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Transportation Safety Board of Canada

Transportation Safety Board of Canada (483)

Dartmouth, Nova Scotia, 20 April 2017 – In its investigation report (A15A0054) released today, the Transportation Safety Board of Canada (TSB) found that ineffective crew resource management and an unstable approach led to the August 2015 hard landing of a Beechcraft King Air A100 in Margaree, Nova Scotia.

On 16 August 2015, a Beechcraft King Air A100 operated by Maritime Air Charter Limited was on a flight from Halifax Stanfield International Airport to Margaree Aerodrome, Nova Scotia, with two pilots and two passengers on board. While conducting a visual approach to Runway 01, the aircraft touched down hard approximately 260 feet beyond the runway threshold. Almost immediately, the right main landing gear collapsed, causing the right propeller and wing to contact the runway. The aircraft then slid along the runway for about 1350 feet before veering off the runway to the right. There were no injuries, though the aircraft was substantially damaged.

The investigation found that the crew did not anticipate that landing on a short runway at an unfamiliar aerodrome with high terrain nearby would increase their workload during the approach and landing phase. This increased workload led to the crew's reduced situational awareness. As a result, the crew did not recognize the aircraft's steep rate of descent as being indicative of an unstable approach condition. The aircraft crossed the runway threshold with insufficient energy to reduce the rate of descent immediately before touchdown, resulting in the hard landing.

The findings of this investigation are consistent with a lack of effective crew resource management (CRM). If CRM is not used and continuously fostered, there is a risk that pilots will be unprepared to avoid or mitigate errors encountered during flight. The TSB issued a recommendation (A09-02) which called for Transport Canada (TC) to require smaller commercial operators to provide its crews with modern CRM training. TC has proposed new standards, which should address the safety deficiencies once implemented, thus the Board has assessed TC's action as Satisfactory Intent.

Although not required, Maritime Air Charter had voluntarily implemented a safety management system (SMS). However, the SMS elements were primarily used as a reactive method to address potential safety concerns. If organizations do not use modern safety management practices, there is an increased risk that hazards will not be identified and risks mitigated. Safety management and oversight is on the TSB Watchlist.

Following the occurrence, Maritime Air Charter Limited introduced revised procedures to improve the safety of its operations. These include a preflight risk assessment checklist, a requirement to calculate accelerate-stop distance when taking off from shorter runways, and enhanced training, including increased emphasis on stabilized approach criteria and controlled flight into terrain avoidance.

See the investigation page for more information.

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Dartmouth, Nova Scotia, 6 April 2017 – The Transportation Safety Board of Canada (TSB) today released its investigation report (M16C0016) into the flooding of the fishing vessel Saputi, after it struck a piece of ice and was holed, while fishing in Davis Strait, Nunavut, in February 2016. The report highlights the risks when large fishing vessels are not designed to withstand the flooding of a main compartment and crews do not have access to a damage control plan.

On 21 February 2016, the fishing vessel Saputi, with 30 people on board, was fishing turbot in Davis Strait, Nunavut. At 1935 Atlantic Standard Time, the vessel struck a piece of ice that cracked the hull in the cargo hold. After pumping operations failed to keep up with the ingress of water, the cargo hold was sealed, and it subsequently flooded. The vessel developed a severe list but was able to proceed to Nuuk, Greenland, arriving on 24 February. No injuries were reported.

The investigation determined that, at 1840, the master sighted a single piece of ice on the port side that was not assessed to be of any danger to the vessel. While the master slowly altered the Saputi'scourse to avoid the piece of ice, a wave lifted the vessel, and as the vessel fell off the wave, it made contact with the ice. As a result, a vertical crack in the ship's hull was created, which led to a significant volume of water entering the vessel. The crew of the Saputi unsuccessfully attempted to seal the crack using available materials not specifically intended for damage control. They had also actioned all on board pumps to try controlling the incoming water. If fishing vessels operating in ice-infested waters do not carry a damage control plan and booklet on board, the master and crew may be inadequately prepared for an emergency situation where there is ingress of water, and may be unable to keep the vessel afloat until the arrival of rescue resources.

Early the following day, the master advised Joint Rescue Coordination Centre (JRCC) Halifax that the vessel was unable to keep up with the ingress of water using the pumps on board, and requested additional pumps. Almost six hours later, a Hercules aircraft, tasked by JRCC Halifax, arrived at the Saputi and dropped off four gasoline-powered search and rescue (SAR) pumps to the vessel, which allowed the crew to remove a large volume of water. Shortly after, crew members advised the master that they were having suction issues with all four SAR pumps. Since the situation had deteriorated drastically, all pumping operations were stopped, leaving the cargo hold to flood completely. Large fishing vessels are not required to be designed to withstand the flooding of a main compartment. A naval architect who had completed stability calculations advised that the vessel could remain afloat and stable with the cargo hold flooded. If fishing vessels operating in ice-infested waters are not designed and constructed to withstand the complete flooding of any one of the main compartments, there is a risk that vessels will not be able to remain afloat if they lose their watertight integrity.

