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Transportation Safety Board of Canada

Transportation Safety Board of Canada (488)

Edmonton, Alberta, 25 May 2017 – The Transportation Safety Board of Canada (TSB) today released its investigation report (R15E0173) into a 2015 Canadian Pacific Railway (CP) derailment at Scotford Yard near Fort Saskatchewan, Alberta, citing that a crew member did not observe a switch lined against the movement which subsequently damaged the switch.

On 8 December 2015, at about 1515 Mountain Standard Time, a CP switching assignment, which was being operated by a remote control locomotive system, derailed four loaded tank cars while performing switching operations at Scotford Yard. The derailed tank cars contained styrene monomer, a flammable liquid. Two cars remained upright, one car came to rest on its side, and one car rolled into a ditch, coming to rest upside down and releasing most of its contents. The majority of the product was recovered and disposed of during the initial response and through the removal of the contaminated soil during site remediation. There were no injuries.

The investigation determined that the forward movement of the train through a switch that was lined against the movement had damaged the switch. Unaware that the switch had been damaged, the crew then reversed the movement over the damaged switch, resulting in the derailment of four tank cars. The investigation found that the crew member on the leading end of the movement did not observe the visual cues indicating that the switch was lined in the opposite direction from the intended route.

Following the occurrence, CP initiated a number of safety actions including increasing performance monitoring, implementing pre-shift briefings, and providing mentoring and coaching sessions to ensure improved efficiency.

The transportation of flammable liquids by rail is a TSB Watchlist 2016 issue. As this occurrence demonstrates, the transportation of flammable liquids by rail across North America has created an elevated risk that needs to be mitigated effectively. Based on this investigation and previous ones, Board 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.

See the investigation page for more information.

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Richmond Hill, Ontario, 24 May 2017 – In the release of its investigation report (A16O0016) today, the Transportation Safety Board of Canada (TSB) found that the misinterpretation of a taxi instruction issued by the ground controller led to the January 2016 Air Canada runway incursion and risk of collision at the Lester B. Pearson International Airport (CYYZ) in Toronto, Ontario.

On 30 January 2016, an Air Canada Embraer aircraft was operating as flight ACA726 on a scheduled flight from CYYZ in Toronto, Ontario, to LaGuardia Airport, New York, United States. While taxiing for departure, ACA726 taxied across the hold line and onto Runway 24R without authorization at the same time that an Air Canada Airbus, operating as flight ACA1259, was on final approach for landing on the same runway. As ACA726 was turning onto the runway centreline, the ACA1259 flight crew reported to the airport controller that there was an aircraft on the runway and that they were conducting an overshoot.

The investigation determined that, after completing their pre-departure preparations, the flight crew's expectation that they would quickly receive an authorization to take off, combined with the plain-language phraseology used by the ground controller, likely contributed to the crew's misunderstanding of the taxi instruction. Due to this misinterpretation, ACA726 taxied across the hold line and onto Runway 24R without authorization from the airport controller. This occurrence demonstrates how errors in communication can happen and why the use of standard phraseology that reinforces the clearance limit has the potential to improve safety. If air traffic controllers are not required to use standard phraseology that reinforces the need to hold short of a departure runway, there is an increased risk of miscommunication leading to runway incursions.

The investigation also found that the runway incursion monitoring and conflict alert system (RIMCAS) did not provide a timely warning to the airport controller to provide alternate instructions to the flight crews.

The risk of collisions on runways has been a key safety issue on the TSB Watchlist since 2010. The Board is concerned that unless better defenses are put in place to reduce these occurrences, the risk of a serious collision between aircraft remains.

Following this occurrence, Air Canada Flight Operations convened a working group to review this incident as well as other incursion incidents to identify any common causal factors and to develop recommendations to prevent future incursions. NAV CANADA performed a site review which resulted in adjustments that will increase the RIMCAS warning time to the air traffic controller when a departing aircraft enters the area without authorization.

See the investigation page for more information.

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Halifax, Nova Scotia, 18 May 2017 – In its investigation report (A15H0002) released today, the Transportation Safety Board of Canada (TSB) found that approach procedures, poor visibility and airfield lighting led to the 2015 collision with terrain of Air Canada Flight 624 at the Halifax/Stanfield International Airport in Nova Scotia.

On 29 March 2015, an Air Canada Airbus A320 was operating as Flight 624 from Toronto, Ontario to Halifax, Nova Scotia with 133 passengers and 5 crew members on board. At approximately 00:30 local time, while conducting a non-precision localizer approach to Runway 05 during a snowstorm, the aircraft severed power lines and then struck the snow-covered ground approximately 740 feet before the runway threshold. The aircraft continued airborne through the localizer antenna, and struck the ground twice more before sliding along the runway and coming to rest about 1900 feet beyond the runway threshold. The aircraft was evacuated using the inflatable slides. Twenty-five people sustained injuries and were taken to hospital. The aircraft was destroyed.

The investigation found that the flight crew had set the autopilot to fly the appropriate constant descent flight path angle. Because company procedures did not require the flight crew to monitor the aircraft's altitude and distance to the runway, the crew did not notice that wind variations had caused the aircraft's flight path to move further back from the selected flight path.

Although requested by the flight crew during the approach, the runway lights were not adjusted to their maximum setting. At the time, the tower controller was preoccupied with snowplows on the runway and nearby aircraft on the taxiway. When the aircraft reached the minimum descent altitude for the approach, the flight crew saw some lights, which they interpreted as sufficient visual cues to continue the approach below the minimum descent altitude, expecting the lights to become more visible as they got closer to the airport. It was only in the last few seconds of the flight, after the pilots disengaged the autopilot to land manually, that they then realized that the aircraft was too low and too far back. Although they initiated a go-around immediately, the aircraft struck terrain short of the runway.

