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Transportation Safety Board of Canada

Transportation Safety Board of Canada (370)

Gatineau, Quebec, 21 May 2015 - The Transportation Safety Board of Canada (TSB) today released its annual reassessment of responses to Board recommendations. The reassessments show that while there has been positive movement to improve rail safety, progress towards advancing safety continues to be slow in the aviation and fishing industries.

Recommendations are made when the Board identifies systemic safety issues that pose a serious risk to Canada's transportation system. The Board then reassesses its active recommendations on an annual basis to determine what progress has been made, and to make those accountable for safety in the transportation system aware of outstanding issues.

“Recent initiatives to improve railway crossing safety and the transportation of flammable liquids by rail are encouraging. However, we are concerned that more needs to be done to prevent approach-and-landing accidents and that fishing vessel safety regulations have yet to be put in force.” said Kathy Fox, Chair of the TSB.

The Board is encouraged by the action taken to improve safety in the rail industry, with seven additional recommendations receiving the highest rating of Fully Satisfactory. The new Grade Crossings Regulations will address a number of outstanding recommendations on railway crossing safety. The Board also believes that Transport Canada's announcement of tougher tank car standards will help make the transportation of crude oil by rail safer once they are fully implemented. In the meantime, the Board calls upon Transport Canada to ensure that risk control measures during the transition are effectively managed.  Also, more progress still needs to be made for physical defences against misinterpreting or not following railway signals.

In aviation, Transport Canada has been slow to respond to some recommendations regarding aircraft certification requirements, particularly in the areas of post-impact fires. Progress is also slow in addressing two recommendations which would prevent or minimize the consequences of approach-and-landing accidents, as described in the TSB Watchlist. On the other hand, offshore helicopter operations will become safer, as people aboard those flights will require emergency breathing apparatuses and flights will only be conducted if the sea conditions allow for safe ditching in the event of an emergency.

In the marine mode, progress towards advancing fishing vessel safety is stalled by delays in enacting the new Fishing Vessel Safety Regulations. The new regulations will require additional emergency equipment, education and vessel stability information. Until the regulations are in force, lives will continue to be lost. Because of the delays, the Board has reassessed five fishing vessel safety recommendations and assigned the lowest rating of Unsatisfactory. That said, the Board is pleased that Transport Canada and other stakeholders have developed the National Places of Refuge Contingency Plan and regional plans have been completed, posted and exercised for all regions. This will mitigate risks associated with navigation-related emergencies.

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Québec, Quebec, 11 May 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (M14C0045) into the 22 April 2014, grounding of the chemical/products tanker Halit Bey off Grondines, Quebec. The vessel was proceeding upbound in the St. Lawrence River under the conduct of a pilot when steering control was lost. The vessel veered to port and exited the navigational channel, running aground on the south side of the river off Grondines, Quebec at 0416 Eastern Daylight Time. No damage, pollution, or injuries were reported. The vessel was later refloated with the assistance of two tugs.

The investigation found that steering control from the steering wheel was likely disabled when an unprotected joystick was inadvertently moved, which activated the autopilot override and alarm. The bridge crew was not adequately familiarized with the characteristics of the Halit Bey's steering control system and did not know how to regain control after the autopilot override alarm activated. Once steering control was lost, the vessel veered towards the shore and the crew's attempts to reduce speed and anchor the vessel were unsuccessful to prevent the vessel from running aground.

On 29 May 2014, the TSB sent Marine Safety Advisory (MSA) letter 05/14 to the vessel owners regarding issues with the steering gear control configuration and the familiarization of the navigation crew members with the steering gear system on board the Halit Bey.

Following the grounding, complete emergency change-over procedures were posted on the bridge of the Halit Bey, taking into account the particularity of the steering control that could be disabled if someone activated the autopilot override mode.

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Richmond, British Columbia, 7 May 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (M14P0121) into the 12 June 2014, capsizing and sinking of the fishing vessel Five Star in Johnstone Strait, British Columbia.

The Five Star was on its way back to Kelsey Bay, British Columbia, after a 3-day crab-fishing voyage, with the master and one crew member aboard. The vessel was carrying approximately 1250 kg of crabs in 22 holding cages stowed on the deck. While underway, approximately one third of the catch was transferred to a large empty tote positioned on the centreline of the deck and secured to port and starboard of the vessel. Later in the voyage, the vessel encountered increased winds and 1-metre waves affecting the vessel on its stern quarters. To ensure the catch would remain alive, the crew member filled the tote with sea water, increasing its weight to 1100 kg. Soon after, the vessel heeled to port and the line securing the tote to the starboard side of the vessel broke. The tote and holding cages then shifted to the port side, causing the vessel to list to port. The deck eventually became flooded and the vessel capsized.

