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Transportation Safety Board of Canada

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Richmond Hill, Ontario, 30 June 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (A14O0077) into the loss of control and subsequent collision with water and fatality involving a Cessna 185E at Taylor Lake, Ontario.

On 24 May 2014, a privately-registered Cessna 185E, equipped with amphibious floats, departed the Guelph Airpark for a flight to Taylor Lake, Ontario. The pilot was the sole occupant of the aircraft. While conducting a glassy-water landing, the pilot lost control and the aircraft cartwheeled and sank. The aircraft fuselage was damaged by impact forces and the pilot’s door could not be opened. The pilot survived the impact but was not able to escape the submerged aircraft before drowning.

The investigation found that the right float contacted the water first, dug in, and resulted in a loss of control and the aircraft cartwheeling. With respect to contributing factors, the investigation determined that the number of hours the pilot had flown in recent years had decreased, and the pilot was likely less proficient than in earlier years. This would make the glassy-water landing more difficult. Glassy-water conditions are considered to present the most difficulty for landing a seaplane, regardless of experience. The mirror effect created by glassy-water conditions affects depth perception making it difficult for pilots to determine the aircraft’s height above the water.

The investigation also found that the pilot did not have emergency egress training. Although not required by regulation, egress training has been shown to improve the chances of exiting a submerged aircraft following a survivable accident.

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Winnipeg, Manitoba, 29 June 2015 – In its investigation (A12Q0216) into the Perimeter Aviation Flight 993 that crashed while landing in Sanikiluaq, Nunavut, on December 22, 2012, the Transportation Safety Board of Canada (TSB) determined that the aircraft came in too high, too steep, and too fast, striking the ground 525 feet past the end of the runway after an unsuccessful attempt to reject the landing. The 2 crew and 6 adult passengers, secured by their seatbelts, suffered injuries ranging from minor to serious. A lap-held infant, not restrained by any device or seatbelt, was fatally injured.

"Every day, families board commercial aircraft with babies and young children, and the majority trust that, if something goes wrong, a parent's arms can restrain their child safely,” said Kathy Fox, Chair of the TSB. “In the case of severe turbulence, a sudden deceleration, or a crash such as this one, research has proven that adults are not strong enough to adequately restrain a lap-held infant just by holding on to them. And just like in cars, adult lap belts are not suitable to restrain young children. This accident saw an infant ripped from his mother's arms and killed in the subsequent impact, even though everyone else survived.”

In its report released today, the Board is issuing two recommendations aimed at making air travel safer for infants and children. First, it is recommending that Transport Canada require commercial air carriers to collect data, and report on a routine basis, the number of infants and young children travelling. Currently, these statistics are not available, and better data is required to conduct research, assess risks, and outline emerging trends related to the carriage of infants and children.

Second, the Board is recommending that Transport Canada work with industry to develop age and size appropriate child restraint systems for infants and young children travelling on commercial aircraft and mandate their use to provide an equivalent level of safety compared to adults.

“This investigation identified issues associated with pre-flight planning, crew communication and unstable approaches—but what stands out most was the tragic fate of the baby on this aircraft,” added Fox. “We think infants and children deserve an equivalent level of safety as adults on board aircraft, and that is why we are calling on Transport Canada and the aviation industry to take action. It's time to do right by our children.”

Approach-and-landing accidents are on the TSB Watchlist. The TSB continues to call on Transport Canada and operators to do more to reduce the number of unstable approaches that are continued to a landing.

See investigation page for more information.

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Winnipeg, Manitoba, 25 June 2015 – The Transportation Safety Board of Canada (TSB) will hold a news conference on 29 June 2015, to make public its report (A12Q0216) on the investigation into the Perimeter Aviation aircraft that crashed on 22 December 2012 in Sanikiluaq, Nunavut.

When:
29 June 2015
1:30 p.m. Central Daylight Time
Who:
Kathy Fox, TSB Chair
Gayle Conners, Investigator-in-charge
Missy Rudin-Brown, Senior Human Factors Investigator
Where:
Holiday Inn Winnipeg International Airport Hotel by Polo Park
1740 Ellice Avenue
Winnipeg, Manitoba

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

The news conference will be webcast live from Winnipeg. You can view the webcast at the following address http://www.ustream.tv/channel/transportation-safety-board-of-canada.


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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Moncton, New Brunswick, 19 June 2015 – In its investigation report (R14M0002) released today, the Transportation Safety Board of Canada (TSB) determined that a wheel with an undetected defect broke, leading to the January 2014 derailment and fire involving a Canadian National (CN) train near Plaster Rock, New Brunswick.

