Aviation.ca - Your Number One Source for Canadian Aviation News, Jobs and Information!

Transportation Safety Board of Canada

Transportation Safety Board of Canada (451)

Dartmouth, Nova Scotia, 27 September 2016 – Citing a combination of track conditions and rail wear as contributing factors, the Transportation Safety Board of Canada (TSB) today released its investigation report (R15M0034) into the April 2015 Canadian National Railway (CN) derailment near Saint-Basile, New Brunswick.

On 17 April 2015, a westbound CN freight train derailed 35 rail cars and one locomotive at Mile 212.8 on the Napadogan Subdivision. The derailment destroyed approximately 900 feet of main track. Twenty of the derailed cars were residue tank cars that had last contained crude oil.

The investigation determined that significant wear on the rail had resulted in the wheel contact shifting outward, which reduced the rail's lateral stability. In addition, as the train was negotiating the curve, track conditions and the curve elevation condition combined to increase lateral forces on the rail, leading to the train's derailment.

The investigation observed that if track gauge is close to maintenance tolerances, it is harder to protect against incremental gauge-widening forces, increasing the risk of derailments. It also highlighted the limited guidance available to track maintenance personnel faced with a combination of track conditions. The TSB notes that there are no clear criteria for addressing combination defects (more than one defect occurring within 100 feet of track) that can pose a threat to safe rail operations, increasing the risk that unsafe combinations of track conditions can be missed or remain unaddressed during track inspections.

In 2014, the transportation of flammable liquids by rail was added to the TSB Watchlist. Based on this investigation and previous ones, recommendations, and other safety communications, the TSB reiterates that flammable liquids must be shipped in more robust tank cars to reduce the likelihood of a dangerous goods release during accidents. Fortunately, in this accident, all the derailed tank cars were residue cars.

Following the occurrence, CN reduced the combined wear limit for 136-pound rail and initiated gauge restraint measurement to enhance its assessment of lateral strength of the track structure.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Gatineau, Quebec, 19 September 2016 – The Transportation Safety Board of Canada (TSB) today released the report on its safety study, Expanding the use of locomotive voice and video recorders in Canada. The study looked at technology, legislative and regulatory issues, the potential safety benefits of installing recorders in locomotives, and the appropriate use of locomotive voice and video recorders (LVVR) information, among other subjects.

“The need for on-board voice and video recorders has been on the TSB Watchlist since 2012,” said Kathy Fox, Chair of the TSB. “In addition to providing important information to TSB investigations, data from these recordings, used in the context of a pro-active, non-punitive safety management system, will be invaluable to help railways identify and mitigate risks before accidents occur.”

The study concluded that expanding the use of these recordings has the potential to enhance safety and provide a better understanding and assessment of operational and human factors within the locomotive cab. In addition to their use in TSB accident investigations, railway companies could—if permitted—use LVVR data to enhance safety by developing and revising employee training programs, assessing and changing equipment designs and company operating procedures, improving crew security, and identifying risky behaviour.

The study also recognized concerns that the expanded use of LVVR could infringe on employees' rights, concluding that successful implementation of LVVR will depend on ensuring that the appropriate balance of rights and obligations for all key stakeholders is achieved through the establishment of a clear framework and guidelines for the use of the data.

Key railway stakeholders participated in the safety study, including Transport Canada, the Railway Association of Canada, Canadian Pacific Railway, Canadian National Railway, VIA Rail, GO Transit, and the Teamsters Canada Rail Conference.

Now that the study is completed, the TSB calls upon the Minister of Transport to take concrete action to initiate implementation of LVVR as soon as possible, and to introduce legislation to permit the expanded use of on-board recorders in all modes of transportation. The TSB is committed to working with Transport Canada on the development of an action plan and appropriate policy options.

See the LVVR study page for more information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Winnipeg, Manitoba, 6 September 2016 – The Transportation Safety Board of Canada (TSB) investigation report (A15C0134) released today shows that the use of an incorrect fuel type led to a forced landing in a forest near Thompson, Manitoba, in September 2015. The occupants sustained varying serious injuries.

