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Transportation Safety Board of Canada

Transportation Safety Board of Canada (384)

Winnipeg, Manitoba, 28 July 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (P14H0011) into the 25 January 2014 rupture of a TransCanada PipeLines Limited pipeline. A 30-inch natural gas pipeline, Line 400-1, ruptured and ignited at the site of Mainline Valve 402 near Otterburne, Manitoba. The escaping gas burned for approximately 12 hours. Five residences in the immediate vicinity were evacuated until the fire was extinguished.

The investigation determined that Line 400-1 failed due to a fracture that occurred at a pre-existing crack that had remained stable for over 50 years prior to the occurrence. This crack had formed at the time of the pipeline's construction likely due to an inadequate welding procedure and poor welding quality. There was no requirement for inspections of every weld by radiography at the time of the pipeline's original construction.

The fracture was caused by incremental stresses to the pipeline, which were likely due to a combination of factors. These included: weakened soil support in the area due to maintenance activities over the years; record low temperatures that winter; recent work at and around the valve site that may have driven frost deeper into the ground; and thermal contraction that may have occurred when the pipeline cooled due to the absence of gas flow for 20 days prior to the occurrence.

Following the occurrence, the National Energy Board required TransCanada to perform several engineering assessments along Line 400-1. TransCanada performed numerous excavations, inspections and repairs along Line 400-1 before returning it to service. Following the pipeline's return to service, TransCanada performed in-line inspections to rule out other threats to the pipeline's integrity.

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Gatineau, Quebec, 16 July 2015 – The Transportation Safety Board of Canada (TSB) released today its investigation report (A13H0003) into the December 2013 runway incursion at the Ottawa/MacDonald-Cartier International Airport, in Ontario. There were no injuries and no damage to aircraft or airport property.

On 1 December 2013, a Piaggio P-180 turboprop aircraft with 2 pilots aboard was authorized to taxi across Runway 14 on its way to Runway 07 at the Ottawa/MacDonald-Cartier International Airport. At the same time, a Jazz de Havilland DHC-8 with 3 crew and 15 passengers aboard was also taxiing to Runway 14 for takeoff. After being cleared for takeoff, the DHC-8 was on its takeoff roll when the P-180 crossed Runway 14, approximately 4400 feet in front of it. Neither aircraft was aware of the runway incursion and continued their flights without further incident.

The investigation determined that the NAV CANADA ground controller issued instructions to the P-180 to taxi unrestricted from the apron to Runway 07, across Runway 14, despite the frequent use of Runway 14 for departing aircraft. Additionally, after issuing taxi instructions to the P-180, the ground controller did not transfer the information to the airport controller. While operating procedures require that this be done, they do not indicate exactly when the transfer must be performed. As such, the airport controller’s display did not indicate that the P-180 was taxiing for Runway 07 when take-off clearance was issued to the DHC-8. The investigation also found that the Tower was staffed below unit guidelines at that time.

Following the occurrence, the Ottawa Tower issued a directive instructing controllers to indicate that a vehicle or aircraft was cleared to cross a runway by activating a runway crossing indicator (RCI) on the flight data entry. The RCI can only be deactivated once the aircraft or vehicle has left the protected area on the other side of the runway. NAV CANADA also made changes to its procedures when operating short-staffed.

The risk of collisions on runways has been identified as one of the risks to Canada’s transportation system and is included on the TSB's 2014 Watchlist. The Board is calling for improved procedures and enhanced collision warning systems to be implemented at Canada's airports.

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Ottawa, Ontario, 15 July 2015 – Today the Transportation Safety Board of Canada (TSB) released its investigation report (A14H0002) into the June 2014 runway incursion and risk of collision at the Macdonald-Cartier International Airport. There were no injuries.

On 5 June 2014, Ornge's Agusta AW 139 helicopter, operating as Life Flight 4 Medevac (LF 4 Medevac), was departing Ottawa's Macdonald-Cartier International Airport destined for Pembroke, Ontario, on an Instrument Flight Rules (IFR) flight plan. As instructed, LF 4 Medevac contacted the tower when holding short of Runway 25. The airport controller amended LF 4 Medevac's IFR clearance, and then observed LF 4 Medevac taxiing across the hold line while a Federal Express Airbus 300 was landing on Runway 25. The airport controller instructed LF 4 Medevac to stop. The runway incursion and risk of collision occurred when LF 4 Medevac crossed the hold line on Taxiway Echo at the intersection of Runway 25, after the Airbus had landed.

