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Transportation Safety Board of Canada

Transportation Safety Board of Canada (436)

Richmond, British Columbia, 30 June 2016 – In its investigation report (R15V0003) into the January 2015 Canadian Pacific Railway (CP) derailment near Stoney Creek, British Columbia, released today, the Transportation Safety Board of Canada (TSB) concluded that not following marshalling rules appropriate to the route contributed to the occurrence. There were no injuries and no dangerous goods were involved.

On 13 January 2015, a CP freight train travelling westward on the north main track of the Mountain Subdivision derailed 6 empty platforms near Stoney Creek, British Columbia. The derailment occurred on the Stoney Creek Bridge at Mile 76.7. The investigation determined that the six empty platforms from two intermodal flat cars derailed when the train was proceeding under high power in an 8.75 degree curve while ascending a 2.2% grade.

The train had been re-routed due to impending train delays and congestion on the adjacent track. Believing that the revised routing was operationally acceptable, the train crew did not completely re-verify the train for all applicable marshalling conditions, despite marshalling violations identified by Train Area Marshalling (TrAM), CP’s computerized train marshalling tool. Further, the investigation determined that there were no specific instructions for re-verifying a train for TrAM violations before it is re-routed. In addition, the director of rail traffic control was in a fatigued state at the time the decision was made to re-route the train; however, it could not be determined whether fatigue played a role in the director not verifying that the train was TrAM compliant.

Following the occurrence, CP made changes to its rail equipment scanner system to provide TrAM violation alerts when a train marshalling restriction is identified after a train passes the scanner. The railway company also made changes to the roles and responsibilities of the rail traffic controller with respect to TrAM. CP’s General Operating Instructions were also updated.

Published in Transportation Safety Board of Canada
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Québec, Quebec, 28 June 2016 – In its investigation report (M15C0028) released today, the Transportation Safety Board of Canada (TSB) determined that delays in responding after the vessel dragged anchor due to contact with an ice floe contributed to the April 2015 grounding of the bulk carrier CWB Marquis near Beauharnois, Quebec. There were no injuries or pollution, but the vessel sustained minor damage.

On 03 April 2015, the CWB Marquis was anchored for the night at the Pointe Fortier anchorage area, below the Lower Beauharnois lock, on the St. Lawrence Seaway when it was struck by an ice floe. The ice floe pushed the vessel out of the anchorage area and caused it to go aground. The vessel was refloated later that day with the assistance of two tugs.

The investigation determined that although the anchorage area itself was free of ice, most of the surrounding water was covered with fast ice—which is ice attached to the coastline or sea floor. As the wind increased during the night, an ice floe broke free and drifted into the anchorage area where four vessels, including the CWB Marquis, were anchored. One of the other vessels was struck by an ice floe, but it was able to promptly raise anchor; however it did not report this event. As an ice floe later came into contact with the CWB Marquis, it pushed against the anchored vessel, preventing the anchor from being raised immediately. The investigation found that a delay in crew response when the vessel began dragging anchor, combined with the time it took to raise anchor, resulted in the ship going aground outside the anchorage area.

Before the opening of the Seaway on 02 April, the St. Lawrence Seaway Management Corporation (SLSMC) was responsible for the development of a vessel traffic management plan for the four vessels scheduled to enter the Seaway. Although the plan deemed it necessary to stop the four vessels in the Pointe Fortier anchorage area, the investigation determined there were shortcomings in the plan and operations; some factors included: fast ice remained in the surrounding waters; forecasted increased winds were not taken into account; and the assisting icebreaker was directed to spend the night above the Beauharnois locks away from the four vessels.

Following the occurrence, the Algoma Central Corporation, the vessel's management company, advised the SLSMC that its vessels would secure at available lock approach walls rather than anchoring in the presence of ice. Further, the corporation amended its safety management system with respect to anchoring in the presence of ice. For its part, the SLSMC added the Canadian Coast Guard manual Ice Navigation in Canadian Waters to its winter process toolkit.