On 15 September 2015 at 18:17 Central Daylight Time, a Keystone Air Service Ltd. (Keystone) Piper PA-31-350 departed Thompson Airport on an instrument flight rules flight to Winnipeg/James Armstrong Richardson International Airport with two pilots and six passengers on board. Shortly after takeoff, both engines began to lose power. The crew attempted to return to the airport, but the aircraft was unable to maintain altitude. The landing gear was extended in preparation for a forced landing on a highway southwest of the airport. However, because of vehicle traffic, the crew chose to conduct the forced landing in a forested area next to the highway.

The investigation found that the aircraft had been fuelled with the incorrect type of aircraft fuel. The piston-engined Piper PA-31-350 requires AVGAS, but it was refuelled with Jet-A1 fuel, which is used for gas turbine engines. The incorrect fuel caused a loss of power from both engines, and made it necessary for the crew to conduct a forced landing. A number of defenses implemented to prevent such fuelling errors failed. In particular, a flared spout, meant for use on Jet-A1 fuel filler openings, was replaced with a spout to enable the delivery of Jet-A1 fuel into the PA-31's smaller fuel tank openings. The fuelling operations were also not adequately supervised by the flight crew, and the fuel slip indicating that Jet-A1 fuel had been delivered was not available for their review.

Following the occurrence, an urgent memo by Keystone's management was circulated to all its pilots, reiterating the importance of crew supervision of aircraft fuelling in compliance with the company's operations manual.

A post-accident inspection conducted by Transport Canada (TC) revealed safety concerns that resulted in the suspension of Keystone's air operator certificate. TC subsequently conducted an in-depth review of Keystone's aviation safety record and cancelled its air operator certificate, citing public interest and the company's aviation safety record.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Gatineau, Quebec, 31 August 2016 – In its investigation report (R15H0005) released today, the Transportation Safety Board of Canada (TSB) determined that the complete failure of an already-cracked rail led to the January 2015 derailment of a Canadian Pacific Railway (CP) freight train that was carrying dangerous goods near Nipigon, Ontario. This investigation also made findings about the performance of pressure tank cars during derailments and the risks to train crews when dangerous products are released.

On 13 January 2015, a CP freight train was proceeding eastward on the Nipigon Subdivision when it derailed 21 cars, including seven dangerous goods tank cars loaded with propane, near the Dublin siding, approximately 34 km east of Nipigon, Ontario. As a result of the derailment, one tank car lost its entire load of propane and another tank car loaded with propane released product. One crew member sustained minor inhalation injuries due to exposure to propane.

The investigation determined that rail within a joint failed catastrophically as the train passed over it, leading to the derailment of the 11th to 31st cars. The rail failure originated at a bolt hole crack within a joint in the south rail which had propagated diagonally downward through the base of the rail likely due to one or more elevated wheel impacts that occurred prior to the arrival of the occurrence train.

Despite regular inspections, the rail defect was not detected because the bolt hole crack and the rail base fracture were behind the joint bars which made visual detection difficult, especially in the winter months when snow covered the rail base. The cold temperature at the time of the accident also made the rail more susceptible to brittle failure.

Despite the conductor's repeated exposure to the propane, medical assistance was not specifically requested until two hours later. The investigation found that CP training, procedures, and guidelines were insufficient to protect the conductor from the hazards associated with the derailment and release of a large volume of propane while conducting the site assessment.

A number of deficiencies posed additional risk in this occurrence, particularly with respect to the lack of information available to crews and rail traffic controllers about the risk of ignition and the health hazards posed by products involved in a derailment.

Although five of the six tank cars generally performed as intended, this derailment demonstrated that even a DOT-112 pressure tank car with improved design can be vulnerable to releasing product when exposed to high impact forces and sharp impact punctures.

Published in Transportation Safety Board of Canada
Written by
Read more...

Dorval, Quebec, 17 August 2016 – The Transportation Safety Board of Canada (TSB) investigation report (A13Q0098) released today shows that fuel exhaustion led to the forced landing of a Beechcraft King Air 100 in a field near the St-Mathieu-de-Beloeil Airport, Quebec, in June 2013. The TSB also identified deficiencies in the pilot’s performance and the company’s supervision of flights, as well as weaknesses in Transport Canada’s (TC) process for approving operators’ appointments of operations management personnel and in the regulatory oversight of flight operations.

