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Transportation Safety Board of Canada

Transportation Safety Board of Canada (333)

Gatineau, Quebec, 24 November 2014 – Following a catastrophic failure on one of the cargo handling cranes aboard the bulk carrier Seapace in Bécancour, Quebec, the Transportation Safety Board of Canada (TSB) today issued a warning to vessel owners.

On 13 August 2014, the bulk carrier Seapace sustained a failure of its cargo crane #4. The slewing ring bearing broke apart and the complete cabin and jib assemblies collapsed into a cargo hold, injuring the crane operator. The TSB is participating in the investigation of the occurrence with Transport Malta’s Marine Safety Investigation Unit.

There is a possibility that the same progressive failure of a slewing ring bearing will occur on any vessel fitted with similar cargo handling cranes. While the TSB has asked the International Association of Classification Societies (IACS) to share information about the safety risks, there is no known central database of such vessel owners. The TSB is therefore communicating this message to help reach vessel owners.

The bulk carrier is one of a series of 443 sister ships that were constructed between 2008 and 2014, by various shipyards located in China. The cargo handling crane was built for Ishikawajima-Harima Heavy Industries Co. Ltd. (IHI) of Japan, under licence by Wuhan Marine Machinery Plant Co. Ltd. (WMMP) of China. It was an electro-hydraulic jib crane of the slim type SS36T (serial number DC09-11102-4). The slewing ring bearing assembly was fabricated by Dalian Metallurgical Bearing Co. Ltd. of China under the standard JB/T2300 of the type 133.34.2300.00.03 (2-row roller slewing ring bearing with internal gear, serial number D00984). For pictures of the occurrence, visit our Flickr page.

Vessel owners should take whatever measures considered appropriate to ensure the integrity of any similar unit in service on board vessels. The TSB would appreciate being advised of any measures implemented either by phone at 1-800-387-3557 or by email at This email address is being protected from spambots. You need JavaScript enabled to view it..

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Ottawa, Ontario, 24 November 2014 - The Transportation Safety Board of Canada (TSB) will hold a news conference to release its 2014 Watchlist. The Watchlist contains the issues that the TSB considers to be the biggest risk to Canada’s transportation system.

When:

26 November 2014 at 1:30 pm. Eastern Savings Time

Where:

Lady Elgin Room
Lord Elgin Hotel
100 Elgin Street, Ottawa, Ontario

Who:

Kathy Fox, Chair
Faye Ackermans, Member of the Board
John Clarkson, Member of the Board
Joseph Hincke, Member of the Board

This event is for media only. Media representatives will need to show their outlet identification.


The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

For more information or to schedule an interview, please contact:
Transportation Safety Board of Canada
Media Relations
819-994-8053

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Vancouver, British Colombia, 21 November 2014 – In its investigation report (M14P0023) released today on the February 2014 loss of propulsion of a tug on the South Arm Fraser River in British Columbia, the Transportation Safety Board of Canada (TSB) highlighted the need to follow manufacturer’s recommendations for engine maintenance.

On 11 February 2014, the tug Jose Narvaez sustained a loss of propulsion due to a main engine seizure while towing an empty barge down the South Arm Fraser River in British Columbia. The tug and barge were towed back to the dock and secured. The main engine was deemed a constructive loss. There were no injuries or pollution.

The investigation determined that the lubricating oil was contaminated with combustion, freshwater, and/or anti-freeze, because the system had never been completely flushed out and cleaned after past major engine failures—even though this was recommended by the manufacturer. Investigators also found that the oil cooler was not maintained as per the manufacturer's recommendations, and it developed internal leaks that further contaminated the oil system, ultimately resulting in a loss in oil pressure. Furthermore, the loss of lubrication and piston cooling caused by the contaminated oil caused the engine cylinders to overheat. This further exacerbated the overheating of the rest of the engine and eventually led to its seizure and loss of propulsion.

Following the occurrence, Lafarge, the owner/operator of the tug, initiated weekly meetings to review safety procedures, drills, and preventive maintenance at the beginning of a shift. They also replaced the main engine and the cooling system on the Jose Narvaez, including upgrades to the monitoring system and alarm panel.

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Gatineau, Quebec, 14 November 2014 - The Transportation Safety Board of Canada is launching a campaign to raise awareness about its SECURITAS program. The Canadian public and transportation industry employees are encouraged to confidentially report unsafe transportation acts and conditions through SECURITAS. While employees are urged to use existing internal company-specific safety reporting systems, not all transportation companies have such systems and some employees may not feel comfortable using them. SECURITAS offers an additional way for people to share safety concerns in the aviation, marine, railway and pipeline industries which the employee or public believes is not being addressed or when they believe there is no other recourse.