Published in Transportation Safety Board of Canada
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Toronto, Ontario, 15 June 2016 – In its investigation report (A13H0001) released today, the Transportation Safety Board of Canada (TSB) found that several organizational, regulatory and oversight deficiencies led to the fatal May 2013 crash of a Sikorsky S-76A helicopter in Moosonee, Ontario. As such, the Board is making 14 recommendations in 3 key areas.

On 31 May 2013, at 0011 Eastern Daylight Time, a Sikorsky S-76A helicopter operated by 7506406 Canada Inc. (Ornge Rotor-Wing (RW)) departed from the Moosonee Airport destined for Attawapiskat, Ontario. As the helicopter climbed through 300 feet into darkness, the first officer commenced a left-hand turn and the crew began carrying out post-takeoff checks. During the turn, the aircraft's angle of bank increased, and an inadvertent descent developed. The pilots recognized the excessive bank and that the aircraft was descending; however, this occurred too late, and at an altitude from which it was impossible to recover. A total of 23 seconds had elapsed from the start of the turn until impact, approximately one nautical mile from the airport. The aircraft was destroyed by impact forces and the ensuing post-crash fire. All four on board—the captain, first officer and two paramedics—were killed.

“This accident goes beyond the actions of a single flight crew. Ornge RW did not have sufficient, experienced resources in place to effectively manage safety,” said Kathy Fox, TSB Chair. ”Further, Transport Canada (TC) inspections identified numerous concerns about the operator, but its oversight approach did not bring Ornge RW back into compliance in a timely manner. The tragic outcome was that an experienced flight crew was not operationally ready to face the challenging conditions on the night of the flight.”

The investigation uncovered several issues. The night visual flight rules regulations do not clearly define “visual reference to the surface”, while instrument flight currency requirements do not ensure that pilots can maintain their instrument flying proficiency. At Ornge RW, training, standard operating procedures, supervision and staffing in key safety/supervisory positions did not ensure that the crew was ready to conduct the challenging flight into an area of total darkness. The training and guidance provided to TC inspectors led to inconsistent and ineffective surveillance of Ornge RW, as inspectors did not have the tools needed to bring a willing but struggling operator back into compliance in a timely manner, allowing unsafe practices to persist.

As a result of risks to the aviation system found during this investigation, the Board is issuing 14 recommendations to address deficiencies in the following areas:

  • Regulatory oversight
  • Flight rules and pilot readiness
  • Aircraft equipment

More details about the Board's recommendations can be found in the backgrounder.

“Both Ornge RW and TC have taken significant action since this accident, but there are still a number of gaps that need to be addressed,” added Chair Fox. “Our recommendations will help ensure that the right equipment is on board, that pilots are suitably prepared, and that operators who cannot effectively manage the safety of their operations will face not just a warning, but a firm hand from the regulator that knows exactly when enough is enough, and is prepared to take strong and immediate action.”

Published in Transportation Safety Board of Canada
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Dorval, Quebec, 13 June 2016 – In its investigation report (R15D0073) released today, the Transportation Safety Board of Canada (TSB) determined that a hand-operated crossover switch in Farnham Yard, Quebec, had been damaged, resulting in the derailment of a Central Main & Québec Railway (CMQ) freight train. There were no injuries.

On 10 August 2015, an eastbound CMQ freight train was scheduled to depart Farnham Yard. The train's cars had been marshalled on 3 separate tracks. At about 1400 Eastern Daylight Time, a certified car inspector began his shift and was tasked with inspecting the cars destined for the train. The inspector used a pickup truck to drive from one location to the next and complete various assigned tasks.

The investigation found that while the inspector drove between locations in the yard, the bumper of the pickup truck had contacted a switch stand which resulted in tie damage and misalignment of the switch points. However, the incident was not reported and the switch was not inspected for damage. Subsequently, as the CMQ freight train departed Farnham Yard, the wheel of a freight car became lodged between the misaligned switch point and bent stock rail which caused the derailment of that car and the following 14 cars.