On 10 June 2013 at 1700 Eastern Daylight Time, a Beechcraft King Air 100 operated by Aviation Flycie Inc. took off from the Montréal/St-Hubert Airport (CYHU), Quebec, with one pilot and three passengers on board for a test flight. While on its way back to the airport, 24 minutes after take-off, the aircraft ran out of fuel. The pilot decided to divert to the St-Mathieu-de-Beloeil Airport. When the pilot realized that the aircraft would not reach the runway, the pilot attempted a forced landing in a field near the airport. The forced landing ended in an aerodynamic stall and the aircraft struck the ground 30 feet short of the selected field. The aircraft was extensively damaged, and the four occupants sustained minor injuries.

While preparing for the flight, the pilot relied exclusively on the fuel gauges, misread them, and assumed that the aircraft had enough fuel on board for the flight. During the flight, the pilot did not monitor the fuel gauges and, when returning to the airport, decided to extend the flight to practise a simulated instrument landing approach, without noticing there was insufficient fuel to complete it.

The investigation found the pilot had a history of performance that did not meet expected standards to act as pilot-in-command for that aircraft type. Despite a marginal performance during the check flight, the pilot had successfully passed a pilot proficiency check, and TC had approved the individual's appointment to the position of chief pilot.

Meanwhile, the company's operations manager, who had no previous experience in commercial air carrier operations, was unable to fully appreciate the significance of the chief pilot's marginal performance or to detect deviations from regulations in the commercial flights performed over the company's first three months of operations, which preceded the accident. TC had also approved the appointment of the operations manager.

In addition, the investigation revealed that the person responsible for maintenance (PRM), a new co-pilot on the company's BE10, had no previous experience in maintenance or in air taxi flight operations. TC had also approved the appointment of the PRM.

The TSB determined that TC's appointment approval process was not effective and that, once the appointments had been approved, the management team's inability to perform the duties and responsibilities was not grounds for TC to revoke them.

The TSB has identified safety management and oversight as a Watchlist issue. As this occurrence demonstrates, some transportation companies are not effectively managing their safety risks. The Board has been calling on TC to implement regulations requiring all operators in the aviation industry to have formal safety management processes, and for TC to oversee these companies' safety management processes.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Edmonton, Alberta, 11 August 2016 – In its investigation report (A15W0069) released today, the Transportation Safety Board of Canada (TSB) found that during firefighting operations, the aircraft encountered a fire whirl, which led to a loss of control and impact with terrain. The pilot was fatally injured in the accident, which occurred near Cold Lake, Alberta, on 22 May 2015.

The Conair Air Tractor AT-802A Fire Boss was operating as Tanker 692 in support of wildfire management operations 25 nautical miles northwest of Cold Lake. It was the last in a formation of four Fire Boss aircraft that had just completed two drops on the northern edge of the fire. The tankers were conducting their drops at a specified bombing height of approximately 150 to 200 feet above ground level (agl), and after releasing their loads, the aircraft would climb back up to the circuit height of approximately 1000 feet agl. As Tanker 692 was coming out of its third drop, it encountered severe turbulence, which caused the aircraft to enter an undesired nose-up attitude, then roll to the left and pitch nose-down. The aircraft's low altitude while fighting the wildfire made recovery improbable, resulting in impact with the terrain.

The investigation determined that the aircraft had encountered a tornado-like event generated by the fire, which is known as a fire whirl. A number of factors such as a large heat source, unstable atmosphere, and low winds can cause a fire whirl. When Tanker 692 completed its third drop on the fire, the pilot could not see the fire whirl and would not have anticipated it being in the flight path.

The investigation found that if fire behaviour training is not provided to personnel involved in fire-suppression activities, there is a risk of aircraft being flown into unsafe conditions. The investigation also found that not all types of restraint system adequately protect pilots from the effects of severe turbulence, although this did not contribute to the accident.

