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Transportation Safety Board of Canada

Transportation Safety Board of Canada (478)

Winnipeg, Manitoba, 21 March 2017 – The Transportation Safety Board of Canada (TSB) found that inadequate securement and insufficient employee supervision led to the March 2016 uncontrolled movement of a tank car in Regina, Saskatchewan. The results of the investigation are detailed in the report (R16W0059) released today.

On 1 March 2016, while a Cando Rail Services assignment was switching tank cars loaded with asphalt at the Co-op refinery in Regina, one of the tank cars rolled away uncontrolled. The tank car, which travelled about 2.7 miles (4.3 kilometres) before coming to rest, reached a speed of 19 mph and traversed seven public crossings and a railway interlocking that crossed the Canadian Pacific Railway Lanigan Subdivision. The grade crossing warning system at each of the seven crossings functioned as required, protecting the roadway traffic. There were no injuries nor dangerous goods involved.

The investigation determined that the incident occurred when the crew left the tank car unattended, secured only by emergency air brakes. These slowly lost pressure until they released, allowing the car to roll away. Hand brakes had not been applied to the unattended equipment, nor had crew members performed hand brake effectiveness tests, conducted a briefing with all crew members, or initiated an emergency radio broadcast when the tank car rolled away. Although the crew did attempt to catch the runaway car with their locomotive, they were unable to do so without violating the restrictions of their operating limits.

The TSB's investigation revealed that routine adaptations to rules and procedures by employees went undetected by the company prior to the incident. If adaptations are made to operating rules and procedures, safety margins built into the rules are often reduced, increasing the risk of unsafe operations and accidents.

Most uncontrolled railway movements in Canada are directly related to securement issues. Following the 2013 Lac-Mégantic accident, the TSB recommended that Transport Canada (TC) require Canadian railways to put additional physical defences in place to prevent runaway equipment (TSB Recommendation R14-04). Although TC revised the rules regarding train securement, the report indicates that the number of runaway equipment occurrences due to inadequate train securement had increased, from 21 in 2014 to 33 in 2015. There were 27 in 2016.

Following this occurrence, Cando Rail Services took a number of measures to increase the safety of its operations. This included issuing a system-wide bulletin requiring that all equipment have the minimum number of hand brakes applied, even if attended by an employee.

See the investigation page for more information.

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Richmond Hill, Ontario, 9 March 2017 – In its investigation report (A15O0015) released today, the Transportation Safety Board of Canada (TSB) determined that the continuation of an unstable approach following a loss of visual reference led to a Jazz Aviation LP aircraft contacting the surface short of the runway at the Sault Ste. Marie Airport, Ontario, in February 2015. There were no injuries, but there was significant damage to the aircraft.

On 24 February 2015, a de Havilland DHC-8-102, operating as Jazz Aviation LP flight JZA7795 and carrying 15 passengers, departed Toronto/Lester B. Pearson International Airport, Ontario, for a scheduled flight to Sault Ste. Marie Airport, Ontario. While on approach to Runway 30, in conditions of twilight and reduced visibility due to blowing snow, the aircraft touched down approximately 450 feet prior to the runway threshold. Following touchdown, the aircraft struck and damaged a runway approach light before coming to a stop approximately 1500 feet past the threshold.

The investigation determined that a significant power reduction and subsequent decrease in airspeed, while flying below the minimum stabilization height of 500 feet, resulted in an unstable approach. This rapid deceleration steepened the aircraft's vertical path. The crew had reduced power in order to reach the target airspeed for the final approach and landing.

The crew had followed what they understood to be the correct speeds for the approach according to the company's guidance material. Due to ambiguity in the guidance and uncertainty as to the required speed during the approach, the flight crew did not recognize that the approach was unstable and continued the approach to a landing.

The investigation also found that the rapidly changing weather decreased the flight crew's visibility of the runway, and that the steepened vertical profile created as a result of the power reduction went unnoticed, and uncorrected. Although the loss of visual reference required a go-around, the flight crew continued the approach.

An examination of over 500 similar flights on Jazz DHC-8-102s showed that company aircraft routinely fly decelerating approaches below the minimum stabilization height of 500 feet. If approaches that require excessive deceleration below established stabilization heights are routinely flown, then there is a continued risk of an approach or landing accident.