The investigation also found that the locomotive event recorder (LER) did not record data from the locomotive correctly. If an LER does not accurately record the required parameters of a train's operation, the accuracy and validity of any analysis conducted using that incorrect information can be compromised.

On 12 November 2015, the TSB issued a Rail Safety Information Letter to Transport Canada (TC) regarding the incorrect data recorded by the LER. TC replied that railway companies are responsible for carrying out yearly inspections and accuracy testing of LERs and the event recorder's memory module. TC indicated that its regional office verified the data extracted from the LER of the occurrence locomotive and reported that it has been fixed and was working properly.

Published in Transportation Safety Board of Canada
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Winnipeg, Manitoba, 2 June 2016 – In its investigation report (A15C0005) released today, the Transportation Safety Board of Canada (TSB) found that an unanticipated increase in cable tension during stringing operations, along with other events, led the helicopter to a collision with terrain. The helicopter sustained substantial damage. The pilot, who was the sole occupant, sustained serious injuries but was able to evacuate without assistance.

On 21 January 2015, the pilot of a Eurocopter AS350 B2, operated by Airspan Helicopters Ltd., was conducting aerial work approximately 11 nautical miles southeast of Key Lake Airport, Saskatchewan. The work consisted of pulling feeder cable through a row of electrical transmission towers using a 37 foot­–long tool called a needle. The pilot completed the first 10 towers of the centre phase without incident. As the pilot was continuing the stringing operation, the needle suddenly lunged and abruptly stopped. The helicopter then began an uncommanded roll and rotation to the left, descended, and collided with the terrain.

The investigation found that the needle's abrupt stop was possibly caused by the needle contacting the tower or by the feeder cable catching on an obstacle on the ground. The consequent increase in cable tension, in conjuction with a slight drift of the aircraft and a crosswind, contributed to an effect called dynamic rollover, which led to the loss of control and subsequent collision with the ground.

The investigation also revealed a number of systemic safety risks. These included: training that does not adequately prepare pilots for abnormal flight conditions; not using available shoulder harnesses; not following normal checks and procedures; inadequate ground monitoring; and incomplete and unclear flight manual supplements.

Airspan did not have a fully implemented safety management system in place, but it was not required to by regulation. The TSB has identified safety management and oversight as a Watchlist issue. As this occurrence demonstrates, some transportation companies are not effectively managing their safety risks. The Board has been calling on Transport Canada (TC) to implement regulations requiring all operators in the aviation industry to have formal safety management processes and for TC to oversee these companies' safety management processes.

Following the occurrence, Airspan suspended AS350 helicopter stringing operations until further notice. They reviewed and amended their standard operating procedures, including amendments to pre-flight checks, stringing operations, and feeder cable–pulling procedures. The operator also hired third-party consultants to audit the company's safety management system.

Published in Transportation Safety Board of Canada
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Dartmouth, Nova Scotia, 5 May 2016 – In its investigation report (M15A0009) released today, the Transportation Safety Board of Canada (TSB) concluded that due to insufficient monitoring of the vessel’s navigation, the bridge team of the roll-on roll-off passenger ferry Grace Sparkes was unaware of the vessel’s position in the harbour channel and the vessel struck Burnside Rock. There were no injuries or pollution, but the vessel sustained damage to the hull and the bilge keel.

On 21 January 2015, at 1746 local time, the Grace Sparkes was voyaging with 8 crew and 4 passengers onboard along a route that deviated to the east-southeast of the course line specified in the standard passage plan. The master was steering the vessel and navigating, limiting his ability to use paper and electronic charts to monitor the vessel's position in relation to the planned route. Although the master navigated visually at night, the position of the vessel was not being cross-referenced by the bridge team using other navigational aids as was recommended by the company's safety management manual. After the striking, the vessel continued its voyage and docked at Burnside a few minutes later.