When the TSB receives a confidential report, investigators analyze the information and determine the appropriate action to be taken. The TSB may forward the information, often with its suggestion for corrective action, to the appropriate regulatory authority. Sometimes the TSB can contact specific transportation organizations, companies and/or agencies directly if they are the ones best placed to correct the problem. In other cases, the TSB may choose to launch its own investigation. However, the TSB will not take any action that might reveal the reporter's identity. The identity of the person making the report always remains confidential.

The TSB SECURITAS program provides industry insiders and the public with a way to report possible safety concerns and to help make Canada's transportation system safer. You can access the program by This email address is being protected from spambots. You need JavaScript enabled to view it., fax or telephone. The SECURITAS web page has more information on the program and on how to make a confidential report.

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Dartmouth, Nova Scotia, 13 November 2014 – In its investigation report (M13M0102) into a fatal accident involving the fishing vessel Marie J released today, the Transportation Safety Board of Canada (TSB) concluded that a wide turn close to a sandbar, and successive breaking waves contributed to the grounding and sinking of the vessel. The three people onboard drowned.

On 18 May 2013, the small lobster fishing vessel grounded on a sandbar in bad weather while returning to McEachern's Point Harbour in Tabusintac Bay, New Brunswick. The investigation found that the vessel made a wide turn around the first red buoy at the beginning of the channel, positioning the vessel close to the sandbar. Two successive breaking waves struck the vessel, set it to port and caused it to ground on the sandbar. The waves continued to strike the vessel, pushing it over the sandbar where it sank.

The TSB also determined that two other contributing factors to the grounding were that both the accuracy of the locations of the buoys and the position of the sandbar could not be determined because the tidal gully was prone to silting and bottom shifting.

Since the occurrence, the Canadian Coast Guard reviewed buoy placement in the channel, and five green port hand buoys were added to the channel. For its part, Fisheries and Oceans Canada commissioned a study to assess alternative strategies for improving navigational safety to access McEachern's Point Harbour at Tabusintac Bay. The study identified multiple options and found future environmental changes may cause additional breaches in the sandbars, decreasing tidal flow and increasing sedimentation.

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Toronto, Ontario, 30 October 2014 – In its report released today (R13T0122), the Transportation Safety Board of Canada (TSB) identified the catastrophic failure of a roller bearing and subsequent burnt-off axle journal on the first car behind the locomotives as contributing factors in a June 2013 derailment near Sudbury, Ontario.

On 2 June 2013, a Canadian Pacific Railway (CP) freight train was heading north on the Parry Sound Subdivision when 6 intermodal cars derailed as the train approached the bridge over the Wanapitei River. Some of the derailed cars impacted and severely damaged the bridge while a number of the cars and containers fell down the embankment and into the river. No injuries were reported.

The investigation also determined that when reconditioned roller bearing components are used, bearing service life is further reduced. Because the roller bearing failed between CP hotbox detector (HBD) stations, the investigation further concluded that when HBD systems are not configured for real-time monitoring and data trending, roller bearings which are beginning to fail may not be detected before failure.

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Vancouver, British Columbia, 23 October 2014 – The Transportation Safety Board of Canada today released its investigation report (M14P0014) into the grounding of container vessel Cap Blanche on the Fraser River, British Columbia in January 2014. The report identified fog and reliance on predicted vessel positions based on inaccurate information as factors contributing to the grounding.

On 25 January 2014, the container vessel Cap Blanche was on its way to the Fraser Surrey Docks on the Fraser River, British Columbia. The vessel was under conduct of a pilot and visibility was reduced due to fog. The pilot used a function on his portable pilotage unit to assess the rate of turn to transit through the Steveston Bend. The information given by the equipment was inaccurate because it was subject to an unidentified GPS smoothing interval. The Cap Blanche grounded within the buoyed channel in the Stevenson Bend. The vessel was refloated approximately 30 minutes after the groundingwith minimal damage. No injuries or pollution were reported.

The investigation found that if a navigator primarily relies on a single piece of navigational equipment or information, there is a risk of potential errors going undetected. It further identified that the bridge team was unaware of the silting on the south side of Steveston Bend so they were unable to assist the pilot or identify the developing unsafe condition. The investigation also found decisions based on imprecise information can be made if pilots do not make use of the most accurate navigational equipment available to them.

Since the occurrence, the TSB issued a Marine Safety Advisory letter to the Pacific Pilotage Authority, providing information about the discrepancy between inputs from a vessel’s automatic identification system (AIS) and the pilots’ wide area augmentation system (WAAS)-based differential global positioning system antennas. The Pacific Pilotage Authority distributed the safety advisory to all pilots.

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Québec, Quebec, 9 October 2014 – The Transportation Safety Board of Canada today released its investigation report (M13L0123) into the collision between bulk carrier Heloise and tug Ocean Georgie Bain in the Port of Montreal, Quebec. The investigation determined that language barriers on board the Heloise, and the failure to use available navigation resources on board both vessels contributed to the collision.