In this occurrence, the gasoline-powered pumps provided by SAR resources did not perform efficiently, and therefore did not control the ingress of water. To effectively address an emergency, it is critical that the equipment provided to a vessel in distress by SAR resources perform adequately.

Commercial fishing safety is a TSB Watchlist issue. Although regulations have been published and will likely lower some of the risks associated with outstanding safety deficiencies, gaps remain and these new regulations apply only to small fishing vessels up to 24.4 metres. Future phases of the regulations will address large fishing vessels over 24.4 metres; however, no work has commenced.

See the investigation page for more information.

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Dorval, Quebec, 3 April 2017 – In its investigation report (A15Q0126) released today, the Transportation Safety Board of Canada (TSB) found that a loss of directional control led to the September 2015 fatal helicopter accident near Sept-Îles, Quebec. Two passengers sustained fatal injuries, while the pilot and two other passengers suffered serious injuries.

On 2 September 2015, a Bell 206B helicopter operated by Héli-Nord was flying from the airport in Sept-Îles, Quebec, with one pilot and four passengers on board. The purpose of the flight was to inspect a salmon pass on Nipissis River, approximately 20 nautical miles north of Sept-Îles. During the final approach to the landing site at a river camp, a few feet from the ground, the helicopter began an uncommanded rotation to the right. After turning a few times, the helicopter crashed heavily into a rock on its front right side. A fire started in the engine tailpipe, and was immediately extinguished by persons on site.

The investigation determined that the helicopter was operating at a weight and in a flight regime that led to a loss of directional control at an altitude that did not allow any recovery. During the final approach, the pilot noticed that the engine torque had exceeded its limits and that the nose of the helicopter was starting to turn to the right. To counteract the uncommanded turn, the pilot reduced the engine torque while applying full left anti-torque pedal. However, the nose of the aircraft continued turning to the right and the helicopter kept losing altitude. The pilot increased the torque to reduce the rate of descent and tried to gain airspeed, but the right turn rate increased. Realizing that control of the aircraft was lost, the pilot cut the engine power and prepared for impact. The helicopter was in a nose-down position to the right before it collided with terrain. The investigation determined that the pilot's lack of experience on a Bell 206B helicopter with a shorter tail rotor than the one he had previously trained on prevented him from recognizing the loss of tail rotor effectiveness and counteracting it in a timely manner. The TSB also found that, if occupants do not wear safety belts correctly during a flight, there is an increased risk of serious injuries or death in the event of an accident.

See the investigation page for more information.

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Winnipeg, Manitoba, 29 March 2017 – In the release of its investigation report (R16W0004) today, the Transportation Safety Board of Canada (TSB) determined that a broken wheel, caused by a service-related failure, led to the January 2016 derailment of a Canadian National Railway Company (CN) freight train near Webster, Ontario.

On 9 January 2016, a CN freight train proceeding westward on the Redditt Subdivision experienced a train-initiated emergency brake application at Mile 21.74, near Webster, Ontario. A total of 26 cars had derailed, including six Class 111 residue tank cars that last contained diesel fuel. There were no injuries and no product was released.

The investigation revealed that a progressive fracture on a wheel of the second car from the head end eventually allowed the wheel to move inboard on the axle and derail. The train proceeded on the track for approximately eight more miles before cars derailed, setting off the train-initiated emergency brake application.

The investigation determined that about 14 minutes prior to the accident, the train passed a wayside inspection system (WIS) where a wheel impact load detector (WILD) recorded the impact load of the defective wheel. While the reading exceeded the Association of American Railroads (AAR) condemning limits, CN WILD guidelines permitted the wheel to remain in service without restriction until it reached its certified car inspection location. The development and implementation of WILD technology has been an industry initiative to enhance rail safety by proactively identifying wheels with defects that can cause derailments or damage to track infrastructure. However, if railway WILD guidelines do not provide adequate guidance for dealing with wheel impacts that are condemnable under AAR rules, there is an increased risk that wheels with emerging defects will not be identified and removed from service before progressing to failure.