In addition to not cross-referencing navigational aids, the investigation found deficiencies in several areas. These included a delay in reporting the occurrence to the Canadian Coast Guard; a lack of crew training in bridge resource management; issues with the marine medical certification process for the master, and assessing fitness for duty; and a lack of signage for lifesaving equipment. Further, when the vessel struck the rock, the passengers and crew members were not properly informed. It was also determined that safety drills included only crew members and no passengers, and thus did not provide realistic training.

The investigation also identified a number of issues related to the TSB Watchlist: the operator's safety management system and Transport Canada's (TC) oversight. If TC oversight does not assess the effectiveness for passenger safety-related emergency procedures, there is a risk these will not achieve their intended purpose. Additionally, if there is no follow-up to verify that non-conformities raised during internal and external audits have been addressed, there is a risk that unsafe conditions may persist.

Following this occurrence, the operator, the Newfoundland Department of Transportation and Works, took a number of corrective actions which included providing chart correction procedures to all vessels; adding lifesaving equipment signage; repairing the public address system; and providing instruction to clarify procedures for obtaining accurate passenger counts.

Published in Transportation Safety Board of Canada
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Québec, Quebec, 28 April 2016 – In its investigation report (M15C0045) released today, the Transportation Safety Board of Canada (TSB) concluded that shortly after it departed Rimouski, Quebec, a fire broke out in the engine compartment of the Frederike. C-2, possibly due to a failure in the generator engine.

At 0145 on 28 April, 2015, the Frederike. C-2 left Rimouski with a master and three crew members onboard. At approximately 0230, charred wood could be smelled in the wheelhouse and a crew member went to the engine compartment to discover that it was filled with dense smoke. After the master decided to return to Rimouski, and after an unsuccessful attempt was made to put out the fire, the life raft was inflated and the crew abandoned ship at 0300. The crew was rescued by the fishing vessel Marie-Karine D around 0330. The Canadian Coast Guard (CCG) Cap Perce was dispatched to assist. The vessel burned to the waterline and sank by 1515. No injuries were reported.

The investigation uncovered a number of safety deficiencies. The master’s certificate had expired more than two years before the occurrence. The crew had not received onboard familiarization and safety training before starting their duties. Nor had steps been taken to ensure that the crew understood the use and location of the lifesaving and fire-extinguishing appliances onboard. Further, the master did not communicate the event in accordance with the Canadian Radiocommunication Regulations or use Standard Marine Communications Phrases. Instead of alerting the Marine Communications and Traffic Services (MCTS), the master believed no CCG intervention was required and called the master of the Marie-Karine D, who then reported the situation to the MCTS.

The investigation also found that electrical and various other repairs were not reported to Transport Canada Marine Safety and Security (TCMSS) nor were two previous engine failures reported. Additionally, on 19 June 2012, a TCMSS inspector issued a Notice of Deficiency to the authorized representative (AR) of the Frederike. C-2 stating that the vessel required a safety familiarization and training manual onboard, specifically relating to firefighting and lifesaving equipment, and all tasks related to the safe operation of the vessel. The notice did not indicate any timeframe for rectifying the deficiency. On 25 March 2013, when TCMSS inspected the vessel again, there was still no familiarization and training manual on board. However, no further action was taken by TCMSS in this matter and the vessel was allowed to continue operating.

The TSB has identified safety management and oversight as a Watchlist issue. As this occurrence demonstrates, some transportation companies are not effectively managing their safety risks. The Board has been calling on Transport Canada (TC) to implement regulations requiring all operators in the marine industry to have formal safety management processes and for TC to oversee these companies' safety management processes.

In this occurrence, there were no fatalities; however, there continues to be approximately one fishing-related fatality per month in Canada. Loss of life on fishing vessels is also a Watchlist issue, and the TSB also conducted a Safety Issues Investigation (SII) into fishing safety. In this occurrence, two of the 10 safety significant SII issues: training and the cost of safety.