On 7 January 2014, a CN freight train travelling from Toronto, Ontario, to Moncton, New Brunswick, derailed 19 cars and 1 mid-train locomotive near Plaster Rock. Seven Class 111 tank cars carrying petroleum crude oil and other dangerous goods, and 5 Class 112 pressurized tank cars carrying butane were among those that derailed. Approximately 230,000 litres of crude oil spilled from the tank cars and caught fire. About 150 residents were evacuated within a 1.6 kilometre radius of the fire. A total of 350 feet of track was destroyed, and there were no injuries.

The investigation determined that a wheel on the 13th car shattered due to an area of subsurface porosity that led to fatigue cracking. The subsurface porosity was not detected during the ultrasonic testing when the wheel was manufactured in 1991, or when it was reprofiled in 2006. The broken wheel and the wheel on the opposite side of the same axle derailed inside the track gauge, causing track damage leading to the derailment of the 19 cars and the mid-train locomotive.

The derailed cars included 4 older Class 111 tank cars, 3 Class 111 tank cars built to the CPC-1232 standard, and 5 Class 112 pressurized tank cars. The couplers of other cars punctured 2 of the older Class 111 tank cars, causing them to release their contents and feed a large pool fire. The CPC-1232 cars fared better, although it was difficult to determine whether their performance was attributable to the enhancements or simply to their position in the train and the types of impacts they sustained. The Class 112 cars did not sustain any impact damage. However, the pressure relief device gaskets on 2 Class 112 cars and 1 Class 111 car degraded due to heat from the pool fire, causing some product to be released from these cars.

The investigation also found that appropriate and effective measures were taken in response to the emergency. The environmental response plan and derailment site remediation ensured a minimal and contained environmental impact.

Transportation of flammable liquids by rail is a TSB Watchlist issue. The TSB is calling on railway companies to conduct route planning and analysis, and perform risk assessments to ensure that risk-control measures are effective. This accident also underscores the TSB’s longstanding call for tougher standards for tank cars transporting crude oil to reduce the likelihood of a dangerous goods release during accidents. On 1 May 2015, Transport Canada introduced new regulations for a more robust tank car standard, retrofit requirements and an implementation timeline.

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Dartmouth, Nova Scotia, 17 June 2015 - The Transportation Safety Board of Canada (TSB) will hold a media availability on 19 June 2015, to make public its report (R14M0002) on the investigation into the CN train that derailed and caught fire in Plaster Rock, New Brunswick on 7 January 2014.

When:

19 June 2015
10:15 a.m. Atlantic Daylight Time

Who:

Don Ross, Regional Senior Investigator (English)
Guy Laporte, Investigator-in-Charge (French)

Where:

Dieppe Public Library
333 Acadie Avenue
Dieppe, 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 or to schedule an interview, please contact:
Transportation Safety Board of Canada
Media Relations
819-994-8053

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The occurrence

On 29 March 2015, an Air Canada Airbus A320-200 aircraft (registration C-FTJP, serial number 233), was being operated as Flight AC624 from Toronto, Ontario, to Halifax, Nova Scotia, with 133 passengers and 5 crew on board.

The aircraft was flying the localizer approach procedure to land on Runway 05 at the Halifax Stanfield International Airport. A localizer approach only provides pilots with lateral guidance to align the aircraft with the runway for landing. During the approach, the engines of the aircraft severed power transmission lines, and then the main landing gear and rear fuselage impacted the snow-covered ground about 225 metres before the runway threshold. The aircraft continued through a localizer antenna, then impacted the ground in a nose down attitude, about 70 metres before the threshold. It then bounced and slid along the runway, coming to rest on the left side of the runway about 570 metres beyond the threshold.

The passengers and crew evacuated the aircraft; 25 people sustained injuries and were taken to local hospitals. The aircraft was substantially damaged. There was no post-crash fire.

Investigation team work

The Investigator-in-charge, Doug McEwen, is assisted in this investigation by TSB investigators with backgrounds in flight operations, aircraft performance, aircraft systems, aircraft engines, human performance, and air traffic control. Representatives from Air Canada, Airbus, NAV CANADA, Transport Canada, France’s BEA (Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile), the RCMP, Halifax International Airport Authority, and the Halifax Regional Police department are also providing assistance.

Work to date

A large number of technical and operational documents, weather reports, air traffic control communications, and incident reports have been gathered and are being reviewed by investigation team members. Numerous interviews have been conducted with passengers and individuals from various organizations.