Following the occurrence, Conair Group Inc. commissioned a fire behaviour study to look into the environmental conditions during the occurrence, and contracted a study into the accident. In addition, the company added a session to its training program focused on awareness of environmental conditions and the dangers around forest fires. It also conducted an operational review and installed five-point harnesses in its AT-802 fleet.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Dartmouth, Nova Scotia, 5 August 2016 – The Transportation Safety Board of Canada (TSB) is issuing a clarification concerning investigation report M15A0189, which it released on 2 August 2016. It emphasizes that the accident and fatality statistics for commercial fishing vessels data in Table 3 of the report, are for Newfoundland and Labrador, not for Canada as a whole.

From 2000 to 2015, there were 31 commercial fishing-related fatalities in Newfoundland and Labrador, and 189 in Canada.

Loss of life on fishing vessels is an issue on the TSB's Watchlist, and the Board completed a Safety Issues Investigation into fishing safety in 2012. The Board continues to call for concerted and coordinated action by federal and provincial authorities and by leaders in the fishing community to improve the safety culture in fishing operations.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Dartmouth, Nova Scotia, 2 August 2016 – In its investigation report (M15A0189) released today, the Transportation Safety Board of Canada (TSB) is again emphasizing the wide range of safety risks that persist for small fishing vessels.

On the evening of 16 June 2015, the small fishing vessel CFV 130214, an open boat with three people on board, was reported overdue from a crab fishing trip in Placentia Bay, Newfoundland and Labrador. Joint Rescue Coordination Centre Halifax initiated a search, and the bodies of all three crew members were found the next day on Bar Haven Island. The crew members were not wearing personal flotation devices. The vessel was not found and is believed to have sunk.

As the vessel was lost at sea and there were no witnesses or survivors, the investigation could not determine with certainty the primary cause or causes of the occurrence.

With only a few weeks left in the fishing season and none of his crab quota filled, the master was under increased pressure to fish. The master had modified a smaller secondary vessel, a 7.1-metre open boat, to use for crab fishing while his primary vessel was under repair, but the modifications were not assessed or tested for stability. The investigation found that the added weight from the modifications, combined with the weight of the crew members, bait, ice, and the catch on board would have significantly reduced the vessel's freeboard, making it more susceptible to taking on water, with a negative impact on the vessel's stability. Deteriorating weather and sea conditions put the heavily loaded vessel at further risk of taking on water.

To lease another vessel, the master would have had to formally ask the Department of Fisheries and Oceans (DFO) for an exemption from the Fisheries Licensing Policy for the Newfoundland and Labrador Region. It could not be determined why the master did not do so, or whether the request would have been approved. It also could not be determined whether the master fully understood that an exemption was an option or how he might have obtained one. The investigation found that there was no information about the exemption on the DFO website or in any other publication. If information about the fisheries licensing policy is not disseminated proactively to fishermen, they may not seek approval to use the safest means available to them to go fishing, thereby increasing the risk to safe fishing operations.

The investigation ascertained that the open boat was not carrying a distress communication device (it was not required to have one on board). Previous TSB investigations have found that carrying an emergency position-indicating radio beacon (EPIRB) can help save lives, and the Board has recommended (TSB Recommendation M00-09) that small fishing vessels carry one or other similar equipment. An EPIRB automatically sends a distress signal once it is immersed in water, so that search and rescue can be initiated immediately.

Loss of life on fishing vessels is a Watchlist issue, and a Safety Issues Investigation into fishing safety was completed in 2012. The Board continues to call for concerted and coordinated action by federal and provincial authorities and by leaders in the fishing community to improve the safety culture in fishing operations.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Richmond, British Columbia, 21 July 2016 – The Transportation Safety Board of Canada (TSB) found that a lack of familiarity with the territory and the misinterpretation of a communication contributed to a Canadian Pacific Railway (CP) train exceeding its limits of authority near Cranbrook, British Columbia, in March 2015, according to its investigation report (R15V0046) released today. No injuries were reported and no dangerous goods were involved.

On 11 March 2015, a CP rail traffic controller stopped a train, consisting of two locomotives and 130 empty cars near Mile 102 on the Cranbrook Subdivision, after the train had departed Cranbrook and travelled east for five miles without authorization. There were no conflicting movements.

