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Transportation Safety Board of Canada

Transportation Safety Board of Canada (550)

Gatineau, Quebec, 23 February 2018 – The Transportation Safety Board of Canada released today its investigation report (R17H0015) on a collision between a school bus and a train at a railway crossing near Colborne, Ontario. The investigation examined the requirement for school buses to stop at all railway crossings, driver practices, winter tire performance data, and deficiencies in company procedures for railway crossing emergencies.

On 13 February 2017, a Canadian Pacific freight train, travelling eastward on the Belleville Subdivision, struck a school bus that became immobilized at the Town Line Road public crossing near Colborne, Ontario. The crossing was equipped with flashing lights and a bell. Prior to the collision, the school bus driver and two occupants exited the bus and were standing a safe distance away. The bus and a signal mast on the north side of the tracks were destroyed. The locomotive sustained minor damage.

The investigation found that, after stopping as required at the railway crossing, the bus became immobilized when the driver slowed the bus to look both ways a second time while driving over the crossing. Given that the bus had previously come to a stop and that snow had accumulated on the road, the rear tires could not provide the traction required to propel the bus up the incline. The driver believed that crossing slowly and looking in both directions once on the tracks was safer, despite company training instructions to move quickly and without hesitation across the tracks. Yearly company evaluations did not identify the driver's practice of reducing speed when travelling over crossings.

Once the bus was immobilized, the driver followed company procedures and notified the dispatcher of the emergency. Before contacting the railway, the dispatcher confirmed the location of the bus, including the identity of the crossing. However, railway companies post information at the crossing about the identity of the crossing and contact information to facilitate quick notification in an emergency. Notification time would likely have been reduced had the information posted at the crossing been provided immediately to the dispatcher. If emergency response procedures of commercial road transport operators do not include immediate notification to the railway company using the emergency information posted at crossings, opportunities to avoid crossing collisions will be missed.

Many jurisdictions require school buses to stop in advance of all railway crossings, even when crossing warning systems such as bells and lights are not activated. Although this is believed to improve safety, there have been a number of recent accidents where a school bus stopped in advance of a crossing protected by warning systems, continued onto the crossing, and then was struck by an oncoming train. A 1985 study had determined that there would be a decrease in bus-train accidents if stopping wasn't required. However, in the absence of up-to-date risk analysis to determine whether buses should stop at railway crossings, even when warning devices are not activated, there is a risk of railway crossing safety not being optimized. As part of its investigation (R13T0192) into a fatal collision between a public transit bus and a VIA Rail Canada train in Ottawa, Ontario, the Board expressed its concern that, without a comprehensive study that deals with the risks associated with all buses stopping at all railway crossings, decision makers may not make the best choices possible to ensure an adequate level of safety.

At the time of this occurrence, there were no regulatory or industry standards to evaluate school bus tire traction test results, similar to those for passenger vehicles or light trucks, to determine which tires were most suitable for winter driving. As such, bus operators relied on their experience and information from tire manufacturers. If school bus operators do not have access to independent and objective assessments of winter tire performance, there is an increased risk that the most suitable winter tire will not always be chosen.

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Gatineau, Quebec, 20 February 2018 – The Transportation Safety Board of Canada (TSB) released today its preliminary transportation occurrence statistics for 2017. The TSB, Transport Canada, the transportation industry, as well as many other organizations and researchers, use these statistics on reportable occurrences in the air, marine, railway and pipeline modes of transportation for the identification and analysis of trends. An initial review of the preliminary occurrence information highlights some noteworthy observations. In early spring, the TSB will release its complete and final statistical reports for 2017, including accident rates and a more thorough analysis of the data.

Air transportation

In 2017, 239 aviation accidents were reported to the TSB, which is slightly lower than the 5‑year average of 259. After a five-year decline, the number of accidents among commercial operators increased in 2017. This increase is partly due to a higher number of flight training accidents. The December 2017 accident in Fond-du-Lac, Saskatchewan, was the first fatal accident in Canada involving a Canadian airliner since the accident in Resolute Bay, Nunavut, in 2011.