The flight data recorder (FDR) and cockpit voice recorder (CVR) have been examined. With assistance from external specialists, the TSB has retrieved information from the aircraft's Data Access Recorder, which records additional flight and aircraft parameters. Further analysis of this recorded data will be conducted.

What we know

Weather

Prior to landing, the crew received an updated weather report at 12:15 am Atlantic Time which included: windspeed 20 knots gusting to 26 knots from the north north west; 350° true; with a forward visibility of ½ statute mile in snow and blowing snow. The vertical visibility was 300 feet above the ground, temperature of minus 6°C, dewpoint minus 7°C, and altimeter setting of 29.63 inches of mercury.

The aircraft

Preliminary examination of the FDR indicates the aircraft was correctly configured for landing, the airspeed was consistent with a normal approach speed, and the altimeters were set to 29.63 inches of mercury. No mechanical deficiencies were identified with the aircraft's engines, flight controls, landing gear and navigation systems. During the review of the aircraft's maintenance records, no discrepancies were noted. Approximately 4900 litres of fuel was recovered from the aircraft.

Post-impact damage

The forward right and both rear exits were not used during the evacuation. No discrepancies were noted during the initial examination of these exits. Examination of the aircraft revealed that the right side cabin floor in seat rows 31 and 33, and the floor adjacent to the flight attendant fold-down seat near the rear of the cabin were punctured from below by aircraft structure. No pieces of the localizer antenna structure penetrated the cockpit.

Next steps

Work will include:

  • Recreating the accident flight profile as closely as possible to add to the understanding of the challenges encountered by the pilots of AC624.
  • Completing a detailed site survey illustration, examining relevant aircraft components and developing an animation of the aircraft's flight profile.
  • Evaluating pilot training and experience, human performance aspects, crew resource management, industry standards and company operating procedures.
  • Reviewing flight attendant training and experience as well as company procedures and regulatory requirements.
  • Examining survivability issues such as cabin and cockpit crashworthiness, passenger evacuation, and airport emergency response.
  • Reviewing non-precision localizer approaches utilizing a stabilized constant descent angle.
  • Conducting additional interviews as required.
  • Ongoing examination of aircraft structural damage.

Approach-and-landing accidents

The TSB Watchlist identifes approach-and-landing accidents as one issue which poses the greatest risk to Canada's transportation system. These accidents include runway overruns, runway excursions, landings short of the runway, and tail strikes. The TSB has called on operators, regulators, and air navigation service providers need to take more action to prevent approach-and-landing accidents, and to minimize the risks of adverse consequences if a runway overrun occurs.

Communication of safety deficiencies

Should the investigation team uncover a safety deficiency that represents an immediate risk to aviation, the Board will communicate without delay so it may be addressed quickly and the aviation system made safer.

The information posted 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 final report. The investigation is ongoing.

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Richmond, British Columbia, 15 June 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (M14P0110) into the loss of life involving the fishing vessel Diane Louise in Queen Charlotte Sound, British Columbia, on 6 June 2014.

A crew member on the fishing vessel Diane Louise went overboard while setting prawn traps 9 nautical miles west of Calvert Island in British Columbia. Although recovered within minutes and CPR was performed, the crew member succumbed to his injuries. The investigation found that the crew member became entangled in the groundline. The forward momentum of the vessel and the drag from the submerged traps attached to the groundline then pulled the crew member overboard. Unable to get free from the entanglement, the crew member was pulled underwater and drowned.

The investigation also identified a number of risk factors, including the lack of comprehensive risk assessments which could have identified unsafe work practices. It also determined that the crew were not using personal flotation devices (PFDs) while working on deck, nor were there any available for use. This can increase the risk of drowning for anyone going into the water.

Loss of life on fishing vesselsison theTSB Watchlist. Although regulations have been proposed by Transport Canada to address deficiencies with respect to fishing safety, there have been significant delays in implementation. The TSB is calling for concerted and coordinated action by federal and provincial authorities and by leaders in the fishing community to improve the safety culture in fishing operations, recognizing the interaction of safety deficiencies.

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Dartmouth, Nova Scotia, 9 June 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (M14A0051) into the 14 March 2014 flooding, grounding, and subsequent evacuation of the bulk carrier John I off the southwest coast of Newfoundland and Labrador. There were no injuries to the 23 crew members.