Unstable approaches are one of the key safety issues on the 2016 TSB Watchlist. There is also an outstanding Board recommendation (A14-01) calling for Transport Canada to require commercial air services to monitor and reduce unstable approaches that continue to a landing.

Following the occurrence, Jazz Aviation LP undertook a number of safety actions such as making amendments to the Jazz DASH 8 Aircraft Operating Manual, by introducing significant changes to the "Stabilized Approach Factors" subsection and adding simulator scenarios to the training syllabus.

See the investigation page for more information.

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Gatineau, Quebec, 8 March 2017 – Citing poor track conditions and inadequate drainage as important factors, the Transportation Safety Board of Canada (TSB) today released its investigation report (R15H0092) into the Huron Central Railway (HCRY) train derailment in 2015 near Spanish, Ontario.

On 1 November 2015, at approximately 2250 Eastern Standard Time, an HCRY freight train was proceeding westward on the Webbwood Subdivision at 25 mph when a train-initiated emergency brake application occurred at Mile 72.08, near Spanish, Ontario. Two separate groups of equipment derailed destroying about 225 feet of roadbed. No dangerous goods were involved and there were no injuries.

The investigation determined that the first group, three locomotives and the first eight cars of the train, derailed when the roadbed collapsed and the north rail joint broke apart under the train. The second group, five empty cars near the middle of the train, derailed due to compressive in-train forces when the cars impacted one another as the train rapidly decelerated during the derailment. The investigation also determined that HCRY's track inspection and maintenance program was not effective in dealing with various track infrastructure issues such as drainage, track instability, and rail joint defects. In this occurrence, a blocked culvert had resulted in inadequate drainage over several days of rain, allowing water to pool, migrate through the railway embankment and saturate the subgrade. If track inspectors are not provided with appropriate training on precursor ground hazards such as inadequate drainage, unstable ground conditions may not be detected in a timely manner, increasing the risk of derailment due to track conditions. Furthermore, a large number of rail joint defects were allowed to remain in service without performing the necessary follow up inspections regularly.

Following the occurrence, slow orders were issued for any identified track defects on the Webbwood Subdivision and the defects were repaired. The slow orders were removed only after repairs were completed and inspected by a supervisor.

As HRCY is a provincially regulated railway, the TSB investigation was conducted in accordance with a Memorandum of Understanding with the Province of Ontario.

See the investigation page for more information.

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Edmonton, Alberta, 27 February 2017 – The Transportation Safety Board of Canada (TSB) continues to advance its investigation into the accident involving a Tecnam P2006T aircraft operated by Mount Royal University, near Cochrane, Alberta. The TSB offers its condolences to the families and friends who lost loved ones in this accident.

What we know

  • A Tecnam P2006T twin-engine aircraft, operated by Mount Royal University, departed Calgary/Springbank Airport, AB (CYBW) at 1635 (Mountain Standard Time), during daylight hours.
  • The aircraft climbed to 8000 feet above sea level and progressed to the northwest.
  • Thirty minutes after departure, the last radar return from the aircraft was recorded at 7900 feet above sea level. This last radar return was 0.13 nautical mile southeast of the accident site location. The aircraft struck terrain 32 nautical miles northwest of CYBW at approximately 1705 (Mountain Standard Time).
  • All of the major aircraft components were located at the accident site but were destroyed by impact forces and a post-impact fire.
  • The aircraft was not equipped with, nor was it required to carry, a cockpit voice recorder (CVR) or a flight data recorder (FDR).

Work to date

  • The examination and documentation of the wreckage scene is complete and investigators have collected the data they needed from the accident site.
  • The wreckage was removed and transported to the TSB facility in Edmonton, Alberta, for further analysis.
  • We have requested the aircraft's maintenance history.
  • We have obtained most of the radar data and most of the air traffic control audio; we are waiting for a few more files and we are in the process of analyzing it.

Next steps

With the conclusion of the field phase, the examination and analysis phases begin. In the coming days and weeks, as part of its investigation process, the team will

  • examine components such as the engines and propellers;
  • send selected components to the TSB Engineering Laboratory in Ottawa, Ontario, for further analysis;
  • gather additional information about weather conditions;
  • gather information on air traffic control communications, and radar information;
  • examine aircraft maintenance records;
  • examine pilot training, qualifications, proficiency records and medical history;
  • continue interviews with the aircraft operator and other such witnesses;
  • review operational policies and procedures;
  • examine the regulatory requirements;
  • reconstruct events to learn more about the accident sequence (i.e., to validate data, test hypotheses, and verify assumptions);

Communication of safety deficiencies

Investigations are complex and we take the time needed to complete a thorough investigation. However, should the investigation team uncover safety deficiencies that present an immediate risk, the Board will communicate them without delay.

