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Transportation Safety Board of Canada

Transportation Safety Board of Canada (363)

Winnipeg, Manitoba, 14 April 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (A13C0150) into the November 2013 fatal aircraft accident in Red Lake, Ontario. Two flight crew members and 3 of the 5 passengers lost their lives when the aircraft crashed just south of the airport near a highway.

On 10 November 2013, a Bearskin Airlines Fairchild SA227 Metro III, on a flight from Sioux Lookout, Ontario, was on final approach to the Red Lake airport. The crew reported that they were 5 miles from the airport, and shortly thereafter declared an emergency. The aircraft struck trees along with some power lines, and was destroyed by a post-impact fire. Two passengers were able to evacuate the aircraft with non-life threatening injuries.

The investigation found that the crew experienced a near total loss of power in the left engine at 500 feet above ground level due to a failure of an internal engine component. The crew was unable to identify the nature of the engine malfunction, preventing them from taking timely action to control the aircraft. The aircraft’s landing configuration generated higher drag which, combined with the engine malfunction, resulted in the aircraft losing airspeed in an asymmetric power state. As the aircraft slowed, the crew lost control at an altitude from which a recovery was not possible.

Following the occurrence, the aircraft operator revised its single engine and engine failure procedures to ensure that the propeller on a malfunctioning engine does not cause excessive drag. Honeywell, the engine manufacturer, increased the inspection frequency on fuel nozzles and clarified inspection procedures. Transport Canada issued a Civil Aviation Safety Alert regarding issues with the negative torque sensing (NTS) system on Honeywell TPE-331 engines, to emphasize the need to feather and secure propellers during engine power loss events.

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The occurrence

On 29 March 2015, at approximately 1240 a.m., Air Canada flight ACA 624, an Airbus A320 , on a scheduled flight from Toronto's Lester B. Pearson International Airport, Ontario, to Halifax, Nova Scotia, collided with terrain approximately 1100 feet from the threshold of Runway 05, eventually coming to rest about 1100 feet down the runway. There were 133 passengers and 5 crew members on board; all of whom exited the aircraft. Twenty-five people were taken to hospital for treatment of injuries.

What we know

The initial impact was significant and caused substantial damage to the aircraft. The main landing gear separated and the underside of the aircraft was heavily damaged (fuselage and wings). During this impact, the aircraft collided with a localizer antenna array – part of the instrument landing system – and became airborne again, travelling forward on Runway 05. There is an extensive debris field between the localizer antenna location and the threshold of the runway.

During the first day on site, Transportation Safety Board of Canada (TSB) investigators documented the wreckage, the impact marks and the debris field. The cockpit voice recorder (CVR) and the flight data recorder (FDR) were recovered from the aircraft and have been sent to the TSB Engineering Laboratory in Ottawa, Ontario.

Investigation team work

The investigation team is led by the Investigator-in-Charge, Doug McEwen. Mr. McEwen has been an investigator with the TSB for 18 years. He is assisted in this investigation by experts in flight operations, air traffic services, weather, aircraft structures, aircraft systems, aircraft engines, and human performance.

Some of these experts come from within the TSB, but assistance is also being provided by the following organizations: Transport Canada (TC), NAV CANADA, the Royal Canadian Mounted Police, Airbus, and France's Bureau d'Enquêtes et d'Analyses. This is a normal part of any investigation, as these experts play a key role in helping the team uncover and understand all of the underlying factors which may have contributed to the accident.

Watchlist

Although more analysis is required, this accident displays some of the characteristics of an approach-and-landing accidents which is on TSB's Watchlist.

Next steps

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

  • survey the impact and wreckage site
  • continue examining and photographing the wreckage
  • removing the aircraft from the runway to restore normal operations
  • gather Air Traffic Control voice and data recordings
  • conduct witness interviews
  • gather meteorological information
  • collect operational information from the aircraft
  • preliminary review of the recorders at the TSB Lab to assist field investigators
  • determine which wreckage to collect for closer examination
    • further examination will be at the TSB Lab

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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Gatineau, Quebec, 27 March 2015 — This Sunday will mark the 25th anniversary of the creation of the Transportation Safety Board of Canada (TSB). On March 29, 1990, the TSB was created by an Act of Parliament and given the mandate to investigate marine, pipeline, rail and aviation accidents. The TSB has evolved over the past quarter century establishing itself as a world-class independent, investigative body whose top priority is contributing to the safest possible Canadian transportation system.