The John I entered ice-covered waters off the southwest coast of Newfoundland on its way to Montreal, Quebec, from Las Palmas, Spain. After the engine cooling water temperature began to rise, the crew opened the sea water strainer and found it was plugged. As the crew began removing ice and slush from the strainer, water began to overflow from the open strainer box. When the crew attempted to close the leaking sea chest valve to stop the flow of water, its operating mechanism failed. Sea water began to enter the vessel in an uncontrolled manner, overflowing into the engine room. The master then ordered the vessel to be blacked out, causing it to drift. As the vessel drifted towards the shore, commercial towing assistance was requested, but delayed due to the weather.

Upon its arrival on scene, the Canadian Coast Guard (CCG) vessel Earl Grey offered to tow the John I away from the shore. Further delays were encountered while the John I's master conferred with the vessel's managing company, the CCG and the Joint Rescue Coordination Centre (JRCC). When the master finally accepted the tow, the first attempt to establish a tow line failed, and the vessel's proximity to the shoals did not allow for completion of a second attempt. The John I then ran aground on the shoals. The crew members were evacuated by helicopter. The vessel's hull sustained minor damage.

The investigation found that warmed sea water from the engine cooling system was being partially discharged overboard and partially returned to the main sea water pump suction, rather than being recirculated to the low sea chest to prevent ice buildup. The strainer became plugged with ice and slush. The sea chest valve was prevented from fully closing, likely due to ice buildup, and the valve operating mechanism failed due to overstress when the crew forcibly attempted to close it, which led to the flooding.

The JRCC did not have the authority to direct the master of the John I to accept the tow. Neither the Department of Fisheries and Oceans Environmental Response nor Transport Canada, both of which had the authority to direct the vessel to accept the tow, were actively involved at an earlier stage when it was clear that the time to take action was running out and the environmental risks posed by the vessel going aground were increasing. The delay in starting the towing operation was caused both by the master's reluctance to accept the tow and by the way that authorities managed the situation. If all authorities responsible for dealing with an emergency are not involved in a timely and coordinated manner, there is a risk that response options will be limited and the situation will escalate.

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Ottawa, Ontario, 5 June 2015 - Transportation Safety Board of Canada (TSB) is pleased to open its doors to the public for guided tours of its Engineering Laboratory facilities on Saturday 6 June 2015.

The TSB Engineering Laboratory plays a pivotal role in the investigation of marine, pipeline, railway, and aviation accidents. Its staff helps determine whether mechanical, electrical, material, structural or other deficiencies contributed to accidents. Lab experts analyze information from data recorders ("black boxes"), electronic equipment, field photographs and site surveys, to piece together the sequence of events leading to an accident.

Visitors can expect to see some wreckage and components related to accident investigations, equipment used by investigators to examine materials and electronic systems, and the flight recorder analysis area. Visitors will also be able to speak with TSB investigators about their areas of expertise.

Limited tours of the materials analysis, systems engineering and flight recorder areas will be available on a first come, first served basis. Tours start at 9 a.m. and the last tour begins at 3:00 pm.

When:
Saturday 6 June 2015
9:00 am to 4:00 pm

Where:
Engineering Laboratory
1901 Research Road
Ottawa, ON

Directions from downtown Ottawa:

South on Bronson Ave.
Bronson Ave. becomes the Airport Parkway
Continue South
Take Uplands Dr. exit and turn right
Turn Left at Research Rd
1901 Research Rd. is at intersection with Canadair Priv.

We look forward to seeing you at the Lab!

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Gatineau, Quebec, 3 June 2015 – The Transportation Safety Board of Canada (TSB) is pleased to invite journalists to a tour of its Engineering Laboratory facilities. It is an opportunity to provide a "sneak peak" of what the public will see during Doors Open Ottawa on Saturday 6 June 2015, and to learn about the important work the Laboratory does during accident investigations.

The TSB Engineering Laboratory plays a pivotal role in the investigation of marine, pipeline, railway, and aviation accidents. Its staff help determine whether mechanical, electrical, material, structural or other deficiencies contributed to accidents. Experts analyze information from data recorders ("black boxes"), electronic equipment and field photographs and site surveys to piece together the sequence of events leading to an accident.

Journalists can expect to see some wreckage and components related to accident investigations, equipment used by investigators to examine materials and electronic systems, and the flight recorder analysis area.

When:
Thursday 4 June 2015 from 11 a.m. to 12 p.m. Eastern Time
Where:
Engineering Laboratory
1901 Research Road
Ottawa, ON

We look forward to seeing you there!

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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