In response to a 2011 TSB Rail Safety Advisory, Transport Canada (TC) had indicated that it would create a joint TC-industry forum to conduct a comprehensive review of WIS and WILD criteria. However, there has not been any progress by TC relating to guidelines, standards or rules for the use of WILD technology. In the absence of WILD condemning limits within the TC-approved Railway Freight Car Inspection and Safety Rules and/or other related TC guidance, WILD company guidelines may not be sufficiently robust to consistently protect against wheel failures.

See the investigation page for more information.

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Dorval, Quebec, 28 March 2017 – The Transportation Safety Board of Canada (TSB) investigation report (A14Q0155) into the 7 October 2014 runway excursion of an Air Canada Airbus A330 at Montréal/Pierre Elliott Trudeau International Airport illustrates the risks posed when conducting approaches and landings in the presence of thunderstorms.

On 7 October 2014, the Air Canada Airbus A330 was operating as flight ACA875 from Frankfurt, Germany, to Montréal-Pierre Elliott Trudeau International Airport with 217 people aboard. There was a thunderstorm north of the airport as the aircraft was on approach to Runway 24R in daytime visual conditions. Runway 24R was the only runway in operation, and the flight crew had been advised that the runway lights were out of service. During the final approach, the aircraft entered a heavy rain shower and encountered a strong right crosswind. It then deviated from its path before touching down to the left of the runway centreline. Soon after, the outboard tires of the left main landing gear departed the runway surface for a distance of approximately 600 feet. The aircraft returned to the centreline before taxiing to the terminal gate, where the passengers disembarked without further event.

The investigation determined that during the approach in the presence of a thunderstorm, a pilot-induced aircraft rolling movement resulted in the aircraft being in a left bank as it crossed the runway threshold, which, combined with a strong right crosswind, caused it to drift rapidly to the left. After crossing the runway threshold, the intensity of the rain suddenly increased, causing the pilot flying to have very few visual references. The rain and the absence of runway lighting made it difficult to detect the aircraft's lateral movement and prevent the runway excursion. In addition, during the final approach, weather conditions had changed rapidly to those requiring runway lighting. As the runway lights were not working, that runway should not have been used under those weather conditions.

This occurrence demonstrates how flight conditions near thunderstorms can change dramatically and abruptly, posing a risk to flight safety. As part of its investigation (A05H0002) into the 2005 Air France runway overrun in Toronto, the TSB issued a recommendation (A07-01) calling on Transport Canada (TC) to establish clear standards for limiting approaches and landings in convective weather. TC issued an Advisory Circular to alert Canadian air operators to the hazards associated with flight operations in or near convective weather conditions and did propose that this issue be addressed at the international level. However, it stopped short of issuing the recommended standards. If TC does not take action to develop clear standards for avoiding thunderstorms during approach and landing, approaches in the presence of thunderstorms will continue, exposing aircraft to multiple, unpredictable hazards.

The report also notes that Montréal-Pierre Elliott Trudeau International Airport is not equipped with a low-level wind shear alert system, nor is it required to by regulation. If airports are not equipped with a low-level wind shear alert system, crews landing may not be aware of the presence of rapidly changing wind direction and speed, and therefore are exposed to the risk of approach-and-landing accidents.

Following the occurrence, Aéroports de Montréal, the operator of Montréal-Pierre Elliott Trudeau International Airport, reviewed conditions for closing a runway when approach and runway lighting is out of service. Air Canada also developed new guidance for its flight crews regarding approach and visibility requirements.

See the investigation page for more information.

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Winnipeg, Manitoba, 21 March 2017 – The Transportation Safety Board of Canada (TSB) found that inadequate securement and insufficient employee supervision led to the March 2016 uncontrolled movement of a tank car in Regina, Saskatchewan. The results of the investigation are detailed in the report (R16W0059) released today.

On 1 March 2016, while a Cando Rail Services assignment was switching tank cars loaded with asphalt at the Co-op refinery in Regina, one of the tank cars rolled away uncontrolled. The tank car, which travelled about 2.7 miles (4.3 kilometres) before coming to rest, reached a speed of 19 mph and traversed seven public crossings and a railway interlocking that crossed the Canadian Pacific Railway Lanigan Subdivision. The grade crossing warning system at each of the seven crossings functioned as required, protecting the roadway traffic. There were no injuries nor dangerous goods involved.

The investigation determined that the incident occurred when the crew left the tank car unattended, secured only by emergency air brakes. These slowly lost pressure until they released, allowing the car to roll away. Hand brakes had not been applied to the unattended equipment, nor had crew members performed hand brake effectiveness tests, conducted a briefing with all crew members, or initiated an emergency radio broadcast when the tank car rolled away. Although the crew did attempt to catch the runaway car with their locomotive, they were unable to do so without violating the restrictions of their operating limits.