"Throughout the years, we have conducted major investigations and have been at the forefront of important changes to the transportation industry,” said Kathy Fox, Chair of the TSB. “Our raison d’être hasn’t changed—we investigate transportation accidents to find out what happened and why, with a view to ensuring those accidents never happen again. And we don’t shy away from putting a spotlight on critical safety issues as we do with our Watchlist.”

In addition to investigating accidents involving Swiss Air 111, Queen of the North, Cougar 91, and the tragedy in Lac-Mégantic, we have been the instigator for several changes made as a result of our findings. These include the requirement for many of today’s aircraft to carry terrain awareness and warning systems; and for safe towing procedures that have significantly reduced safety risks associated with towing small vessels in ice-infested waters. Canadian railway companies have also put in place measures to reduce the dangerous in-train forces that can sometimes cause derailments; and the pipelines throughout our country are now being built to even tougher standards.

In recognition of this milestone, we are launching a TSB@25 Web portal that highlights our accomplishments and the dedication of our people in various ways. It includes:

  • A video message from the Chair
  • The history of the TSB
  • A list of former Chairs
  • Blog posts by long-term employees and others
  • Employee video profiles
  • Photos – 25 years of TSB at work
  • Photos – Accident sites: 1990-2015

TSB employees are proud of the role they play and the work they do. Canadians can be assured that the TSB will continue to be diligent in its role of advancing transportation safety during the next 25 years and beyond.

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Dorval, Quebec, 26 March 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (A14Q0011) into the runway excursion of a Piper Malibu Mirage aircraft in Alma, Quebec.

On 23 January 2014, a privately operated Piper Malibu Mirage aircraft departed Montréal International (Mirabel) Airport for Alma, Quebec, with a pilot and one passenger on board. The flight was uneventful until the landing when the nose wheel contacted the runway and directional control was lost. The aircraft veered left and departed the runway surface 400 feet after the loss of control. The aircraft came to a stop about 100 feet from the runway edge in a compacted snow bank. There were no injuries. The aircraft was substantially damaged.

During the approach, the pilot selected the landing gear down and was provided with an indication in the cockpit that all three landing gears were down and locked. However, the nose gear was not fully down and locked, so the unaware pilot continued with the landing. This accident sequence is consistent with an equipment failure. The part that failed was the landing gear component of the engine mount. It prevented the nose gear from extending fully forward.

The investigation revealed that the right-side nose landing gear component of the engine mount fractured mainly in overstress from a pre-existing fatigue crack. The inspection criteria dictated an examination at 740 flying hours; however, that type of crack may appear before the original scheduled inspection period. On 5 June 2014, Piper Aircraft issued Service Bulletin (SB 1103E) changing the inspection period to 200 hours. The investigation noted that if the requirements prescribed in SB 1103E are not made mandatory for private operators in Canada, there is a continued risk that fatigue cracks may not be discovered in a timely manner.

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Québec, Quebec, 25 March 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (M13L0185) into the 15 December 2013 loss of tow and subsequent grounding of the service vessels I.V. NO. 9, and I.V. NO. 10. The two service vessels broke free from Tug Andre H which was also towing barge I.V. NO. 8. No injuries or pollution were reported.

The investigation revealed that the master had underestimated the risk posed by the forecast northeasterly winds for the area and chose to continue the voyage after a 7-hour delay. Furthermore, the towing arrangement was inadequate for the environmental and operational conditions. The synthetic rope couplers employed in the towing arrangement were in a degraded condition and parted during the voyage, causing the service vessels to break from the tow. The crew of the Andre H. was unable to recover the service vessels that broke free, due to reduced visibility and weather.