The SII emphasizes that the safety of fishermen will be compromised until the complex relationship and interdependency among safety issues is recognized and addressed by the fishing community. The Board continues to call 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.

Following the occurrence, TCMSS inspectors at the Marine Safety Service Centre in Rimouski added compliance deadlines to Notices of Deficiency issued in relation to the familiarization and training manual. Failure to comply with this notice by the deadline will result in administrative monetary penalties.

Published in Transportation Safety Board of Canada
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Gatineau, Quebec, 19 April 2016 – The Transportation Safety Board of Canada (TSB) today released its assessments of the responses to its five recommendations arising from the investigation (R13T0192) into the collision between an OC Transpo bus and a VIA Rail train in Ottawa, Ontario, on 18 September 2013. These recommendations are aimed at reducing the risk of railway crossing accidents.

“There are a few good initiatives proposed by the regulator to address some of the safety deficiencies we identified in our investigation. But I'm concerned these efforts don't go far enough, fast enough,” said TSB Chair Kathy Fox. “To advance railway crossing and passenger safety even further, Transport Canada's research, review and consultation must lead to concrete action in a timely manner.”

Distracted driving guidelines (R15-01)

Recommendation R15-01 calls for Transport Canada (TC), in consultation with the provinces, to develop comprehensive guidelines for the installation and use of in-vehicle video monitor displays to reduce the risk of driver distraction. TC has indicated it will request that the Canadian Council of Motor Transport Administrators (CCMTA) Distracted Driver Working Group consider developing these guidelines. As co-chair of this group, TC will also suggest that experts and industry stakeholders be consulted to identify the challenges and effective strategies for limiting distracted driving due to video displays. Although meaningful results from the planned action will not likely occur in the short term, the Board is encouraged that TC will be taking a leadership role in the development of the guidelines. Therefore, the Board assesses the response to this recommendation as having Satisfactory Intent.

Bus crashworthiness (R15-02)

Recommendation R15-02 calls on TC to develop and implement crashworthiness standards for commercial passenger buses to reduce the risk of injury. TC has said it will conduct a review of accident data from urban centers around the world to evaluate the existing crashworthiness of commercial passenger buses. Beyond this commitment, there are no explicit plans to develop and/or implement crashworthiness standards for commercial passenger buses. Furthermore, no specific timeline has been provided for the planned review and analysis. Therefore, the Board assesses the response to this recommendation as being Satisfactory in Part.

Vehicle event data recorders (R15-03)

Recommendation R15-03 asks TC to require commercial passenger buses be equipped with dedicated, crashworthy, event data recorders (EDRs). TC has committed to researching EDR technologies and reviewing available international commercial vehicle EDR standards and recommended practices. TC will then review the results of the research and the review to evaluate the feasibility of developing an EDR standard or guideline for commercial passenger buses. While the Board is encouraged by TC's response, the work will take time and no specific outcome or timeline has been provided. In addition, there are no explicit plans for the development of EDR standards for commercial passenger buses. Therefore, the Board assesses the response to this recommendation as being Satisfactory in Part.

Grade separation guidelines (R15-04)

Recommendation R15-04 calls for TC to provide specific guidance as to when grade separation at railway crossings should be considered. TC has acknowledged that the new Grade Crossings Regulations (2014) do not specify when grade separation should be implemented at existing level grade crossings. TC has committed to working with the provinces and railways to develop guidelines to help determine when grade separation should be considered. The Board is encouraged that TC will work with key stakeholders to develop guidelines for determining when grade separation should be considered. Although no timelines have been established yet for this work, the Board assesses the response to this recommendation as having Satisfactory Intent.

Grade separation of Woodroffe Avenue, the Transitway and Fallowfield Road (R15-05)

Recommendation R15-05 calls on the City of Ottawa (the City) to reconsider the need for grade separations at the Woodroffe Avenue, Transitway, and Fallowfield Road level crossings. The City has responded that, in financial partnership with VIA Rail, it will conduct a feasibility study to review the technical requirements for providing grade separation at those crossings, as well as at two additional crossings. The action proposed by the City is a positive first step towards more effectively managing the risk of vehicle-train collisions at these five level crossings. The Board assessed the response to this recommendation as having Satisfactory Intent.