Just prior to the vessel capsizing, the crew member, who was wearing a lifejacket, jumped overboard. The master, who was not wearing a flotation device, escaped into the water through a cabin window. Both fishermen hung onto the hull until they abandoned ship and began to swim to shore. Halfway to shore, the crew member lost sight of the master and the vessel. The vessel is presumed to have sunk and the master is presumed to have drowned.

The investigation found that the decision to continue the voyage to Kelsey Bay exposed the Five Star to sea and wind conditions that caused the vessel to heel to port. This, in turn, led to the failure of the securing line and the shifting of the load, causing the vessel to capsize. Furthermore, as the vessel was not carrying equipment capable of transmitting an automatic distress signal, search and rescue was not initiated until the crew member reached shore and called 9-1-1.

The investigation also found a number of factors as to risk, including the lack of a requirement for most fishing vessels to undergo a formal stability assessment and the risk of not carrying equipment capable of automatically transmitting a distress signal. The investigation also determined there was a need for comprehensive assessments for emergency preparedness and emergency drills. The report cites 7 previous occurrences where the lack of a stability assessment was a contributing factor. The TSB also made a previous recommendation (M00-09) calling for automatic distress signaling equipment.

Loss of life on fishing vessels is a TSB Watchlist issue. Although regulations have been proposed by Transport Canada to address several deficiencies with respect to fishing safety, there have been significant delays in their implementation. There needs to be a 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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Gatineau, Quebec, 29 April 2015 – The Transportation Safety Board of Canada (TSB) is once again participating in an exercise at the Vancouver International Airport (YVR) in British Columbia (B.C.). Today, the airport authority and several partners, including the TSB, will collaborate to test their emergency response to a major air disaster.

TSB investigators from the Richmond, B.C. regional office, along with communications personnel, will practice their emergency preparedness and response. The TSB applauds YVR's efforts to regularly conduct exercises with a view to improving safety, and is pleased to take part in the event.

For more information about this exercise, please visit the Vancouver International Airport website.

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Gatineau, Quebec, 30 April 2015 – On the occasion of Rail Safety Week (27 April – 3 May), the Transportation Safety Board of Canada (TSB) reiterates its ongoing support of Operation Lifesaver’s efforts to raise awareness about rail safety. Many organizations involved with the railway industry including the Railway Association of Canada, Transport Canada (TC), provincial and municipal governments, police, and community groups cooperate to save lives by educating Canadians about the hazards surrounding rail property and trains.

In the aftermath of the Lac-Mégantic train derailment and other recent accidents, rail safety has been top of mind for Canadians across the country. “Over the past 18 months, positive action has been taken by industry and TC to address the rail safety deficiencies we've identified through our investigations,” said Jean L. Laporte, Chief Operating Officer of the TSB. “We're on the right path, but there is more work to be done.”

The TSB created its Watchlist to focus attention on the issues that pose the greatest risk to Canada's transportation system; and five of the current Watchlist issues concern railway safety. One of these issues is the need for voice and video recorders in locomotives to capture in-cab communications which provides additional information to investigators when an accident occurs. To address this outstanding Watchlist issue, the TSB is pleased to announce that it will be working with TC to conduct a joint safety study on locomotive voice and video recorders.

The safety study will look at the potential safety benefits of recorders in locomotives, identify and assess related technology issues, and identify legislative and regulatory considerations. The results of this study will provide valuable information leading to the development of an action plan for the implementation of locomotive voice and video recorders. “We're looking forward to working with TC and engaging other key stakeholders on this important safety initiative,” added Mr. Laporte.

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Edmonton, Alberta, 28 April 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (A14W0046) into the 29 March 2014 runway incursion at the Calgary International Airport, in Alberta. There were no injuries, damage to aircraft or airport property.

On 29 March 2014, during the hours of darkness, an Air Georgian Beech 1900D turboprop aircraft was being taxied to a holding bay adjacent to runway 29 by company aircraft maintenance staff to perform engine performance checks. An air traffic controller issued instructions for taxiing north from the company facility to the holding bay. The maintenance staff mistakenly taxied the aircraft to an area southwest of the maintenance facility. A runway incursion occurred when the aircraft entered the south end of an active runway (Runway 17R). A departing Boeing 737 was already airborne when the Beech 1900D entered the runway.