There were 921 aviation incidents reported to the TSB in 2017, which represents a significant increase compared to the previous year (833) and the 5-year average (737). This trend is partly due to an increase in the risk of collision and loss of separation incidents. The first known collision between a commercial aircraft and an unmanned aerial vehicle (drone), in Canada, also occurred in 2017.

Marine transportation

There were 276 marine accidents reported to the TSB in 2017, down 10% compared to 2016, but close to the 5-year average of 284. There were 10 fatal accidents, which resulted in 11 fatalities. Three of those fatalities occurred in the fishing industry. Although this number has decreased in the last two years, so have the number of registered fishing vessels and the number of fishermen.

Some 875 marineincidents were reported to the TSB in 2017, which is a 36% increase compared to the 5-year average of 645. The increase consists mainly of incidents where vessels made bottom contact, and incidents of total failure of machinery or technical system.

Railway transportation

In 2017, 1,090 railway accidents were reported to the TSB, a 21% increase over 2016 but close to the 5-year average of 1,028. There were 77 rail-related fatalities – 11 more than the previous year but close to the 5-year average of 75. Among these, 53 involved trespassers, compared to 47 in 2016 and to the 5-year average of 39.

Among all TSB-reported railway accidents, 115 involved dangerous goods, up from 100 in 2016 but a 9% decrease compared to the 5-year average of 127. Five of those accidents in 2017 resulted in a dangerous goods release.

There were 274 railway incidents reported to the TSB in 2017, a 16% decrease from 2016 and a 13% decrease from the 5-year average. About half of these (122) were movement exceeds limits of authority incidents – 11 fewer than in 2016 but close to the 5-year average of 124.

Pipeline transportation

The number of pipeline occurrences reported to the TSB involving a release of product in 2017 was up following five consecutive years of decrease. Only one of the 72 occurrences in 2017 involved a release from the pipeline body. There was one serious injury related to a federally-regulated pipeline occurrence in 2017, the first since 2012. There was also a larger than usual number of incidents involving soil erosion. This is likely due, in part, to the unusually wet weather in 2017.

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Edmonton, Alberta, 22 February 2018 – The Transportation Safety Board of Canada issued its investigation report (A17W0024) into the February 2017 loss of control and collision with terrain involving a Tecnam P2006T aircraft operated by Mount Royal University near the Calgary/Springbank Airport, Alberta.

On 13 February 2017, a Tecnam P2006T aircraft departed from the Calgary/Springbank Airport, Alberta, on an instructional flight. On board, there was a flight instructor and a pilot undergoing multi-engine training, who was also a flight instructor at Mount Royal University. Approximately 30 minutes into the flight, the aircraft departed from controlled flight and collided with terrain 32 miles northwest of the airport. There was a post-impact fire and the aircraft was destroyed. Both occupants were fatally injured.

The investigation found that for unknown reasons, the aircraft entered a spin from a stall exercise. The instructor and trainee recovered the aircraft from the spin, but insufficient altitude remained to recover from the ensuing dive.

The flight training material at Mount Royal University mentioned two types of stall recoveries: one for when the aircraft approaches a stall and the other for when the aircraft has stalled. However, guidance material issued by both Transport Canada (TC) and the United States Federal Aviation Administration indicate that a reduction in the angle of attack should be the only stall recovery technique to be used for either scenario. Further, TC issued an advisory to emphasize the importance of reducing the angle of attack during a stall or approach to stall. This information was not incorporated into TC's instructor guide for the multi-engine class rating. If flight training units do not emphasize that the most important reaction to a stall or approach to stall is a reduction in the angle of attack, a loss of aircraft control may occur.

Following the occurrence, Mount Royal University took a number of safety actions. These include: an increase in the minimum altitude at which an aircraft should be recovered from a stall; the issuance of a memo to all instructional staff clarifying the roles of the designated instructor and the designated student, when two instructors are conducting staff training flights together; the acquisition of a different aircraft type for its multi-engine training program; and the production of revised multi-engine standard operating procedures.

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Moncton, New Brunswick, 15 February 2018 – Today the Transportation Safety Board of Canada (TSB) is calling on Transport Canada (TC), railway companies and road authorities across Canada to take steps to improve safety at railway crossings that are designated for persons using assistive devices, such as wheelchairs, arm supports, hearing aids, visual aids, and others. The recommendation (R18-01) asks TC to collaborate with these stakeholders to identify and assess the effectiveness of various engineering options for designated railway crossings, and update its regulatory provisions accordingly.

