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Transportation Safety Board of Canada (319)
Georgian Bay 2013 accident underscores the need to document aircraft modifications and adhere to strict weight allowances
Richmond Hill, Ontario, 10 September 2014 – The Transportation Safety Board of Canada (TSB) today released its report (A13O0125) into the 4 July 2013 accident involving a privately-registered Cessna 182 equipped with amphibious floats. While conducting a visual approach to Runway 27 at Griffith Island, Ontario, the overweight aircraft aerodynamically stalled and collided with the water approximately 1000 feet south-east of the runway threshold. The three occupants of the aircraft were fatally injured.
The TSB investigation team determined that the aircraft was over its maximum weight allowances, thus increasing the risk of an aerodynamic stall. Furthermore, the team found that the aircraft had undocumented major modifications to the seat and safety-belt installations, and that it was not in conformance with applicable airworthiness standards at the time of the crash.
The investigation concluded that while the impact forces were survivable, they were sufficient enough to cause extensive damage to the airframe, seats, and safety-belt attachments. The two occupants in the front seats did not survive due to the severity of the impact; the occupant in the rear seat who was wearing an improperly-installed seatbelt survived the impact, but then drowned.
Overloading a central cause of 2013 water bomber accident on Moosehead Lake, Newfoundland and Labrador
Halifax, Nova Scotia, 28 August 2014 – he Transportation Safety Board of Canada (TSB) today released its report (A13A0075) into the loss of control and collision with water of a Government of Newfoundland and Labrador Air Services Division water bomber engaged in firefighting duties. The report found that the aircraft took on too much water and failed to resume flight. The aircraft came to rest upright on the lake and partially submerged. There were no injuries to the two crew members, however the aircraft was destroyed.
On 3 July 2013, at about 2:15 p.m. Atlantic Daylight Time, the Bombardier CL-415 amphibious aircraft operating as Tanker 286, departed Wabush, Newfoundland and Labrador, to fight a nearby forest fire. Shortly after departure, Tanker 286 touched down on Moosehead Lake to scoop a load of water. About 40 seconds later, the captain initiated a left hand turn and almost immediately lost control. The aircraft came to rest upright, but partially submerged. The crew exited the aircraft and remained on the top of the wing until rescued by boat.
The TSB accident investigation found that the PROBES AUTO/MANUAL switch position check was not included on the checklist, and it is likely that the PROBES AUTO/MANUAL switch was inadvertently moved from the AUTO to MANUAL selection. The switch controls the probes, which is the equipment used to scoop water from a lake. The report warns that, if a checklist does not include a critical item, and flight crews are expected to rely on their memory, then there is a risk that the item will be missed and safety could be jeopardized.
The investigation also found that the flight crew was occupied with other flight activities during the scooping run and did not notice that the water quantity exceeded the predetermined limit until after the tanks had filled to capacity. The flight crew then decided to continue the take-off with the aircraft in an overweight condition.
Some safety action has been taken by the Government of Newfoundland and Labrador Air Services Division. Changes have been made to the storage and securement of safety gear and the installation of a portable satellite telephone in their aircraft. Water bomber pilots and maintenance personnel will be subject to new training and an increased training flight schedule. Finally, the checklist has been amended to include PROBES AUTO/MANUAL switch verification.
Low speed, high descent rate led to September 2012 hard landing and aircraft damage of Jazz Aviation flight in Gaspé, Quebec
Dorval, Quebec, 7 August 2014 – In its investigation report (A12Q0161) released today, the Transportation Safety Board of Canada (TSB) determined that a landing approach below the optimum approach slope at a low speed and high descent rate led to the hard landing and fuselage strike of a de Havilland DHC-8-301 at the Gaspé Airport on 10 September 2012. There were no injuries to the 32 passengers and 3 crew members, but the aircraft sustained significant damage to its rear fuselage.
The Jazz Aviation DHC-8 was on a scheduled flight from Iles-de-la-Madelaine, Quebec to Gaspé, Quebec. While on its final approach to land, the aircraft reached the optimum descent angle of 3 degrees and continued its approach, descending gradually below the slope indicated by the runway’s precision approach path indicator (PAPI) lights. At 170 feet above the runway threshold, the aircraft descended below the lower limit of the PAPI light descent slope and the pilot flying reduced power, thus reducing speed and increasing the descent rate. This indicated an intention to touch down near the runway threshold. At 45 feet above the runway threshold, the pilot reduced power to idle, further increasing the descent rate and reducing airspeed. The nose was raised just prior to touchdown, and the aircraft landed hard resulting in the lower part of the aft fuselage contacted the runway surface during the landing.