The investigation found that the training received by the Aircraft Maintenance Engineer (AME) was inadequate for the operation of an aircraft at a large airport at night. This resulted in the AME not correctly following the taxi instruction, resulting in the runway incursion. The investigation also found that the ground controller did not assign a transponder code as per air traffic control procedures. A transponder code allows aircraft to be positively identified on the ground radar display, giving the controller on duty situational awareness of where the aircraft is taxiing. Additionally, the investigation revealed that the airport does not require positive control over vehicles operating on a taxiway, except during reduced/low visibility operations. This, combined with the unidentified target seen on the ground radar display as a result of the lack of a transponder code, led to the controller making an incorrect assumption that this aircraft was a vehicle operating south of the company facility.

Following the occurrence, the Calgary Airport Authority required AMEs to be trained for and to hold airside vehicle operator permits allowing them to tow and taxi aircraft around the airport. All vehicles operating on a taxiway now require transponders so that air traffic control can identify them. Air Georgian revised its procedures for taxiing and towing aircraft around airports and improved training for its maintenance staff.

This issue has been identified as one of the key risks to the transportation system and it is included on the TSB's 2014 Watchlist. Improved procedures and enhanced collision warning systems must be implemented at Canada's airports.

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Edmonton, Alberta, 27 April 2015 – According to a Transportation Safety Board of Canada (TSB) investigation report (A13W0120) published today, a cylinder failure on the right engine, and the fact that the aircraft exceeded its maximum certified take-off weight, led to the wheels-up landing just after take-off of a Buffalo Airways DC-3C aircraft in August 2013. There were no injuries to the 21 passengers or the 3 crew members.

On 19 August 2013, the Buffalo Airways aircraft was operating as a scheduled passenger flight from Yellowknife to Hay River, Northwest Territories. After lift-off from Runway 16 at 1708 Mountain Daylight Time, there was a fire in the right engine. The crew performed an emergency engine shut-down and made a low altitude right turn towards Runway 10. The aircraft struck a stand of trees southwest of the threshold of Runway 10 and touched down south of the runway with the landing gear retracted.

The TSB investigation found that Buffalo Airways did not have an effective safety management system (SMS) in place to identify and mitigate risk in its operations. Along with the findings as to cause, the investigation also uncovered a number of findings as to risk, both for the air operation, and with regard to Transport Canada oversight. As for Transport Canada, the current approach to regulatory oversight, which focuses on an operator’s SMS processes almost to the exclusion of verifying compliance with the regulations, is at risk of failing to address unsafe practices and conditions. If Transport Canada does not adopt a balanced approach that combines inspections for compliance with audits of safety management processes, unsafe operating practices may not be identified increasing the risk of accidents. This is an issue on the TSB Watchlist.

Buffalo Airways has begun to enforce the practice of weighing individual passengers and baggage in order to calculate a weight and balance prior to departure. The company has also contracted the development of Net Take-off Flight Path charts for its flights, and has revised its Company Operations Manual. The company has also made organizational changes such as: a comprehensive re-training of the Operations Manager; hiring of an operations consultant to assist with regulatory compliance; adjusting the Operations Manager's responsibilities to identify and more effectively address non-compliance with regulations; and developing policies and procedures by the Accountable Executive and the Operations Manager to ensure regulatory compliance.

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Winnipeg, Manitoba, 14 April 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (A13C0150) into the November 2013 fatal aircraft accident in Red Lake, Ontario. Two flight crew members and 3 of the 5 passengers lost their lives when the aircraft crashed just south of the airport near a highway.

On 10 November 2013, a Bearskin Airlines Fairchild SA227 Metro III, on a flight from Sioux Lookout, Ontario, was on final approach to the Red Lake airport. The crew reported that they were 5 miles from the airport, and shortly thereafter declared an emergency. The aircraft struck trees along with some power lines, and was destroyed by a post-impact fire. Two passengers were able to evacuate the aircraft with non-life threatening injuries.

The investigation found that the crew experienced a near total loss of power in the left engine at 500 feet above ground level due to a failure of an internal engine component. The crew was unable to identify the nature of the engine malfunction, preventing them from taking timely action to control the aircraft. The aircraft’s landing configuration generated higher drag which, combined with the engine malfunction, resulted in the aircraft losing airspeed in an asymmetric power state. As the aircraft slowed, the crew lost control at an altitude from which a recovery was not possible.