The recommendation is being issued as part of a TSB investigation report (R16M0026) into a 2016 accident in which a person in a wheelchair was struck and fatally injured by a Canadian National (CN) freight train at a railway crossing in downtown Moncton, New Brunswick. The individual's motorized wheelchair became immobilized in the gravel at the edge of a sidewalk at the Robinson Street public crossing and was struck at about 1:43 a.m. on 27 July 2016. The investigation found that several crossing conditions contributed to the accident, including a void in the asphalt and the lack of visual cues to navigate safely.

"Designated crossings are used by persons who have particular needs, so it only makes sense that they require particular consideration as to their design and safety features," said TSB Board member Faye Ackermans. "More than 2 million Canadian adults identify as having a mobility disability, including 300 000 wheelchair users. Moreover, the number of persons with an assistive device is on the rise."

The investigation also found that federal regulations required railway companies and road authorities to share certain information regarding crossings by November 2016. This requirement included the identification of those crossings equipped with a sidewalk, path or trail designated for persons using assistive devices. The Board is concerned that some of this information has yet to be shared. "Until this happens and these crossings are identified," said Mrs. Ackermans, "required improvements may not be implemented in a timely manner, and Canadians, particularly those using assistive devices, will continue to be at an elevated risk at railway crossings."

"Despite new standards introduced in 2014, there remains a clear need for additional improvements. Today is an opportunity to do exactly that," added Mrs. Ackermans. Upgrades for designated crossings could include improved lighting, additional visual and audio cues, flangeway fillers, changing the angle of the sidewalk and textured surfaces, for example.

Since the accident, CN has made several repairs to the Robinson Street crossing, including the sidewalk areas. The City of Moncton notified CN that the crossings at Robinson Street and nearby Victoria Street have been designated for persons using assistive devices. The city is also developing its own crossing standards, which are planned for implementation in 2018.

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Dorval, Quebec, 14 February 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A17Q0162) into the 12 October in-flight collision between a drone and a Beechcraft King Air A100 near the Québec/Jean-Lesage International Airport, Quebec. Damage to the aircraft was minor and the drone disintegrated upon impact. There were no injuries.

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Richmond, British Columbia, 13 February 2018 – In its investigation report (A17P0007) released today, the Transportation Safety Board of Canada determined that operational factors and pilot decision-making contributed to the January 2017 collision with trees and power lines at the Duncan Aerodrome, British Columbia.

In the early afternoon of 19 January 2017, a Cessna 172 aircraft operated by the Victoria Flying Club departed from Victoria International Airport, British Columbia, on a visual flight rules training flight with an instructor and student on board. About 1.5 hours into the flight, the crew elected to conduct a short-field landing on Runway 31 at the Duncan Aerodrome. The runway is situated atop a hill, with terrain dropping away steeply on all sides, including both ends of the runway. The runway does not have overrun areas at either end of the runway, nor are these required by regulation. The aircraft touched down approximately one-third of the way down the runway and after attempting to stop, a take-off was attempted. The aircraft struck trees and then power lines off the north end of the runway and came to rest upside down under the power lines. The instructor was seriously injured, while the student sustained minor injuries. The aircraft was substantially damaged. There was no post-impact fire.

The investigation determined that the short-field landing at the Duncan Aerodrome was carried out with a light and variable tailwind on a short runway with no overrun area. No pre-flight short-field landing calculations were made prior to the flight. After being high and fast on approach, the aircraft crossed the runway threshold above the intended touchdown speed and remained airborne for at least one-third of the runway length before touching down. The landing attempt was continued to a point where there was insufficient runway distance remaining to bring it to a stop. A takeoff was then attempted; however, there was insufficient airspeed and runway distance remaining. The aircraft then left the runway below a safe flying speed and it sank below the runway elevation, resulting in its collision with several trees and power lines.

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

When:

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

Who:

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

Where:

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

This event is for media only. Media representatives will need to show their outlet identification.


The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

For more information, contact:
Transportation Safety Board of Canada
Media Relations
Telephone: 819-994-8053
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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