The investigation found that the pilot monitoring did not realize that the aircraft was flying too slowly in time to intervene and prevent the hard landing. An attempt to reduce the rate of descent by applying an abrupt nose-up attitude was ineffective, as the aircraft was already flying too slowly. The aft part of the fuselage striking the runway caused significant structural damage to the aircraft. Furthermore, the crew had not received training on the manufacturer’s recommended technique to reduce descent rates close to the ground (increasing engine power and limiting nose-up attitude).
Following the occurrence, Jazz Aviation now provides training on recovery from high descent rates close to the ground to all DHC-8 pilots, and has made improvements to its operating procedures, including amending its short-field landing technique and clarifying stabilized approach and landing criteria.
Several factors led to a risk of collision for an aircraft landing at Toronto's Lester B. Pearson Airport in March 2013
Toronto, Ontario, 30 July 2014 – In its investigation report (A13O0045) released today, the Transportation Safety Board of Canada (TSB) determined that a number of factors contributed to an unattended maintenance van crossing the active runway while an aircraft was landing at the Toronto/Lester B. Pearson International Airport on 11 March 2013. There were no injuries.
A Sunwing Airlines aircraft maintenance technician was in a van parked near the nose of one of the company’s aircraft. The technician exited the van to perform various duties outside the aircraft and then boarded it to check the cockpit. Meanwhile, the van had rolled to and crossed the active arrival runway as an aircraft prepared to land. Air traffic control noticed a ground radar target as the driverless van crossed the runway, and instructed the Air Canada Embraer 190 to pull up and go around. Despite two calls to go around, the Air Canada flight continued its approach, flew over the van at a height of approximately 35 feet and landed.
The investigation found that the van rolled across the active arrival runway because it was left unattended with the engine running and the drive gear engaged. The first air traffic control instruction to the Embraer’s flight crew to go around was masked by the sound of the ground proximity warning system in the cockpit, and therefore not heard by the flight crew. The second go-around instruction went unnoticed by the flight crew because it was truncated and the crew did not hear the aircraft call sign. Without supporting visual cues, the crew did not interpret the second call as applying to them.
Following the occurrence, the Greater Toronto Airports Authority (GTAA) issued directives to the Toronto Pearson aviation community reiterating the prohibition against leaving vehicles idling and unsecured on the airside. The GTAA also published and disseminated information on the luminosity requirements for vehicle roof beacons and did spot checks to inspect beacons and require inoperative or inadequate beacons to be repaired or replaced. Sunwing Airlines reported to Transport Canada that it has inspected all of its airside vehicles and ensured that their roof beacons meet specified luminosity standards.
Risk of collisions on runways is a TSB Watchlist issue. Watch the video!
Statement by Wendy A. Tadros, Chair, Transportation Safety Board of Canada, on the anniversary of the Lac-Mégantic train accident
Gatineau, Quebec, 4 July 2014 – As we approach the first anniversary of the most devastating train accident in Canadian history, I assure the people of Lac-Mégantic, and all Canadians, that the ongoing investigation into this tragedy remains our top priority.
Investigations are complex, and we take the time to conduct a thorough, science-based examination to find out what happened and why. We have a team of highly-skilled experts dedicated to this investigation, and we expect to release the TSB's report in the next few months. However, if crucial safety information needs to be communicated right away, we don't wait for the final report to be released. Throughout this investigation we issued 3 recommendations and 4 safety advisory letters which are all found on the active investigation page on the TSB website.
On this somber anniversary, I would like to say to the families who lost loved ones – you will soon have more answers, and we will continue advocating for the changes needed to ensure this never happens again.
Loss of situational awareness and control likely caused fatal 2013 Manitoba helicopter accident
Winnipeg, Manitoba, 17 July 2014 – In the release of its investigation report (A13C0073) today, the Transportation Safety Board of Canada cited the loss of situational awareness and loss of control as the likely causes of a fatal helicopter crash at Gull Lake, Manitoba, in July of 2013.
At 4 pm Central Daylight Time, on 1 July 2013, the Bell 206B helicopter, operated by Custom Helicopters Ltd., left Gillam Lake, Manitoba, for Gull Lake, to pick up a work crew. At 830 pm the helicopter was declared missing. A search ensued and debris was found the following morning along the shore line of Gull Lake. The pilot was fatally injured.