Further, it is important not to draw conclusions or speculate as to causes at this time. There are often many factors that can contribute to an accident.

Additional updates will be provided as required.

See the investigation page for more information.

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Richmond Hill, Ontario, 25 February 2017 – On February 25, 2017, Air Canada Flight 623 was travelling from Halifax to Toronto/Lester B. Pearson airport with 118 persons on board. Towards the end of the flight, the aircraft was flying an ILS approach to Runway 15R. Just after midnight, during the landing sequence, the aircraft travelled through the grass on the western side of the runway, eventually coming to a stop on the runway centerline. The passengers were deplaned on the runway and transported by bus to the terminal. There were no reported injuries, and apparent damage to the aircraft at this point is minor. The aircraft will be thoroughly examined to further determine the extent of the damage. Five runway edge lights were also damaged.

What we know

TSB investigators were deployed in the early morning to Pearson Airport to examine the aircraft and gather information. To date, we have:

  • Taken possession of the CVR and FDR. These will be sent to the TSB Lab in Ottawa for further analysis.
  • Gathered airborne radar, ground radar and audio data from Air Traffic Control.
  • Gathered the initial weather information.
  • Examined and took measurements of the occurrence site.
  • Conducted preliminary examination of the aircraft.

Next steps

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

  • Interviewing the flight crew, air traffic control and other witnesses.
  • Gathering all information surrounding this flight, such as: weather, the approach, navigation systems, communications, the crew, training, the organization.
  • Analyzing data from FDR/CVR.
  • TSB investigators have to examine all the information before drawing any conclusions. It is too early to say what the causes and contributing factors of this occurrence might be.

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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Dorval, Quebec, 27 February 2017 – In the release of its investigation report (R15D0118) today into the December 2015 derailment of a VIA Rail passenger train in Montréal, Quebec, the Transportation Safety Board of Canada (TSB) again highlights the risk of serious train collisions or derailments if railway signals are not consistently recognized and followed.

On 11 December 2015, at approximately 0910 Eastern Standard Time, VIA Rail passenger train No. 605 (the train) left Central Station in Montréal, Quebec, with 14 passengers on board. The train was travelling west on the north track when, at Turcot-Ouest (Mile 6.26), it derailed after negotiating a crossover at 55 mph, where the authorized speed was 15 mph. One of the locomotives and the track sustained minor damage and a VIA Rail on-board service employee suffered minor injuries.

The investigation determined that the train passed a signal at Turcot-Ouest that called for a speed of 15 mph, but no action was taken to slow down the train. At the time, the train was operating under a foreman's instructions. When trains travel through a protected work area on the track, train crews must communicate with foremen to obtain instructions. The foreman must specify the tracks that can be used and the restrictions, if any. In this case, the foreman's instructions were limited to the south and north tracks and did not include the adjacent freight track. The instructions, as well as the train's regular routing, led the train crew to think they would remain on the north track beyond Turcot-Ouest. If track foremen's instructions do not include all required information, train crews could misunderstand and misinterpret the instructions, increasing the risk of accidents.

The lead locomotive was equipped with a forward-facing camera and a prototype in-cab locomotive voice recorder. The recording of the in-cab conversations synchronized with the forward-facing camera assisted greatly in the investigation by making it possible to confirm the actions of the train crew and the dynamics of the derailment. This investigation reinforces the importance of TSB recommendations (R03-02 and R13-02) and the Watchlist item relating to on-board voice and video recorders.

A number of TSB investigations have cited train signal misinterpretation or misperception as a cause or contributing factor in the accident, and that is why this issue is on our Watchlist. If other physical defence methods for controlling trains in signalled territory are not in place, the risks of collision and derailment are increased when signal indications are not correctly recognized or followed. The Board has previously issued two recommendations for additional physical defenses (R00-04 and R13-01) to protect against missed railway signals.

