionally, the TSB documented an incident where the crossing protection remained activated in fail-safe mode following a malfunction and 3 OC Transpo buses subsequently traversed the crossing while AWD protection was activated. The TSB suggested that OC Transpo and VIA Rail may wish to develop and implement Standard Operating Procedures to ensure safe operations when unusual activations or malfunctions of crossing automated protection occur. The City of Ottawa and VIA Rail have since implemented procedures to respond to these types of occurrences.
As the investigation continues, the TSB will:
- undertake further assessment of crossing and roadway alignment including a review of previous grade separation studies;
- review the studies relating to buses stopping at railway crossings;
- continue to analyze what may have influenced driver behaviour and information processing;
- gather and analyze information related to OC Transpo transit operations and bus driver training; and
- conduct a crashworthiness assessment of the bus.
This information is factual in nature and does not contain any analysis. Analysis of the accident and the findings of the Board will be part of the accident report. The investigation is ongoing.
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
Dorval, Quebec, 23 September 2014 – The Transportation Safety Board of Canada (TSB) today released its investigation report (A12Q0029) into the appearance of smoke in the cabin and emergency landing of a Pascan Aviation Inc. Beechcraft B100 aircraft.
On 21 February 2012, flight PSC123 left the Montreal/Saint-Hubert airport at 9:07 Eastern Standard Time on a chartered flight to Bagotville, Quebec, with 2 passengers and 2 flight crew on board. During the climb out, through 15 400 feet above sea level, the crew noticed very light smoke in the cabin. At 9:28, the flight crew declared an emergency and requested a return to the Montreal/Saint-Hubert Airport. The aircraft touched down at 9:51 on Runway 24R with emergency services in attendance. There were no injuries and there was no fire.
The TSB investigation found that three hot air duct sections carrying air that is bled from the engines to heat the cabin, were melted, collapsed and perforated due to overheating. The air ducts are located under the floor on the right side of the main cabin and the heat escaping from them likely caused the appearance of light smoke in the cabin. This led the Board to conclude that the material employed to manufacture the hot air ducts does not resist the highest temperatures to which they may be exposed under operating conditions and consequently may not have been suitable for this purpose.
Pascan Aviation Inc. has taken steps to address the issues by reminding its maintenance personnel to inspect the hot air ducts and underfloor bleed air line installation closely.
Georgian Bay 2013 accident underscores the need to document aircraft modifications and adhere to strict weight allowances
Richmond Hill, Ontario, 10 September 2014 – The Transportation Safety Board of Canada (TSB) today released its report (A13O0125) into the 4 July 2013 accident involving a privately-registered Cessna 182 equipped with amphibious floats. While conducting a visual approach to Runway 27 at Griffith Island, Ontario, the overweight aircraft aerodynamically stalled and collided with the water approximately 1000 feet south-east of the runway threshold. The three occupants of the aircraft were fatally injured.
The TSB investigation team determined that the aircraft was over its maximum weight allowances, thus increasing the risk of an aerodynamic stall. Furthermore, the team found that the aircraft had undocumented major modifications to the seat and safety-belt installations, and that it was not in conformance with applicable airworthiness standards at the time of the crash.
The investigation concluded that while the impact forces were survivable, they were sufficient enough to cause extensive damage to the airframe, seats, and safety-belt attachments. The two occupants in the front seats did not survive due to the severity of the impact; the occupant in the rear seat who was wearing an improperly-installed seatbelt survived the impact, but then drowned.
Overloading a central cause of 2013 water bomber accident on Moosehead Lake, Newfoundland and Labrador
Halifax, Nova Scotia, 28 August 2014 – he Transportation Safety Board of Canada (TSB) today released its report (A13A0075) into the loss of control and collision with water of a Government of Newfoundland and Labrador Air Services Division water bomber engaged in firefighting duties. The report found that the aircraft took on too much water and failed to resume flight. The aircraft came to rest upright on the lake and partially submerged. There were no injuries to the two crew members, however the aircraft was destroyed.
On 3 July 2013, at about 2:15 p.m. Atlantic Daylight Time, the Bombardier CL-415 amphibious aircraft operating as Tanker 286, departed Wabush, Newfoundland and Labrador, to fight a nearby forest fire. Shortly after departure, Tanker 286 touched down on Moosehead Lake to scoop a load of water. About 40 seconds later, the captain initiated a left hand turn and almost immediately lost control. The aircraft came to rest upright, but partially submerged. The crew exited the aircraft and remained on the top of the wing until rescued by boat.
The TSB accident investigation found that the PROBES AUTO/MANUAL switch position check was not included on the checklist, and it is likely that the PROBES AUTO/MANUAL switch was inadvertently moved from the AUTO to MANUAL selection. The switch controls the probes, which is the equipment used to scoop water from a lake. The report warns that, if a checklist does not include a critical item, and flight crews are expected to rely on their memory, then there is a risk that the item will be missed and safety could be jeopardized.
The investigation also found that the flight crew was occupied with other flight activities during the scooping run and did not notice that the water quantity exceeded the predetermined limit until after the tanks had filled to capacity. The flight crew then decided to continue the take-off with the aircraft in an overweight condition.
Some safety action has been taken by the Government of Newfoundland and Labrador Air Services Division. Changes have been made to the storage and securement of safety gear and the installation of a portable satellite telephone in their aircraft. Water bomber pilots and maintenance personnel will be subject to new training and an increased training flight schedule. Finally, the checklist has been amended to include PROBES AUTO/MANUAL switch verification.