The investigation also found that there are risks when towing vessel operators do not have procedures and do not adopt standards to ensure the adequacy of the towing arrangement and the condition of the towing equipment. Furthermore, there is a risk of collision when operators and masters do not ensure that the prescribed navigation lights and shapes are exhibited.

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Richmond Hill, Ontario, 18 March 2015 - The Transportation Safety Board of Canada (TSB) is deploying a team to an accident involving a Piper Cherokee aircraft that occurred north of Georgian Bay, Ontario. The TSB will gather information and assess the occurrence.


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
819-994-8053

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The occurence

On 07 March 2015, Canadian National (CN) crude oil unit train U70451-02 was proceeding eastward on CN's Ruel Subdivision near Gogama, Ontario. The train crew was composed of a locomotive engineer, a trainee and a conductor. The train was equipped with 2 head-end locomotives hauling 94 Class 111 tank cars loaded with Petroleum Crude Oil (UN 1267). The train was 6,089 feet long and weighed 14,355 tons.

Around 02:42, while travelling at about 43 mph, a train-initiated emergency brake application occurred near Mile 88.70. Looking back, the crew observed a fireball about 700 feet behind the locomotives. They detached the locomotives and first 5 cars behind the locomotives from the derailed cars, and pulled clear. The temperature at the time was about -10°C.

The train was designated as a “Key Train”Footnote 1 operating on a “Key Route.”Footnote 2 The accident occurred about 3 kilometres west of the town of Gogama, Ontario, in the vicinity of a CN rail bridge that traversed the Makami river. The CN Emergency Response Assistance Plan (ERAP) was implemented and a full incident command structure was established in the Gogama town hall. There were no injuries reported and no evacuation was required. All fires were extinguished by 10 March 2015.

What we know

Site examination revealed that the 6th to the 44th cars behind the locomotives (39 cars in total) had derailed. The 6th and 7th cars derailed to the south, but made it across the bridge to the east side of the river. The derailed trailing end of the 7th car struck the south side of the bridge structure as it crossed, the car rolled down the east embankment and its bottom outlet valve was compromised and released product. The last 2 cars (43rd and 44th) derailed but remained upright and came to rest near mile 88.75 on the west side of the river. The remaining cars derailed near the west end of the bridge. Two of the cars were submerged in the river, 3 cars were partially submerged in the river and the rest were in a pile on the west river bank (see Photo 1). A number of the cars were breached, released product and ignited a large pool fire which destroyed the steel rail bridge. Most of the remaining cars sustained fire damage ranging from minor to severe. About 700 feet of track was destroyed.

While firefighters dealt with the fire, investigators from the Transportation Safety Board of Canada (TSB) examined the area at the west end of the bridge and recovered a section of broken rail within a plug rail joint that had been installed 2 days prior to the accident (see Photo 2). The plug rail was put in place as a repair for an in-service thermite weld failure identified previously at that location. The recovered rail components were sent to the TSB Engineering Laboratory in Ottawa for further analysis.

Tank cars

The TSB conducted a preliminary damage assessment of the derailed tank cars. All of the Class 111 tank cars were constructed in the last 3 years, and were compliant with the industry's CPC-1232 standard. In comparison with the other general service “legacy” Class 111 tank cars, these tank cars have some enhancements which include half-head shields, improved top and bottom fitting protection, and normalized steel.

Preliminary assessment revealed that 1 tank car at the head-end of the derailment sustained minor damage and 2 tank cars at the tail-end of the derailment had no damage. The remaining derailed tank cars sustained more significant damage, releasing product that sustained a large pool fire. At least 5 of the tank cars exhibited thermal tears from exposure to the pool fire. Initial impressions are that these Class 111 tank cars performed similarly to those involved in the Lac-Mégantic accident. The amount of product released to atmosphere, the river or ground has not yet been estimated, but will be determined as site mitigation and clean-up continues.