“The Board is pleased that the City of Ottawa has committed to conducting a feasibility study of grade separation at the recommended crossings, and commends the City for including Merivale and Jockvale roads in the study,” added Chair Fox. “The City's residents deserve the safest crossings on which to travel.”

The Board uses an Assessment Rating Guide to evaluate the responses and their overall effectiveness. Progress made to address TSB recommendations is re-assessed annually by the Board and is reported publicly.

Published in Transportation Safety Board of Canada
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Richmond, British Columbia, 18 April 2016 – The Transportation Safety Board of Canada (TSB) continues its independent investigation into the 11 September 2015 crossing collision between an ambulance and a Canadian National train in Langley, British Columbia.

The occurrence

On 11 September 2015, a northbound Canadian National (CN) train struck an ambulance travelling eastbound at the Crush Crescent–Glover Road, located at Mile 18.81 of the Canadian Pacific (CP) Page Subdivision in Langley, British Columbia. The occupants of the ambulance were two paramedics (one driving and one attending the patient) and one patient. The paramedics sustained injuries and the patient later succumbed to injuries sustained during the collision. The members of the train crew were not injured.

What we know

  • The train was travelling at 32 mph (maximum permissible track speed at the time of the occurrence was 35 mph).
  • During a post-occurrence examination, it was determined that there were no pre-existing mechanical deficiencies on the ambulance that would have contributed to the accident.
  • The main-track crossing is protected by automatic warning devices consisting of flashing lights, a bell, and gates, which were connected to the traffic lights at the intersection.

Progress to date

  • The ambulance was examined to determine whether any mechanical deficiencies might have contributed to the collision.
  • Investigators interviewed witnesses and downloaded information from the automatic warning devices installed at the crossing.
  • The locomotive event recorder and the ambulance data recorder were evaluated.
  • Investigators reviewed the crossing design and the interconnection of the traffic signals.
  • The TSB issued a rail safety advisory (RSA) to Transport Canada concerning safety issues at the Crush Crescent-Glover Road crossing. Further details on the RSA are included below.

Transport Canada Notice and Order

  • Transport Canada issued a Notice and Order on 11 February 2016, to the British Columbia Ministry of Transportation and Infrastructure, the Township of Langley, and the Canadian Pacific Railway.
  • The Notice and Order indicated that the current timing configuration for traffic light pre-emption and warning system gate delay was inadequate for longer vehicles to clear the crossing safely. It was also noted that roadway pavement markings were either absent or faded, such that drivers were not provided with adequate information.
  • As a result of the Notice and Order, some of the changes to the automatic warning devices included increasing the delay time of the crossing gate drop from 7 seconds to 12 seconds, and increasing the road traffic signal pre-emption time from 10 seconds to 15 seconds. These changes were made so that the crossing would be more suitable for use by longer vehicles.

TSB rail safety advisory

On 17 March 2016, the TSB issued a rail safety advisory (RSA) to Transport Canada concerning safety issues arising from conflicting information given by the railway crossing and road traffic signals at the Crush Crescent–Glover Road crossing. The RSA suggested that Transport Canada, British Columbia’s Ministry of Transportation and Infrastructure, and the Canadian Pacific Railway (CP) might wish to review the design and functionality of the Crush Crescent–Glover Road crossing, including the interconnection of the automatic warning devices on the crossing and the road traffic signal system, to ensure that the risks to motorists at this crossing are minimized.