The TSB investigation found that Air Traffic Control used non-standard phraseology when issuing instructions to the pilot and that LF 4 Medevac taxied across the hold line on Taxiway Echo without authorization. It also found that, if flight crews do not follow company standard operating procedures before taxiing onto a runway, there is an increased risk of collision between aircraft.

Immediately after the incident, Ornge issued two bulletins reminding flight crews to be diligent when receiving and acknowledging air traffic control clearances. For its part, NAV CANADA reviewed the occurrence during Ottawa tower refresher training in November 2014, with emphasis on the importance of using standard phraseology.

The risk of collisions on runways has been identified as one of the risks to Canada's transportation system and is included on the TSB's 2014 Watchlist. The TSB is calling for improved procedures and enhanced collision warning systems must be implemented at Canada's airports.

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Winnipeg, Manitoba, 14 July 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (R14W0041) into the 15 February 2014 derailment of a Canadian Pacific (CP) freight train near Keyes, Manitoba.

The freight train originated at Bredenbury, Saskatchewan and was destined for St. Paul, Minnesota. The train consisted of 2 locomotives, 50 loaded cars and 22 empty cars. It was 4403 feet long and weighed 7363 tons.

At about 2211, the train was travelling eastward on the Minnedosa Subdivision at 42 mph when the crew reported encountering a rough section of track near Mile 43.0. Shortly thereafter, the train experienced an unintended emergency brake application indicating that the train air brake line had become disconnected. Subsequent inspection revealed that 25 loaded covered hopper cars and 2 empty cars had derailed. There were no dangerous goods involved and no injuries. At the time of the accident, the sky was clear and the temperature was -21°C.

The TSB investigation determined that the derailed train was the second train through the area, and it derailed after encountering a broken rail that had likely failed under the passage of a previous train approximately 6 hours earlier.

The rail had failed catastrophically, likely due to high wheel impacts imparted on the rail by defective wheels from a car on a previous train which had large flat spots on its wheel treads. The flat spots occurred as a result of brake equipment which had failed enroute. The investigation also identified that risks exist when there are no explicit protocols in place to inspect the track after a train with known high impact wheels passes through non–signaled territory.

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Richmond Hill, Ontario, 30 June 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (A14O0077) into the loss of control and subsequent collision with water and fatality involving a Cessna 185E at Taylor Lake, Ontario.

On 24 May 2014, a privately-registered Cessna 185E, equipped with amphibious floats, departed the Guelph Airpark for a flight to Taylor Lake, Ontario. The pilot was the sole occupant of the aircraft. While conducting a glassy-water landing, the pilot lost control and the aircraft cartwheeled and sank. The aircraft fuselage was damaged by impact forces and the pilot’s door could not be opened. The pilot survived the impact but was not able to escape the submerged aircraft before drowning.

The investigation found that the right float contacted the water first, dug in, and resulted in a loss of control and the aircraft cartwheeling. With respect to contributing factors, the investigation determined that the number of hours the pilot had flown in recent years had decreased, and the pilot was likely less proficient than in earlier years. This would make the glassy-water landing more difficult. Glassy-water conditions are considered to present the most difficulty for landing a seaplane, regardless of experience. The mirror effect created by glassy-water conditions affects depth perception making it difficult for pilots to determine the aircraft’s height above the water.

The investigation also found that the pilot did not have emergency egress training. Although not required by regulation, egress training has been shown to improve the chances of exiting a submerged aircraft following a survivable accident.

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Winnipeg, Manitoba, 29 June 2015 – In its investigation (A12Q0216) into the Perimeter Aviation Flight 993 that crashed while landing in Sanikiluaq, Nunavut, on December 22, 2012, the Transportation Safety Board of Canada (TSB) determined that the aircraft came in too high, too steep, and too fast, striking the ground 525 feet past the end of the runway after an unsuccessful attempt to reject the landing. The 2 crew and 6 adult passengers, secured by their seatbelts, suffered injuries ranging from minor to serious. A lap-held infant, not restrained by any device or seatbelt, was fatally injured.

"Every day, families board commercial aircraft with babies and young children, and the majority trust that, if something goes wrong, a parent's arms can restrain their child safely,” said Kathy Fox, Chair of the TSB. “In the case of severe turbulence, a sudden deceleration, or a crash such as this one, research has proven that adults are not strong enough to adequately restrain a lap-held infant just by holding on to them. And just like in cars, adult lap belts are not suitable to restrain young children. This accident saw an infant ripped from his mother's arms and killed in the subsequent impact, even though everyone else survived.”

In its report released today, the Board is issuing two recommendations aimed at making air travel safer for infants and children. First, it is recommending that Transport Canada require commercial air carriers to collect data, and report on a routine basis, the number of infants and young children travelling. Currently, these statistics are not available, and better data is required to conduct research, assess risks, and outline emerging trends related to the carriage of infants and children.