Transportation of flammable liquids by rail

The transportation of flammable liquids by rail has been identified as one of the key risks to the transportation system and it is included on the TSB's 2014 Watchlist. The TSB has been pointing out the vulnerability of Class 111 tank cars for many years, and the Board has called for tougher standards for all Class 111 tank cars, not just new ones, to reduce the likelihood of product release during accidents. In Lac-Mégantic, investigators found that, even at lower speeds, the unprotected Class 111 tank cars ruptured, releasing crude oil which fuelled the fire.

The tank cars involved in the previous Gogama derailment (R15H0013) which occurred on 14 February 2015, and the tank cars involved in this derailment (R15H0021) were compliant with the CPC-1232 standard and were not equipped with a thermal protection system.Footnote 3 Preliminary assessments of the tank cars involved in both derailments identified that the derailed cars sustained significant damage and did not perform as well as expected. Until a more robust tank car standard with enhanced protection for all tank cars transporting flammable liquids is implemented for North America, the risk will remain.

In response to TSB Recommendation R14-01 issued in January 2014, Transport Canada (TC) adopted the TP 14877 standard in the Transportation of Dangerous Goods Regulations on 02 July 2014, requiring all new tank cars built for the transportation of flammable liquids in Canada to meet the CPC-1232 specifications. At that time, the TSB warned TC that this standard was not sufficient and that more needed to be done to provide an adequate level of protection.

TC-117

On 11 March 2015, TC announced proposed upgraded standards for a new series of tank car—the TC-117. The new standard would require all new tank cars built for the transport of flammable liquids to be constructed using thicker and more impact-resistant steel and to be equipped with jacketed thermal protection, full height head shields, top fittings protection and improved bottom outlet valves. The phase-out of legacy Class 111 tank cars (including the CPC-1232 tank cars) in flammable liquid service would be gradually implemented using a risk-based approach, taking into consideration the features of the tank cars and the characteristics of the flammable liquid being transported.

While the proposed standards look promising, the TSB has concerns about the implementation timeline, given initial observations of the performance of CPC-1232 cars in recent derailments. If older tank cars, including the CPC-1232 cars, are not phased out sooner, then the regulator and industry need to take more steps to reduce the risk of derailments or consequences following a derailment carrying flammable liquids.

Quote

“Canadians expect their government to ensure that the risks posed by the transportation of flammable liquids are minimized to the greatest extent possible,” said Kathy Fox, Chair of the TSB. “I am reiterating my concern expressed in letters I sent to both the Minister of Transport and the Acting Administrator of the Pipeline and Hazardous Materials Safety Administration in the United States in October 2014, in which I urged TC and its U.S. counterparts to adopt the highest possible standards for tank cars carrying flammable liquids, and replace or retrofit existing tank cars as soon as practicable so that they meet new standards.”

Track infrastructure

The CN Ruel Subdivision consists of single main track which extends westward from Capreol, Ontario (Mile 0.00) to Hornepayne, Ontario (Mile 296.20). It is primarily composed of continuous welded rail (CWR) and is rated as Class 4 track under the TC-approved Track Safety Rules. Class 4 track permits track speeds of up to 60 mph for freight trains and 80 mph for passenger trains. However, there were permanent slow orders on much of the subdivision to protect against various infrastructure and track maintenance issues.

Preliminary indications are that track infrastructure failures may have played a role in each of the Gogama accidents and a 3rd accident that involved a mixed manifest train on the Ruel Subdivision near Minnipuka, Ontario on 5 March 2015. Petroleum crude oil unit trains transporting heavily-loaded tank cars will tend to impart higher than usual forces to the track infrastructure during their operation. These higher forces expose any weaknesses that may be present in the track structure, making the track more susceptible to failure. Given the potential damage of a train derailment, particularly when petroleum crude oil unit trains are involved, the TSB has issued a Safety Advisory Letter calling on TC to review the risk assessments conducted for the Ruel Subdivision, assess the track infrastructure condition and determine whether additional risk control measures are required when operating a ”Key Train” on this “Key Route.”