The British Columbia Ministry of Transportation and Infrastructure responded to the RSA on 13 April 2016. Its response indicates that:

  • Ministry traffic engineers have reviewed the design and operation of the railway interconnection with the traffic signal and determined that it is operating as designed.
  • The Ministry is working with CP to ensure the ongoing safe operation of this crossing and further enhancements are planned. These enhancements include an upgrade to the signal bungalow, relocation of the gate arm, and the addition of an active warning LED sign on Crush Crescent.
  • The Ministry is considering the suitability of pre-signals or other means to prevent the movement of road traffic towards the grade crossing.

Follow-up with other stakeholders

When TSB followed up with Transport Canada, it noted the following:

  • There are actually two separate crossings at this location: the automatic warning devices protect the main track while crossbucks protect the Milner storage track.
  • As currently configured, the Milner Storage track crossing must meet the sightline requirements of the Grade Crossings Regulations.
  • The location of the two separate warning devices—one active and one passive—in a single place confuses road users, who think that it is safe to approach the gates when they are active.
  • Because of the interconnection of the crossing warning system and the road traffic signals at this location, the systems can send a conflicting message to road users when a train is approaching: the traffic signals indicate green for go while the crossing warning system indicates stop.

When TSB followed up with Canadian Pacific, it indicated that it would:

  • Install a new crossing warning system, and that British Columbia’s Ministry of Transportation and Infrastructure would install a new traffic signal controller capable of launching the gate-down process;
  • Relocate the crossing gate controlling eastward traffic to the west side of the Milner storage track. Construction on these changes will start in early July 2016.

Railway crossing safety

Railway crossing safety has been identified as one of the key risks to the transportation system, and it is included on the TSB's 2014 Watchlist. The rate of crossing accidents per million main-track train-mile decreased between 2006 and 2010 but it has been stable over the last 5 years, and the TSB is concerned that the risk of trains and vehicles colliding remains too high.

Next steps

  • The TSB continues to investigate the crossing design and the automatic warning devices, their interconnection with the traffic signals, and their timing at this location. It continues to monitor for any further safety action that may be taken.
  • The investigation will continue to examine the crossing and its operation; driver distraction and motor vehicle operation; driver training and supervision; and the operation of the trains approaching the crossing.

Railway Investigation R15V0191

Published in Transportation Safety Board of Canada
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Edmonton, Alberta, 6 April 2016 – In its investigation report (A14W0177) released today, the Transportation Safety Board of Canada (TSB) found that excessive vibrations from a failed tire led to the collapse of the right main landing gear on a Jazz Aviation Bombardier DHC-8-402 in Edmonton, Alberta, in November 2014. Three passengers suffered minor injuries.

On 6 November 2014, Jazz Aviation Flight 8481 departed from Calgary International Airport destined for Grande Prairie, Alberta, with 71 passengers and four crew members onboard. During takeoff, one of the tires on the right landing gear failed. The flight was diverted to the Edmonton International Airport. Shortly after touchdown on landing, the right main landing gear collapsed. The right side propeller blades sheared off on impact with the ground and one of the blades penetrated the cabin wall. All passengers and crew evacuated the aircraft. There was no post-occurrence fire.

The investigation determined that a high rotational imbalance was created on the tire that failed during takeoff, resulting in a significant vibration as the tire began to spin up during touchdown. As this vibration was the same or very close to one of the natural frequencies of the right main landing gear, it falsely triggered a sensor within the main landing gear. This resulted in a reduction of hydraulic pressure to the locking mechanism of the landing gear. In this condition, the excessive vibration then caused the mechanical locking system to release, leading the landing gear to collapse. The investigation concluded that the lack of specific requirements for dynamic vibration testing of aircraft components during certification was a risk factor, as similar systems could fail during high-vibration conditions.

Following the occurrence, Jazz Aviation decided to no longer use retreaded tires on the main landing gear of their DHC-8-402 fleet. Further, the operator made changes to its DHC-8-402 operating procedures to reduce stress on the main landing gear tires when manoevring on the ground. Other operators using this aircraft have adopted similar procedures to reduce main landing gear tire stress.

Published in Transportation Safety Board of Canada
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