Second, the Board is recommending that Transport Canada work with industry to develop age and size appropriate child restraint systems for infants and young children travelling on commercial aircraft and mandate their use to provide an equivalent level of safety compared to adults.

“This investigation identified issues associated with pre-flight planning, crew communication and unstable approaches—but what stands out most was the tragic fate of the baby on this aircraft,” added Fox. “We think infants and children deserve an equivalent level of safety as adults on board aircraft, and that is why we are calling on Transport Canada and the aviation industry to take action. It's time to do right by our children.”

Approach-and-landing accidents are on the TSB Watchlist. The TSB continues to call on Transport Canada and operators to do more to reduce the number of unstable approaches that are continued to a landing.

See investigation page for more information.

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Winnipeg, Manitoba, 25 June 2015 – The Transportation Safety Board of Canada (TSB) will hold a news conference on 29 June 2015, to make public its report (A12Q0216) on the investigation into the Perimeter Aviation aircraft that crashed on 22 December 2012 in Sanikiluaq, Nunavut.

When:
29 June 2015
1:30 p.m. Central Daylight Time
Who:
Kathy Fox, TSB Chair
Gayle Conners, Investigator-in-charge
Missy Rudin-Brown, Senior Human Factors Investigator
Where:
Holiday Inn Winnipeg International Airport Hotel by Polo Park
1740 Ellice Avenue
Winnipeg, Manitoba

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

The news conference will be webcast live from Winnipeg. You can view the webcast at the following address http://www.ustream.tv/channel/transportation-safety-board-of-canada.


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, contact:
Transportation Safety Board of Canada
Media Relations
Telephone: 819-994-8053
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

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Moncton, New Brunswick, 19 June 2015 – In its investigation report (R14M0002) released today, the Transportation Safety Board of Canada (TSB) determined that a wheel with an undetected defect broke, leading to the January 2014 derailment and fire involving a Canadian National (CN) train near Plaster Rock, New Brunswick.

On 7 January 2014, a CN freight train travelling from Toronto, Ontario, to Moncton, New Brunswick, derailed 19 cars and 1 mid-train locomotive near Plaster Rock. Seven Class 111 tank cars carrying petroleum crude oil and other dangerous goods, and 5 Class 112 pressurized tank cars carrying butane were among those that derailed. Approximately 230,000 litres of crude oil spilled from the tank cars and caught fire. About 150 residents were evacuated within a 1.6 kilometre radius of the fire. A total of 350 feet of track was destroyed, and there were no injuries.

The investigation determined that a wheel on the 13th car shattered due to an area of subsurface porosity that led to fatigue cracking. The subsurface porosity was not detected during the ultrasonic testing when the wheel was manufactured in 1991, or when it was reprofiled in 2006. The broken wheel and the wheel on the opposite side of the same axle derailed inside the track gauge, causing track damage leading to the derailment of the 19 cars and the mid-train locomotive.

The derailed cars included 4 older Class 111 tank cars, 3 Class 111 tank cars built to the CPC-1232 standard, and 5 Class 112 pressurized tank cars. The couplers of other cars punctured 2 of the older Class 111 tank cars, causing them to release their contents and feed a large pool fire. The CPC-1232 cars fared better, although it was difficult to determine whether their performance was attributable to the enhancements or simply to their position in the train and the types of impacts they sustained. The Class 112 cars did not sustain any impact damage. However, the pressure relief device gaskets on 2 Class 112 cars and 1 Class 111 car degraded due to heat from the pool fire, causing some product to be released from these cars.

The investigation also found that appropriate and effective measures were taken in response to the emergency. The environmental response plan and derailment site remediation ensured a minimal and contained environmental impact.

Transportation of flammable liquids by rail is a TSB Watchlist issue. The TSB is calling on railway companies to conduct route planning and analysis, and perform risk assessments to ensure that risk-control measures are effective. This accident also underscores the TSB’s longstanding call for tougher standards for tank cars transporting crude oil to reduce the likelihood of a dangerous goods release during accidents. On 1 May 2015, Transport Canada introduced new regulations for a more robust tank car standard, retrofit requirements and an implementation timeline.

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Dartmouth, Nova Scotia, 17 June 2015 - The Transportation Safety Board of Canada (TSB) will hold a media availability on 19 June 2015, to make public its report (R14M0002) on the investigation into the CN train that derailed and caught fire in Plaster Rock, New Brunswick on 7 January 2014.