Next steps

The investigation is ongoing and the next steps include:

  • Examination of rail components from the derailment site.
  • Sampling and testing of product from select tank cars.
  • Review of Wheel Impact Load Detector records for the train and previous trains.
  • Review of track infrastructure maintenance records for the area.
  • Review of CN Engineering Track Standards.
  • Review of TC-approved Track Safety Rules.
  • Review and evaluation of ERAP and emergency response.
  • Conducting of additional interviews as required.

Once all remaining product has been removed from the tank cars and they have been cleaned and purged, the TSB will complete a detailed damage assessment of the cars. The object of the assessment is to compare the performance of these tank cars against the known performance of the legacy Class 111 tank cars that were involved in the Lac-Mégantic accident and the CPC-1232 compliant Class 111 cars involved in the previous CN unit crude oil train accident. This will include further failure analysis, testing and metallurgical examination at the TSB Engineering Laboratory.

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Richmond, British Columbia, 25 February 2015 – In its report into a 2013 British Columbia (B.C.) float plane accident (A13P0278), the Transportation Safety Board of Canada (TSB) expressed its concern that, if multiple modifications are made without adequate documentation of the effects on aircraft handling, pilots may lose control of the aircraft due to unknown aircraft performance.

“Pilots need accurate information on how an aircraft will fly after modifications have been made to it,” said Joseph Hincke, TSB Board Member. “We are concerned that this information is not available consistently and that accidents will continue to occur as a consequence.”

On 24 October 2013, a CBE Construction Ltd. (Air Cab) Cessna C-185E float plane left Port McNeill, B.C. water aerodrome with a pilot and 2 passengers on board for a charter flight to West Cracroft Island, B.C. At 1140, while maneuvering for landing on water, the aircraft experienced an accelerated aerodynamic stall while being flown at an altitude from which recovery was not possible before it collided with the terrain on a small island in Potts Lagoon, West Cracroft Island. The aircraft was destroyed and the 3 occupants were fatally injured.

The investigation found that several approved modifications (Supplemental Type Certificates or STCs) had been made to the aircraft that resulted in undocumented performance and handling characteristics and that the pilot's expectation of the aircraft's performance capabilities may not have been accurate. The investigation also identified a risk if multiple modifications are installed without adequate guidance on how to evaluate and document the effects on aircraft handling and performance. Further, there is an increased risk of stall accidents if advanced stall warning systems, such as angle of attack indicators, are not incorporated on aircraft.

Air Cab has begun emphasizing an awareness of aircraft modifications and their effect on aircraft handling during pilot initial and recurrent training. It is also in the process of implementing a G switch on its aircraft tracking system as a back up to the aircraft's electronic locator transmitter, and installing a disconnect G switch on its aircraft batteries to reduce the risk of a post-crash fire, in response to other issues identified during the investigation.

In November of 2014, the TSB announced that it would conduct a Safety Issues Investigation into Canadian air taxi operations to understand the risks that persist in this important sector of the aviation industry. The study will engage industry, the regulator and other stakeholders to gain a full understanding of the issues affecting air taxi operations. The Board may make recommendations to address any identified systemic deficiencies.

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Richmond Hill, Ontario, 26 February 2015 – The Transportation Safety Board of Canada (TSB) is investigating a landing accident involving a Jazz DHC8-100 aircraft, that occurred on 24 February 2015 at Sault Ste. Marie Airport, Ontario. There were no reported injuries and the aircraft damage is being assessed.

Approach-and-landing accidents are a TSB Watchlist issue.

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Gatineau, Quebec, 3 March 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (R13W0257) into the derailment of a Canadian National Railway (CN) freight train at Nickel Lake, Ontario.

On 10 November 2013, at approximately 1727 Central Standard Time, a CN freight train travelling eastward on the Fort Frances Subdivision derailed 40 loaded grain cars near Nickel Lake, Ontario. There were two separate groups of derailed cars, 12 cars in one group and 28 cars in the other. Several of the derailed cars ruptured and spilled grain. There were no injuries.

The investigation determined that the derailment likely occurred due to a combination of track and rail conditions and the operation of long, heavy-loaded unit trains. Each of these factors on its own would probably not have resulted in the derailment. However, when combined, these factors were likely sufficient to create the necessary derailment conditions.

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