The examination of the small amount of wreckage that was recovered indicated that the helicopter had struck the water at high speed and was destroyed. The investigation concluded that the pilot likely flew into an area of lower visibility, due to either heavy smoke in the area or rain showers, or both. This likely contributed to a loss of situational awareness and would have reduced the pilot’s ability to maintain control of the helicopter. The helicopter descended and struck the water before the pilot was able to regain adequate visual reference.
The TSB cautions that if commercial helicopter pilots do not have basic instrument flying skills, there is an increased risk of a loss of situational awareness and control in situations where visual flight continues into poor meteorological conditions.
Custom Helicopters Ltd. has since incorporated additional standards into its operations that pilots shall meet prior to being dispatched to work in wildfire operations.
Inappropriate control inputs led to January 2013 in-flight breakup of Robinson R44 helicopter over Fox Creek, Alberta
Edmonton, Alberta, 4 July 2014 – In its investigation report (A13W0009) released today, the Transportation Safety Board of Canada (TSB) determined that a Robinson R44 helicopter broke up in flight over Fox Creek, Alberta on 27 January 2013 due to inappropriate control inputs that caused the main rotor blade to make contact with the fuselage.
The Gemini Helicopters Robinson R44 was being used to monitor well sites southwest of Fox Creek, Alberta for a local oil company. After flying to several well sites, the helicopter made an unauthorized flight to a roadside security gate, picked up a passenger, flew to a compressor site and then to a remote cabin. Approximately 50 minutes later, the helicopter departed the cabin and flew back to the security gate to drop off the passenger. Shortly afterwards, the helicopter departed and was observed to be flying erratically during departure. It broke up in flight over a wooded area 5 minutes later, fatally injuring the pilot.
The investigation found that the pilot was flying under the influence of alcohol and made control inputs that caused the main rotor blade to strike the helicopter’s cabin, precipitating the in-flight breakup. In addition, there was a delay of almost 2 hours between the accident and when the aircraft was reported missing. Company flight-following procedures were not adhered to, due in part to the company’s flight follower not receiving adequate training. When the aircraft was identified as missing, the flight following technology the company employed was instrumental in finding the accident site because the emergency locator transmitter (ELT) was broadcasting its signal on an incorrect frequency due to an internal failure.
Following the occurrence, the ELT manufacturer produced an improved mounting plate to reduce the chances of ELT damage in an accident. Gemini Helicopters improved its flight-following procedures and implemented a daily flight risk assessment tool used by the operations and dispatch departments. A management team member also authorizes each flight for every aircraft on a daily basis.
Error in navigation a factor in fatal 2013 accident in Antarctic
Edmonton, Alberta, 20 June 2014 – Drawing attention to improvements made by the operator, the Transportation Safety Board of Canada (TSB) today released its investigation report into the January 2013 collision with terrain of an aircraft operated by Kenn Borek Air Ltd.
On 23 January 2013, the de Havilland DHC-6-300 Twin Otter departed South Pole Station, Antarctica, for a visual flight rules (VFR) repositioning flight to Terra Nova Bay, with a crew of 3 on board. When an anticipated radio position report was missed, the flight was considered to be overdue. Shortly thereafter, an emergency locator transmitter signal was detected and a search and rescue effort was initiated. Extreme weather conditions at the Mount Elizabeth crash site prevented the search and rescue team from accessing the site for 2 days. Once on site, it was determined that the aircraft had impacted terrain and the crew had not survived. Adverse weather, high altitude and the condition of the aircraft prevented the recovery of the crew and a comprehensive examination of the aircraft. However, the cockpit voice recorder (CVR) and a satellite tracking unit were recovered from the exposed tail section of the aircraft.
The TSB found the CVR to be non-functioning on the day of the accident. Because of this, information important to a complete understanding of the accident was unavailable to investigators. However, based on information gathered, the investigation team was able to conclude that the crew of the aircraft made a turn prior to reaching the open region of the Ross Shelf. The aircraft may have entered an area covered by cloud that ultimately led to the aircraft contacting the rising terrain of Mount Elizabeth.
Following the accident and during the TSB investigation, Kenn Borek Air Ltd. has undertaken a number of initiatives to improve safety. For example, it has:
- amended its GPS standard operating procedures;
- improved the accuracy of aviation navigational charts in the Antarctic and developed company VFR routes for flights exceeding 400 nm; and,
- amended its pre-start checklist to confirm an adequate oxygen supply is onboard the aircraft and functionality of the cockpit voice recorder.