Following the occurrence, VIA Rail issued a bulletin with special instructions requiring a radio broadcast to state the signal indication displayed. For its part, CN implemented several mitigating measures to ensure that employees are in full compliance with Planned Protection.

See the investigation page for more information.

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Dorval, Quebec, 22 February 2017 – Following the October 2015 uncontrolled movement and derailment of a parked cut of rail cars (a group of cars coupled together) on a non-main track in Montréal, Quebec, the Transportation Safety Board of Canada (TSB) today released its investigation report (R15D0103), citing that human intervention likely put the rail cars in motion.

On 29 October 2015, a cut of 26 empty intermodal cars, which had been previously secured on a storage track near the Canadian Pacific Railway (CP) Hochelaga Yard in Montréal started to roll. The cars rolled uncontrolled about 120 feet before striking a hinged derail. The derail, a mechanical device designed to stop uncontrolled rolling stock and equipment by derailing it, derailed only the first car before getting torn from the track. The remaining cars continued to descend the grade, reaching a second derail located approximately 400 feet further, which led to the derailment of the following four cars. Meanwhile, the first derailed car traveled over an embankment and struck a residential property. The occupants of this property, as well as those of six nearby homes, were evacuated. The residential property, the cars and the track sustained damage. No dangerous goods were involved, and there were no injuries.

The cut of cars had not moved since it was stored in May 2015. Since there had been no reports of extreme weather in the region, and that handbrake effectiveness does not generally degrade over time, the investigation determined that a human intervention had likely reduced the braking force, allowing gravity to set the cars in motion. Despite heightened surveillance in the area, railway personnel had been encountering trespassers regularly along the tracks where the cars were stored. However, the railway did not identify this condition as a hazard when choosing to store cars at this location, and no special inspections of the cars were being conducted.

In Canada, between 2006 and 2015, 397 occurrences involving uncontrolled movements of rolling stock or equipment were reported to the TSB, and about 8% of these occurrences were caused by human intervention. Because it is relatively simple to release the handbrake mechanism on a rail car, stored rail cars are vulnerable to tampering by unauthorized persons. If measures to prevent tampering with hand brakes on cars stored in areas frequented by trespassers are not taken, there is an increased risk that rolling stock will move uncontrolled. The Board has previously issued a recommendation for the requirement of fencing along the railway right-of-way in areas where there are frequent pedestrian incursions (R91-01).

Following the occurrence, CP took a number of additional measures to eliminate trespassing at this location.

See the investigation page for more information.

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Edmonton, Alberta, 20 February 2017 – Following the release of its investigation report (A15F0165) today, the Transportation Safety Board of Canada is reminding aircraft passengers to comply with flight and cabin crew instructions and to wear their seat belts after 21 people were injured during a turbulence event encountered by Air Canada flight ACA088 in December 2015.

On 30 December 2015, a Boeing 777, operating as flight ACA088, departed Shanghai, China at 1123, travelling toward Toronto, Canada. The flight was planned for 13 hours and 40 minutes. About five hours into the flight, the flight crew received a meteorological information bulletin that forecasted an area of severe turbulence over the southern coastal mountains of Alaska. Approximately two and a half hours later, 35 minutes before entering the area of known turbulence, the first officer directed that the inflight service be stopped and that the cabin be secured. Seat belt signs were turned on, and several announcements were made in English, French and Mandarin, stating that the flight was approaching an area of turbulence and asking the passengers to fasten their seat belts. Despite these measures, many passengers were not wearing their seat belts when the flight encountered severe turbulence.

During the turbulence encounter, 21 passengers were injured, one of whom sustained a serious injury. Once the turbulence subsided, first aid was provided on board the aircraft, as the flight diverted to Calgary, Alberta. This short video describes the occurrence and depicts, in a generic aircraft, what effects the forces associated with severe turbulence would have on passengers who are not wearing seat belts. The investigation found that the flight crew's decision to secure the cabin and reduce to turbulence penetration speed contributed to preventing significant numbers of injuries in the cabin and potential damage to the aircraft.

The investigation also determined that the flight crew were last exposed to information on jet streams (fast-flowing air currents) and turbulence in training taken in 2011 and 2012. Air Canada dispatchers had also received training on clear air turbulence weather and jet streams. However, training material given to both pilots and dispatchers did not contain information on the increased likelihood of turbulence through a wide range of altitudes when jet streams cross mountainous terrain. If training material does not contain complete information pertaining to all of the factors that contribute to turbulence, then there is a risk that the best course of action will not be taken.