The TSB's investigation revealed that routine adaptations to rules and procedures by employees went undetected by the company prior to the incident. If adaptations are made to operating rules and procedures, safety margins built into the rules are often reduced, increasing the risk of unsafe operations and accidents.

Most uncontrolled railway movements in Canada are directly related to securement issues. Following the 2013 Lac-Mégantic accident, the TSB recommended that Transport Canada (TC) require Canadian railways to put additional physical defences in place to prevent runaway equipment (TSB Recommendation R14-04). Although TC revised the rules regarding train securement, the report indicates that the number of runaway equipment occurrences due to inadequate train securement had increased, from 21 in 2014 to 33 in 2015. There were 27 in 2016.

Following this occurrence, Cando Rail Services took a number of measures to increase the safety of its operations. This included issuing a system-wide bulletin requiring that all equipment have the minimum number of hand brakes applied, even if attended by an employee.

See the investigation page for more information.

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Richmond Hill, Ontario, 9 March 2017 – In its investigation report (A15O0015) released today, the Transportation Safety Board of Canada (TSB) determined that the continuation of an unstable approach following a loss of visual reference led to a Jazz Aviation LP aircraft contacting the surface short of the runway at the Sault Ste. Marie Airport, Ontario, in February 2015. There were no injuries, but there was significant damage to the aircraft.

On 24 February 2015, a de Havilland DHC-8-102, operating as Jazz Aviation LP flight JZA7795 and carrying 15 passengers, departed Toronto/Lester B. Pearson International Airport, Ontario, for a scheduled flight to Sault Ste. Marie Airport, Ontario. While on approach to Runway 30, in conditions of twilight and reduced visibility due to blowing snow, the aircraft touched down approximately 450 feet prior to the runway threshold. Following touchdown, the aircraft struck and damaged a runway approach light before coming to a stop approximately 1500 feet past the threshold.

The investigation determined that a significant power reduction and subsequent decrease in airspeed, while flying below the minimum stabilization height of 500 feet, resulted in an unstable approach. This rapid deceleration steepened the aircraft's vertical path. The crew had reduced power in order to reach the target airspeed for the final approach and landing.

The crew had followed what they understood to be the correct speeds for the approach according to the company's guidance material. Due to ambiguity in the guidance and uncertainty as to the required speed during the approach, the flight crew did not recognize that the approach was unstable and continued the approach to a landing.

The investigation also found that the rapidly changing weather decreased the flight crew's visibility of the runway, and that the steepened vertical profile created as a result of the power reduction went unnoticed, and uncorrected. Although the loss of visual reference required a go-around, the flight crew continued the approach.

An examination of over 500 similar flights on Jazz DHC-8-102s showed that company aircraft routinely fly decelerating approaches below the minimum stabilization height of 500 feet. If approaches that require excessive deceleration below established stabilization heights are routinely flown, then there is a continued risk of an approach or landing accident.

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 commercial air services to monitor and reduce unstable approaches that continue to a landing.

Following the occurrence, Jazz Aviation LP undertook a number of safety actions such as making amendments to the Jazz DASH 8 Aircraft Operating Manual, by introducing significant changes to the "Stabilized Approach Factors" subsection and adding simulator scenarios to the training syllabus.

See the investigation page for more information.

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Gatineau, Quebec, 8 March 2017 – Citing poor track conditions and inadequate drainage as important factors, the Transportation Safety Board of Canada (TSB) today released its investigation report (R15H0092) into the Huron Central Railway (HCRY) train derailment in 2015 near Spanish, Ontario.

On 1 November 2015, at approximately 2250 Eastern Standard Time, an HCRY freight train was proceeding westward on the Webbwood Subdivision at 25 mph when a train-initiated emergency brake application occurred at Mile 72.08, near Spanish, Ontario. Two separate groups of equipment derailed destroying about 225 feet of roadbed. No dangerous goods were involved and there were no injuries.

The investigation determined that the first group, three locomotives and the first eight cars of the train, derailed when the roadbed collapsed and the north rail joint broke apart under the train. The second group, five empty cars near the middle of the train, derailed due to compressive in-train forces when the cars impacted one another as the train rapidly decelerated during the derailment. The investigation also determined that HCRY's track inspection and maintenance program was not effective in dealing with various track infrastructure issues such as drainage, track instability, and rail joint defects. In this occurrence, a blocked culvert had resulted in inadequate drainage over several days of rain, allowing water to pool, migrate through the railway embankment and saturate the subgrade. If track inspectors are not provided with appropriate training on precursor ground hazards such as inadequate drainage, unstable ground conditions may not be detected in a timely manner, increasing the risk of derailment due to track conditions. Furthermore, a large number of rail joint defects were allowed to remain in service without performing the necessary follow up inspections regularly.

