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Transportation Safety Board of Canada (315)
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.
Blocked water drainage system led to April 2013 embankment collapse and derailment of a VIA Rail train near Togo, Saskatchewan
Winnipeg, Manitoba, 11 June 2014 – In its investigation report (R13W0124) released today, the Transportation Safety Board of Canada (TSB) determined that inadequate water drainage led to the collapse of an embankment, causing the derailment of a VIA Rail (VIA) train near Togo, Saskatchewan.
On 28 April 2013, a westbound VIA train was passing over a raised portion of CN track when the crew observed a section of track where some of the roadbed ballast was missing. The train emergency brakes were applied, but the train could not stop in time. As the train passed over this location, the embankment further collapsed causing the 2 locomotives, a baggage car and the first passenger car to derail upright. The fuel tanks on each VIA locomotive came into contact with the rail causing the tanks to rupture. The diesel fuel-fed fire that ensued damaged both locomotives. Although the locomotives had been recently rebuilt, they were not equipped with newer puncture resistant fuel tanks. VIA personnel and all passengers on board were safely evacuated. There were no injuries.
A track inspection conducted about 4 hours before the arrival of the train did not note any defects at this location. Subsequently, it was determined that a culvert at the derailment location had been blocked by an ice plug for some time. The plugged culvert, in combination with a sudden, rapid melting of surface snow in the area, led to water saturation and destabilization of the embankment. The embankment began to fail prior to the passage of the train. The investigation determined that the track inspectors responsible for this location had not received any significant training in identifying indicators of potential ground hazards. Without such training, track inspectors may not detect unstable ground conditions in a timely manner, increasing the risk of a derailment.
Following the occurrence, CN produced a video on spring readiness inspections. Two supporting documents were produced, providing additional information specific to signs of potential track embankment instability. The material was provided to all track inspectors and supervisors as a refresher.
Lack of communication between pilot and bridge team contributed to 2012 grounding of bulk carrier Tundra on the St. Lawrence River
Québec, Quebec, 29 May 2014 – In its investigation report (M12L0147), the Transportation Safety Board of Canada found that fatigue and ineffective communication between the pilot and bridge team contributed to the grounding of the bulk carrier Tundra, near Sainte-Anne-de-Sorel, Quebec in November 2012. There were no injuries, but the vessel sustained minor damage.
On 28 November 2012, the Tundra departed Montreal, Quebec under the conduct of a pilot en route to Halifax, Nova Scotia. A master-pilot exchange of vessel technical information took place prior to departure, but passage plans for the voyage were not discussed. That evening, the vessel passed a position where a course alteration is required. However, no orders to change course were given by the pilot. The vessel exited the navigation channel and ran aground.
The investigation found that during the voyage, the pilot and bridge team were not exchanging information regarding navigation and that the bridge team was unaware of a planned course change. The vessel exited the navigation channel and ran aground because the pilot did not make a planned course change. Fatigue was also likely a factor for the pilot at a critical time when the course change was required to maintain safe navigation.
Since the occurrence, the vessel owner reminded its bridge officers to regularly verify and monitor their vessels’ position when under the conduct of a pilot. The Laurentian Pilotage Authority and the Corporation des Pilotes du Saint-Laurent Central committed to studying the risks related to fatigue. As well, they published a brochure for pilots to enhance communications between pilots and ship masters.
Soft ice ingested by engine led to January 2012 fatal crash of RCMP helicopter near Cultus Lake, British Columbia
Gatineau, Quebec, 28 May 2014 – In its investigation report (A12P0008) released today, the Transportation Safety Board of Canada (TSB) determined that the ingestion of soft ice into the engine led to a complete loss of power and the crash after takeoff of a Royal Canadian Mounted Police (RCMP) helicopter near Cultus Lake, British Columbia. The pilot was fatally injured.
On 17 January 2012, the RCMP helicopter, a Eurocopter AS 350 B3 involved in a training exercise, landed near Cultus Lake, B.C.; subsequently, a heavy snowfall began. The helicopter departed following the snowfall but soon after takeoff, a muffled bang, and the sounds of the engine and rotor diminishing rapidly were heard. The aircraft descended almost vertically, colliding with terrain in a nose-down, right-side down attitude.
The investigation found the protective engine covers had not been installed when the helicopter was parked during the heavy snowfall, and that the air intake system was not cleaned and dried prior to engine start. After the helicopter was started and running at low power, soft ice had built up inside the air intake; and during take-off at high power, the ice broke free and was ingested into the engine compressor which led to a complete engine power loss. This caused the rapid loss of the main rotor speed, an extremely high rate of descent, and the impact with terrain that was not survivable.
Since the accident, Eurocopter, the RCMP and Transport Canada (TC) have reminded pilots of the need to ensure the engine air intake system is clean prior to takeoff. However, the investigation concluded that the full range of recommended preventative measures cannot easily be accomplished in field operations and this presents a risk. Given this risk, TC has undertaken to review the engine inlet design of these helicopters.
In the meantime, there are over 500 Eurocopter AS 350 and EC 130 helicopters being operated by 132 operators in Canada. The investigation found these helicopters are susceptible to ice formation in cold weather operations, and the Board is concerned that in certain conditions, these helicopters may be at increased risk of engine flame-out shortly after takeoff.
English: Mark Clitsome
French: Yanick Sarazin
Combination of wing icing and overloaded aircraft led to fatal 2012 Manitoba plane crash
Winnipeg, Manitoba, 15 May 2014 – With the release of its investigation report (A12C0154) on the loss of control and collision with terrain of a Cessna 208B near the airport in Snow Lake, Manitoba, the Transportation Safety Board of Canada (TSB) today again reminds pilots that overloaded aircraft and any amount of ice on an aircraft's wings present risks to passengers, crew and equipment.
On 18 November 2012, a Cessna 208B operated by Gogal Air Services Ltd. left Snow Lake en route to Winnipeg, Manitoba. Shortly after takeoff, the aircraft descended and struck the terrain in a wooded area approximately 1 mile beyond the end of the runway. The pilot did not survive, and the 7 passengers were seriously injured.
The TSB investigation found that the aircraft was approximately 600 pounds over its maximum gross takeoff weight limit and that the wing and tail leading edges were contaminated with ice. These factors had the combined effect of increasing the stall speed of the aircraft, reducing its takeoff and climb performance, and impairing the protection afforded by its stall warning system. As well, the investigation found that that the aircraft had likely been operating in instrument meteorological conditions on the day before the accident, conditions for which Gogal Air Services was not authorized.
Gogal Air Services is a charter air operator and is certified to offer a non-scheduled air service. However, the report notes that a part of the company’s flight operations — moving mine workers between Winnipeg and the mine at Snow Lake — had some of the features of repetitive charter operations (such as scheduled service). These operations incur additional risks, such as customer expectations of performance in various weather conditions. In spite of these risks, Transport Canada does not provide the same degree of oversight as it does for a scheduled operator. Because of this, the risks in the operator’s activities may not be fully evaluated.