Following the occurrence, Air Canada issued bulletins providing dispatchers with guidance on reporting and providing information to support flight crews in avoiding turbulence.

See the investigation page for more information.

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Sudbury, Ontario, 16 February 2017 – Today the Transportation Safety Board of Canada (TSB) is issuing a recommendation (R17-01) calling for Transport Canada (TC) to develop strategies to reduce the severity of derailments involving dangerous goods. This recommendation was issued as part of its investigation (R15H0013) into the February 2015 derailment and fire involving a Canadian National Railway (CN) crude oil unit freight train near Gogama, Ontario.

On 14 February 2015, a CN unit train transporting 100 tank cars loaded with petroleum products derailed. It was travelling at 38 mph, below the 40 mph speed limit in place at the time. Twenty-nine tank cars of petroleum crude oil derailed and 19 of these breached, releasing 1.7 million litres of product. The crude oil ignited, resulting in fires that burned for 5 days. There were no injuries.

"This accident occurred at a speed below the maximum speed permitted by the Transport Canada approved Rules Respecting Key Trains and Key Routes," said Kathy Fox, Chair of the TSB. "The TSB is concerned that the current speed limits may not be low enough for some trains—particularly unit trains carrying flammable liquids. We are also calling for Transport Canada to look at all of the factors, including speed, which contribute to the severity of derailments, to develop mitigating strategies and to amend the rules accordingly."

The investigation found that the derailment occurred when joint bars in the track failed. Pre-existing fatigue cracks in the joint bars at this location had gone unnoticed in previous inspections. Once the fatigue cracks reached a critical size, the combination of the cold temperatures (-31 °C) and repetitive impacts from train wheels passing over the joint caused the joint bars to fail. These defects went undetected as the training, on-the-job mentoring, and supervisory support that an assistant track supervisor received was insufficient.

The cars in this train were Class 111 tank cars built to the newer CPC-1232 standard. Although this standard requires the cars to have additional protective equipment, the TSB determined that the speed of the train had a direct impact on the severity of the tank-car damage. Additionally, the lack of thermal protection contributed to thermal tears in those cars located in the pool fire, which led to additional product release. Consequently, the cars displayed similar performance issues as in the Lac-Mégantic derailment.

"The Transportation of flammable liquids by rail has been on the TSB Watchlist since 2014", said Chair Fox. "While stronger tank cars are being built, the current ones will be in service for years to come. The risks will also remain until all of the factors leading to derailments and contributing to their severity are mitigated. This is the focus of the recommendation we issued today."

See the investigation page for more information.

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Winnipeg, Manitoba, 2 February 2017 – The Transportation Safety Board of Canada (TSB) determined a loss of engine power while hovering at low altitude led to the 2015 fatal helicopter accident near Paynton, Saskatchewan. The details are contained in the investigation report (A15C0146).

On 22 October 2015, a Hughes 369D helicopter, operated by Oceanview Helicopters Ltd., was conducting aerial work installing marker balls onto SaskPower hydro lines with a pilot and an external platform worker on board. During the marker ball installation, the single-engine helicopter was hovering at 325 feet above ground level when it experienced an engine failure. The helicopter began to descend and collided with terrain. Both the pilot and the platform worker sustained fatal injuries, and the helicopter was destroyed in a post-impact fire.

The investigation determined that it is likely that the failure of an internal engine component resulted in the loss of engine power. This occurred while the helicopter was in a hover, and there was insufficient altitude to conduct an autorotation landing (a manoeuvre to land without engine power), which led to the helicopter impacting the terrain.

It was also found that the risk of injury or death increases if a single-engine helicopter is operated at altitudes and airspeeds from which a successful autorotation landing may be difficult to perform.The combination of these altitudes and airspeeds are depicted in rotorcraft flight manuals. In this accident, the engine failure occurred when the helicopter was operating in this area of flight profile.

Following the occurrence, Oceanview Helicopters Ltd. voluntarily suspended external platform worker operations; SaskPower began implementing a helicopter safety program, including enhanced employee training and the recruitment of an aviation operations specialist; and the company contracted to build the hydro towers also reviewed its helicopter operation standards with the view of enhancing safety.

See the investigation page for more information.

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