Following the occurrence, slow orders were issued for any identified track defects on the Webbwood Subdivision and the defects were repaired. The slow orders were removed only after repairs were completed and inspected by a supervisor.

As HRCY is a provincially regulated railway, the TSB investigation was conducted in accordance with a Memorandum of Understanding with the Province of Ontario.

See the investigation page for more information.

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Edmonton, Alberta, 27 February 2017 – The Transportation Safety Board of Canada (TSB) continues to advance its investigation into the accident involving a Tecnam P2006T aircraft operated by Mount Royal University, near Cochrane, Alberta. The TSB offers its condolences to the families and friends who lost loved ones in this accident.

What we know

  • A Tecnam P2006T twin-engine aircraft, operated by Mount Royal University, departed Calgary/Springbank Airport, AB (CYBW) at 1635 (Mountain Standard Time), during daylight hours.
  • The aircraft climbed to 8000 feet above sea level and progressed to the northwest.
  • Thirty minutes after departure, the last radar return from the aircraft was recorded at 7900 feet above sea level. This last radar return was 0.13 nautical mile southeast of the accident site location. The aircraft struck terrain 32 nautical miles northwest of CYBW at approximately 1705 (Mountain Standard Time).
  • All of the major aircraft components were located at the accident site but were destroyed by impact forces and a post-impact fire.
  • The aircraft was not equipped with, nor was it required to carry, a cockpit voice recorder (CVR) or a flight data recorder (FDR).

Work to date

  • The examination and documentation of the wreckage scene is complete and investigators have collected the data they needed from the accident site.
  • The wreckage was removed and transported to the TSB facility in Edmonton, Alberta, for further analysis.
  • We have requested the aircraft's maintenance history.
  • We have obtained most of the radar data and most of the air traffic control audio; we are waiting for a few more files and we are in the process of analyzing it.

Next steps

With the conclusion of the field phase, the examination and analysis phases begin. In the coming days and weeks, as part of its investigation process, the team will

  • examine components such as the engines and propellers;
  • send selected components to the TSB Engineering Laboratory in Ottawa, Ontario, for further analysis;
  • gather additional information about weather conditions;
  • gather information on air traffic control communications, and radar information;
  • examine aircraft maintenance records;
  • examine pilot training, qualifications, proficiency records and medical history;
  • continue interviews with the aircraft operator and other such witnesses;
  • review operational policies and procedures;
  • examine the regulatory requirements;
  • reconstruct events to learn more about the accident sequence (i.e., to validate data, test hypotheses, and verify assumptions);

Communication of safety deficiencies

Investigations are complex and we take the time needed to complete a thorough investigation. However, should the investigation team uncover safety deficiencies that present an immediate risk, the Board will communicate them without delay.

Further, it is important not to draw conclusions or speculate as to causes at this time. There are often many factors that can contribute to an accident.

Additional updates will be provided as required.

See the investigation page for more information.

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Richmond Hill, Ontario, 25 February 2017 – On February 25, 2017, Air Canada Flight 623 was travelling from Halifax to Toronto/Lester B. Pearson airport with 118 persons on board. Towards the end of the flight, the aircraft was flying an ILS approach to Runway 15R. Just after midnight, during the landing sequence, the aircraft travelled through the grass on the western side of the runway, eventually coming to a stop on the runway centerline. The passengers were deplaned on the runway and transported by bus to the terminal. There were no reported injuries, and apparent damage to the aircraft at this point is minor. The aircraft will be thoroughly examined to further determine the extent of the damage. Five runway edge lights were also damaged.

What we know

TSB investigators were deployed in the early morning to Pearson Airport to examine the aircraft and gather information. To date, we have:

  • Taken possession of the CVR and FDR. These will be sent to the TSB Lab in Ottawa for further analysis.
  • Gathered airborne radar, ground radar and audio data from Air Traffic Control.
  • Gathered the initial weather information.
  • Examined and took measurements of the occurrence site.
  • Conducted preliminary examination of the aircraft.

Next steps

The investigation is ongoing and the next steps include the following:

  • Interviewing the flight crew, air traffic control and other witnesses.
  • Gathering all information surrounding this flight, such as: weather, the approach, navigation systems, communications, the crew, training, the organization.
  • Analyzing data from FDR/CVR.
  • TSB investigators have to examine all the information before drawing any conclusions. It is too early to say what the causes and contributing factors of this occurrence might be.

Communication of safety deficiencies

Should the investigation team uncover safety deficiencies that present an immediate risk, they will be communicated without delay so they 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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