On 03 August 2013, the Heloise entered the main channel of the St. Lawrence River, where it met with two upbound vessels and numerous pleasure craft. At about the same time, the Ocean Georgie Bain had left its base to assist another vessel with berthing and was also entering the main channel. The pilot on the Heloise, concerned by the presence of pleasure craft, altered its course. Once the Heloise was clear of the craft, the pilot steadied the course of the vessel in the direction of the Ocean Georgie Bain and the 2 vessels collided. The pilot on the Heloise was not monitoring the Ocean Georgie Bain at the time of the collision, and the bridge crew on the Heloise was not assisting the pilot by maintaining a lookout or using navigational equipment to advise the pilot of relevant traffic.There was considerable damage to the Ocean Georgie Bain but no damage to the Heloise other than traces on the hull.

The investigation identified numerous risks including that operations on the bridge can be affected when language barriers inhibit communication. In addition, vessels in close proximity might not be detected and a collision may occur if available resources for safe navigation, such as radars and an electronic chart system, are not used. The investigation also found that companies and vessel masters must understand and apply all of the safe manning requirements for a vessel to be manned adequately.

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Montreal, Quebec, 6 October 2014 – In its investigation report (R13Q0012) released today, the Transportation Safety Board of Canada (TSB) determined that the May 2013 collision between a VIA Rail Canada Inc. passenger train and a tractor-trailer at a private level crossing in Québec occurred when the train was proceeding through the crossing while the manual gate protecting the crossing was up. There were no injuries.

On 2 May 2013, a VIA Rail Canada passenger train, after disembarking the passengers and refuelling, was travelling in reverse between Gare du Palais and the Limoilou Yard in Quebec, Quebec.   There were two crew members – the operating locomotive engineer in the lead locomotive, and the in-charge locomotive engineer on the ground, who was supervising the reverse movement. Instructions were being communicated to the locomotive engineer by radio. The collision occurred at the private level crossing leading to the Papiers White Birch paper mill. The last passenger car was damaged and the tractor-trailer was destroyed. About 300 litres of diesel fuel from the tractor-trailer's fuel tank spilled on the ground.

The investigation found that when the occurrence tractor-trailer started the turn to enter the paper mill, the manual gates at the crossing were up, and the traffic light controlling access to the plant was indicating that traffic could proceed. Noting that another truck had stopped on the paper mill side, the in-charge locomotive engineer concluded that the manual gate was down, and then informed the operating locomotive engineer that the crossing was protected while it was not. The guard who operates the crossing gates did not immediately recognize the need to lower the gates to protect the crossing, as the view of the train was partially obstructed and the refueling operation had taken less time than usual.

Following the occurrence, VIA Rail Canada Inc. amended its procedures so that trains no longer stop upon exiting Gare du Palaisand changed its refuelling point to move it away from the level crossing. Transport Canada has entered into discussions with the City of Quebec, the Papiers White Birch paper mill and Canadian National to improve the traffic light and crossing protection systems at this location.

The risk of passenger trains colliding with vehicles is a TSB Watchlist issue. Watch the TSB video!

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Québec, Quebec, 2 October 2014 – The Transportation Safety Board of Canada (TSB) investigation into the grounding of the passenger vessel Louis Jolliet highlights the need for comprehensive emergency procedures, training, and drills according to its investigation report (M13L0067) released today.

On 16 May 2013, the passenger vessel Louis Jolliet ran aground off Sainte-Pétronille, Île d’Orléans, Quebec, while on a cruise with 57 passengers on board. The passengers and some crew were evacuated, the vessel sustained minor damage, and was refloated at high tide. There were no injuries or pollution reported.

The investigation found that, although present on the bridge at the time of the grounding, the master was not participating in or supervising the navigation of the vessel, leaving navigation to the recently-hired chief mate, who initiated a course alteration, and went aground.

In examining the events following the grounding, the investigation determined that key crew members were not familiar with their emergency duties. The investigation also determined that the emergency procedures in place for the vessel had shortcomings with respect to passenger safety management, and crew members had not practiced such procedures in a realistic way. Although the task of securing the safety of the passengers was accomplished on the day of the occurrence, the Louis Jolliet may carry up to 1000 passengers, highlighting the need for comprehensive and detailed procedures, training, and drills in passenger safety management. The investigation also highlighted the need for effective oversight of passenger safety by Transport Canada (TC).

Since the occurrence, Croisières AML, the owner/operator of the vessel, has implemented many safety actions addressing the issues outlined by the TSB investigation including new procedures to familiarize the crew with the route and new training and drills related to passenger safety. TC subsequently issued a notice to their inspectors on their requirements under the current regulations and made improvements to their reporting system.

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