Following the occurrence, the aircraft operator revised its single engine and engine failure procedures to ensure that the propeller on a malfunctioning engine does not cause excessive drag. Honeywell, the engine manufacturer, increased the inspection frequency on fuel nozzles and clarified inspection procedures. Transport Canada issued a Civil Aviation Safety Alert regarding issues with the negative torque sensing (NTS) system on Honeywell TPE-331 engines, to emphasize the need to feather and secure propellers during engine power loss events.

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The occurrence

On 29 March 2015, at approximately 1240 a.m., Air Canada flight ACA 624, an Airbus A320 , on a scheduled flight from Toronto's Lester B. Pearson International Airport, Ontario, to Halifax, Nova Scotia, collided with terrain approximately 1100 feet from the threshold of Runway 05, eventually coming to rest about 1100 feet down the runway. There were 133 passengers and 5 crew members on board; all of whom exited the aircraft. Twenty-five people were taken to hospital for treatment of injuries.

What we know

The initial impact was significant and caused substantial damage to the aircraft. The main landing gear separated and the underside of the aircraft was heavily damaged (fuselage and wings). During this impact, the aircraft collided with a localizer antenna array – part of the instrument landing system – and became airborne again, travelling forward on Runway 05. There is an extensive debris field between the localizer antenna location and the threshold of the runway.

During the first day on site, Transportation Safety Board of Canada (TSB) investigators documented the wreckage, the impact marks and the debris field. The cockpit voice recorder (CVR) and the flight data recorder (FDR) were recovered from the aircraft and have been sent to the TSB Engineering Laboratory in Ottawa, Ontario.

Investigation team work

The investigation team is led by the Investigator-in-Charge, Doug McEwen. Mr. McEwen has been an investigator with the TSB for 18 years. He is assisted in this investigation by experts in flight operations, air traffic services, weather, aircraft structures, aircraft systems, aircraft engines, and human performance.

Some of these experts come from within the TSB, but assistance is also being provided by the following organizations: Transport Canada (TC), NAV CANADA, the Royal Canadian Mounted Police, Airbus, and France's Bureau d'Enquêtes et d'Analyses. This is a normal part of any investigation, as these experts play a key role in helping the team uncover and understand all of the underlying factors which may have contributed to the accident.

Watchlist

Although more analysis is required, this accident displays some of the characteristics of an approach-and-landing accidents which is on TSB's Watchlist.

Next steps

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

  • survey the impact and wreckage site
  • continue examining and photographing the wreckage
  • removing the aircraft from the runway to restore normal operations
  • gather Air Traffic Control voice and data recordings
  • conduct witness interviews
  • gather meteorological information
  • collect operational information from the aircraft
  • preliminary review of the recorders at the TSB Lab to assist field investigators
  • determine which wreckage to collect for closer examination
    • further examination will be at the TSB Lab

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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Gatineau, Quebec, 27 March 2015 — This Sunday will mark the 25th anniversary of the creation of the Transportation Safety Board of Canada (TSB). On March 29, 1990, the TSB was created by an Act of Parliament and given the mandate to investigate marine, pipeline, rail and aviation accidents. The TSB has evolved over the past quarter century establishing itself as a world-class independent, investigative body whose top priority is contributing to the safest possible Canadian transportation system.

"Throughout the years, we have conducted major investigations and have been at the forefront of important changes to the transportation industry,” said Kathy Fox, Chair of the TSB. “Our raison d’être hasn’t changed—we investigate transportation accidents to find out what happened and why, with a view to ensuring those accidents never happen again. And we don’t shy away from putting a spotlight on critical safety issues as we do with our Watchlist.”

In addition to investigating accidents involving Swiss Air 111, Queen of the North, Cougar 91, and the tragedy in Lac-Mégantic, we have been the instigator for several changes made as a result of our findings. These include the requirement for many of today’s aircraft to carry terrain awareness and warning systems; and for safe towing procedures that have significantly reduced safety risks associated with towing small vessels in ice-infested waters. Canadian railway companies have also put in place measures to reduce the dangerous in-train forces that can sometimes cause derailments; and the pipelines throughout our country are now being built to even tougher standards.

In recognition of this milestone, we are launching a TSB@25 Web portal that highlights our accomplishments and the dedication of our people in various ways. It includes:

  • A video message from the Chair
  • The history of the TSB
  • A list of former Chairs
  • Blog posts by long-term employees and others
  • Employee video profiles
  • Photos – 25 years of TSB at work
  • Photos – Accident sites: 1990-2015

TSB employees are proud of the role they play and the work they do. Canadians can be assured that the TSB will continue to be diligent in its role of advancing transportation safety during the next 25 years and beyond.

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