The investigation determined that the train had been operated past the east cautionary limits sign at Cranbrook without the required clearance. During the train’s approach to Cranbrook, the train crew had contacted the assistant trainmaster at Fort Steele by radio. The crew members misinterpreted information from the assistant trainmaster, understanding it to be confirmation that the cautionary limits at Cranbrook extended all the way to Fort Steele. As a result, they believed that no additional authority was required and that they could proceed past Cranbrook without requesting a clearance from the rail traffic controller.

These events occurred at about 0120, a time of day that is close to a known circadian rhythm low point when alertness can be compromised. During periods of reduced alertness, there is an increased risk of inadvertent errors such as the misinterpretation of communications.

Although they were qualified for their respective positions, the train crew of three CP management (non-unionized) employees were not familiar with the territory. The investigation identified that if railway management employees who operate trains are not sufficiently familiar with the territory, the limits of operating authority may not be consistently observed, increasing the number of these occurrences and associated risks. It also observed that if the regulations do not adequately address the requirements for training, certification, and territory familiarization for railway management employees who operate trains, trains may be crewed with management employees who are not sufficiently experienced, increasing the risk of unsafe train operations.

Following this occurrence, CP redesignated Cranbrook Yard as a siding. The cautionary limits at the yard were removed, and an adjacent subdivision was combined to operate as one. In addition, CP formalized a requirement for territory familiarization for management crews.

See the investigation page for more information.


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.

Date modified:

Richmond, British Columbia, 19 July 2016 – In its investigation report (R14V0215) released today, the Transportation Safety Board of Canada (TSB) determined that a seized and locked axle, crew fatigue, and misinterpretation of a fault indicator led to the derailment of a Canadian National Railway (CN) train near Kwinitsa, British Columbia. There were no injuries and no dangerous goods were involved.

On 15 November 2014, a westbound CN train, consisting of 2 locomotives and 153 loaded intermodal flat cars, stopped in a siding to let an oncoming train go by. After exiting the siding, the train seemed to take slightly longer than expected to accelerate. About 12.5 miles west of the siding near Kwinitsa, a surge was felt as the train passed through a switch, and soon after that a train-initiated emergency brake application occurred. After coming to a stop, performing the emergency radio call, and inspecting the train, the crew found that the No. 4 axle of the trailing locomotive was locked and had derailed along with 8 intermodal flat cars consisting of 17 platforms.

The investigation determined that the No. 4 axle of the trailing locomotive had locked when overheating parts on the traction motor assembly cooled down and seized together while the train was stopped in the siding. Extensive wear and heat generation had been occurring within the traction motor assembly due to an undersized traction motor shaft. The locked axle prevented the wheels from rotating and caused the wheels to slide along the rail, become deformed, and then derail as the No. 4 axle passed through the switch near Kwinitsa.

The investigation also found that an intermittent wheel slip indicator had activated when the train resumed its movement and left the siding. These indications are not uncommon when locomotives are pulling with high tractive effort, as they do when accelerating from a stop, and the crew was not concerned by its activation.

The train had passed several wayside inspection systems prior to the derailment without triggering any alarms, including one between the siding and the derailment site. That system however, inspected only 9 axles—even though the train had 424 axles—because the damaged wheel set then dislodged the heat sensors on the inspection system. The scan results for those 9 axles were announced about 30 seconds later. However, the crew did not notice that the announcement had been transmitted much earlier than normal.

The crew members were fatigued at the time of the occurrence, because in the preceding days they had erratic sleep patterns due to work shifts with variable start and end times. Such work/sleep patterns cause circadian rhythm disruptions, which can decrease performance and cognitive function. If shift start times are highly variable, train crew members may not be able to get good quality sleep on a regular basis, increasing the risk of accidents due to fatigue.

Following the occurrence, CN reformatted its wayside inspection systems to include axle counts as part of the post-scan announcement.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
Written by
Read more...
         
Aviation.ca is not responsible for the content of external Internet sites. Copyright © 1997-2015 Skytech Dynamics Corporation, All rights reserved exogenous-blank exogenous-blank

Login or Register