Lack of preparation, bad weather, and a mechanical breakdown were factors in 2013 accident involving tug Charlene Hunt
Dartmouth, Nova Scotia, 19 June 2014 – Citing a lack of preparation, bad weather and a mechanical breakdown as three important factors, the TSB today released its investigation report (M13N0001) into the loss-of-tow by the tug boat Charlene Hunt of the MV Lyubov Orlova in waters off the coast of Newfoundland and Labrador (NL).
On 23 January 2013, bound for the Dominican Republic, the tug Charlene Hunt departed St. John’s harbour towing the cruise ship Lyubov Orlova. The tug and tow travelled for approximately 19 hours, until they hit winds estimated at 40 knots and seas of 5 to 6 m. The heavy weather persisted and, at approximately 14:45 on 24 January, the towing arrangement between the tug and tow failed off Cape Race, NL. Throughout the remainder of that day and most of the next day, the Charlene Hunt stood by the Lyubov Orlova and reported to Marine Communications and Traffic Services regularly. Worsening weather and a mechanical breakdown aboard the Charlene Hunt forced the tug to abandon the tow and seek sheltered water near Cape Spear, NL, where the crew began repairs. The tow was not successfully resumed and the Lyubov Orlova was left derelict and adrift in international waters and is presumed sunk.
The TSB investigation revealed a number of inadequacies. Chief among them was that the relief master did not adequately prepare to compensate for the environmental conditions that were encountered during the tow. The report observed that available guidelines respecting the design and construction of towing arrangements were not followed, and that the towing arrangement was inadequate for the intended voyage.
The TSB investigation also made findings as to risk. In Halifax, Transport Canada (TC) inspected the Charlene Hunt and found deficiencies. Repairs were made and the tug proceeded to St. John’s to meet the Lyubov Orlova. Before the vessel’s departure for the Dominican Republic, TC had requested that the master contact their office in St. John’s upon arrival. The master did not report his arrival and the Charlene Hunt departed with the tow. Following the eventual loss of the tow and the vessel’s return to St. John’s, a TC inspection again revealed several deficiencies with the tug. The TSB investigation concluded that had an inspection been undertaken prior to departure, some of these deficiencies would have been identified. If Port State Control is not exercised and vessels that are unseaworthy are permitted to continue operating, there is a risk that the safety of the crew and the environment may be compromised.
Obstructed view contributed to 2013 school bus railway crossing accident in Carlyle, Saskatchewan
Winnipeg, Manitoba, 17 June 2014 – The investigation report (R13W0083) released today by the Transportation Safety Board of Canada (TSB) determined that the school bus driver was unaware of the approaching train. As the driver proceeded from a stop onto a public passive level crossing, the bus was struck by the train.
On 26 March 2013, at about 1515 Central Standard Time, CN freight train L50041-26 was proceeding eastward on the Lampman Subdivision when it struck a southbound school bus transporting 7 elementary school children at the 4th Street East crossing in Carlyle, Saskatchewan. One child suffered minor injuries.
In accordance with provincial school bus regulations, the bus stopped at the stop sign located at the north side of the passive crossing before attempting to cross the tracks. However, the school bus driver did not open the door and did not see or hear the train as it sounded its horn. The investigation determined that the driver was likely distracted by tasks associated with the road traffic and pedestrian activity in the vicinity of the crossing at the time of the accident. In addition, the school bus’ frame (A-pillar) and side mirror adjacent to the door obstructed the driver’s view and concealed the train when the driver looked for a train.
The TSB issued a Rail Safety Advisory Letter in June 2013, suggesting that Transport Canada (TC), in conjunction with provincial authorities, review the requirements for school buses when stopping at, and traversing railway crossings. The letter also indicated that train horns do not consistently provide adequate warning to school buses that have doors and windows closed when stopped at railway crossings. In July 2013, TC responded that it had informed provincial authorities of the issue and was following up with them on provincial requirements for school buses when stopping at, and traversing railway crossings.
The Province of Saskatchewan will amend the School Bus Operating Regulations of its Traffic Safety Act to require the driver of a school bus to open the side door and driver side window when approaching a crossing that is not equipped with an automatic signal device. As well, Saskatchewan Government Insurance will develop and distribute information promoting school bus and rail safety to student transportation providers and will recommend that routine assessment of school bus routes be conducted in order to minimize the risk of railway crossing accidents.