When:

19 June 2015
10:15 a.m. Atlantic Daylight Time

Who:

Don Ross, Regional Senior Investigator (English)
Guy Laporte, Investigator-in-Charge (French)

Where:

Dieppe Public Library
333 Acadie Avenue
Dieppe, New Brunswick

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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The occurrence

On 29 March 2015, an Air Canada Airbus A320-200 aircraft (registration C-FTJP, serial number 233), was being operated as Flight AC624 from Toronto, Ontario, to Halifax, Nova Scotia, with 133 passengers and 5 crew on board.

The aircraft was flying the localizer approach procedure to land on Runway 05 at the Halifax Stanfield International Airport. A localizer approach only provides pilots with lateral guidance to align the aircraft with the runway for landing. During the approach, the engines of the aircraft severed power transmission lines, and then the main landing gear and rear fuselage impacted the snow-covered ground about 225 metres before the runway threshold. The aircraft continued through a localizer antenna, then impacted the ground in a nose down attitude, about 70 metres before the threshold. It then bounced and slid along the runway, coming to rest on the left side of the runway about 570 metres beyond the threshold.

The passengers and crew evacuated the aircraft; 25 people sustained injuries and were taken to local hospitals. The aircraft was substantially damaged. There was no post-crash fire.

Investigation team work

The Investigator-in-charge, Doug McEwen, is assisted in this investigation by TSB investigators with backgrounds in flight operations, aircraft performance, aircraft systems, aircraft engines, human performance, and air traffic control. Representatives from Air Canada, Airbus, NAV CANADA, Transport Canada, France’s BEA (Bureau d'Enquêtes et d'Analyses pour la sécurité de l'aviation civile), the RCMP, Halifax International Airport Authority, and the Halifax Regional Police department are also providing assistance.

Work to date

A large number of technical and operational documents, weather reports, air traffic control communications, and incident reports have been gathered and are being reviewed by investigation team members. Numerous interviews have been conducted with passengers and individuals from various organizations.

The flight data recorder (FDR) and cockpit voice recorder (CVR) have been examined. With assistance from external specialists, the TSB has retrieved information from the aircraft's Data Access Recorder, which records additional flight and aircraft parameters. Further analysis of this recorded data will be conducted.

What we know

Weather

Prior to landing, the crew received an updated weather report at 12:15 am Atlantic Time which included: windspeed 20 knots gusting to 26 knots from the north north west; 350° true; with a forward visibility of ½ statute mile in snow and blowing snow. The vertical visibility was 300 feet above the ground, temperature of minus 6°C, dewpoint minus 7°C, and altimeter setting of 29.63 inches of mercury.

The aircraft

Preliminary examination of the FDR indicates the aircraft was correctly configured for landing, the airspeed was consistent with a normal approach speed, and the altimeters were set to 29.63 inches of mercury. No mechanical deficiencies were identified with the aircraft's engines, flight controls, landing gear and navigation systems. During the review of the aircraft's maintenance records, no discrepancies were noted. Approximately 4900 litres of fuel was recovered from the aircraft.

Post-impact damage

The forward right and both rear exits were not used during the evacuation. No discrepancies were noted during the initial examination of these exits. Examination of the aircraft revealed that the right side cabin floor in seat rows 31 and 33, and the floor adjacent to the flight attendant fold-down seat near the rear of the cabin were punctured from below by aircraft structure. No pieces of the localizer antenna structure penetrated the cockpit.

Next steps

Work will include:

  • Recreating the accident flight profile as closely as possible to add to the understanding of the challenges encountered by the pilots of AC624.
  • Completing a detailed site survey illustration, examining relevant aircraft components and developing an animation of the aircraft's flight profile.
  • Evaluating pilot training and experience, human performance aspects, crew resource management, industry standards and company operating procedures.
  • Reviewing flight attendant training and experience as well as company procedures and regulatory requirements.
  • Examining survivability issues such as cabin and cockpit crashworthiness, passenger evacuation, and airport emergency response.
  • Reviewing non-precision localizer approaches utilizing a stabilized constant descent angle.
  • Conducting additional interviews as required.
  • Ongoing examination of aircraft structural damage.

Approach-and-landing accidents

The TSB Watchlist identifes approach-and-landing accidents as one issue which poses the greatest risk to Canada's transportation system. These accidents include runway overruns, runway excursions, landings short of the runway, and tail strikes. The TSB has called on operators, regulators, and air navigation service providers need to take more action to prevent approach-and-landing accidents, and to minimize the risks of adverse consequences if a runway overrun occurs.

Communication of safety deficiencies

Should the investigation team uncover a safety deficiency that represents an immediate risk to aviation, the Board will communicate without delay so it 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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