Following the occurrence, Air Canada and the Halifax International Airport Authority took safety actions to address the deficiencies identified in this investigation. Air Canada provided its pilots with more specific guidance on required visual references for landing approaches, made explicit warnings on the limitations of the autopilot and vertical navigation using the Airbus Flight Path Angle mode, and now requires instrument monitoring during all approaches when below the minimum descent altitude. For its part, the Halifax International Airport Authority upgraded the approach lighting for Runway 05, reviewed its emergency response plan and made upgrades to emergency assets, including backup power. NAV CANADA published a satellite-based approach on Runway 05 that provides lateral and vertical guidance to suitably-equipped aircraft.

The investigation highlights several factors as to risk, regarding passenger safety. It is important that passengers pay attention to the pre-flight safety briefings, review the safety features card and wear clothing that is appropriate to the season. During an evacuation, passengers must also leave any carry-on items behind to avoid creating delays. This accident also reinforces the need to address the outstanding TSB recommendation (A15-02) to require child restraint systems for infants and young children, to provide an equivalent level of safety to adults aboard commercial aircraft.

See the investigation page and backgrounder for more information.

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Dorval, Québec, 16 May 2017 – In its investigation report (A15Q0075) released today, the Transportation Safety Board of Canada cited high speed, a tailwind, a long landing and delayed use of deceleration devices while landing in heavy rain showers, as contributing factors in the 2015 runway overrun of a Westjet Boeing 737 in Montréal, Quebec.

On 5 June 2015, a WestJet Boeing 737 was operating on a scheduled flight from Toronto/Lester B. Pearson International Airport (CYYZ), to Montreal/Pierre Elliott Trudeau International Airport (CYUL). While approaching CYUL, the flight crew observed heavy rain on the weather radar. Once the aircraft was established on final approach, it was cleared to land on Runway 24L. The aircraft touched down beyond the normal touchdown zone and came to rest on the grass past the end of the runway. There were no injuries and no damage to the aircraft.

The investigation determined that the target approach speed was inaccurately calculated, and the aircraft crossed the runway threshold at a speed that was faster than recommended. This, combined with a tailwind and a slightly high flare, resulted in the aircraft touching down beyond the normal touchdown zone, thus reducing the amount of runway available for the aircraft to come to a stop. Additionally, following touchdown, the delayed and non-maximal use of deceleration devices, combined with viscous hydroplaning while landing in heavy rain showers, increased the distance required for the aircraft to come to a stop. An instruction from the control tower to exit at the end of the runway contributed to the minimal use of deceleration devices early in the landing roll, as the crew were attempting to expedite their exit at the end of Runway 24L.

When a runway overrun occurs, it is important that an aircraft have an adequate safety area beyond the end of the runway to reduce adverse consequences. In this occurrence, Runway 24L had a runway end safety area that allowed the aircraft to decelerate in a controlled manner; no one was injured and the aircraft was not damaged. However, there is currently no requirement in Canada for runways to meet international standards and recommended practices for runway end safety areas (TSB recommendation A07-06). Runway overruns continue to occur at Canadian airports and are identified as a key safety issue on the 2016 TSB Watchlist.

WestJet debriefed all training pilots on the occurrence, and the flight safety annual ground school program now covers a number of topics such as overrun characteristics, as well as an incident review of this occurrence.

See the investigation page for more information.

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Richmond, British Columbia, 10 May 2017 – The Transportation Safety Board of Canada (TSB) today released its investigation report (M16P0062) into the grounding of two barges near Victoria, British Columbia. There were no injuries.

On 2 March 2016, the tug H.M. Scout departed Victoria, British Columbia, heading for Bamberton, British Columbia, with the barges HM Tacoma and HM Blue Horizon in tandem tow, one behind the other. As the tug encountered severe weather, the tow line between the barges parted resulting in HM Blue Horizon floating free and grounding near Clover Point, British Columbia. During a recovery attempt, a piece of the parted tow line fouled H.M. Scout's propeller, causing the tug to be partially disabled. With reduced propulsion and the HM Tacoma in tow, the tug and barge were pushed towards the shore by the sea conditions. Approximately thirty minutes later, HM Tacoma grounded while still in tow. The crew then released HM Tacoma's tow line and subsequently returned to Victoria.

The investigation determined that inadequate towing equipment was used, which allowed the first barge to break free from the tow. If Transport Canada (TC) does not provide easily understandable standards and guidance to assist towing vessel owners and operators to ensure the adequacy of their towing arrangement and the condition of their towing equipment, including the selection of tow ropes, there is an increased risk of the towing equipment failing, resulting in the loss of tow.

The investigation also revealed that the company had not developed any documented operating procedures for its marine operations, and had not formally assessed the risk associated with its tug and barge operations. Despite the fact that the combined size and tonnage of the vessels may be similar to that of a conventional cargo-carrying vessel, tug and barge operations are not required to operate under a safety management system.

Although TC and WorkSafeBC both regulate marine vessel operations for their respective areas of jurisdiction, neither has an inspection program in place to routinely check that owners and operators of tugs less than 15 GT are complying with safety-critical regulations.

Safety management and oversight is a TSB Watchlist issue. The TSB has repeatedly emphasized the advantages of safety management systems (SMS), an internationally recognized framework to allow companies to effectively manage risk and make operations safer. Numerous recent investigations have found that companies have not managed their safety risks effectively. The solution will require all operators in the marine industry to have formal safety management processes, with effective oversight by TC.

See the investigation page for more information.

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Dartmouth, Nova Scotia, 20 April 2017 – In its investigation report (A15A0054) released today, the Transportation Safety Board of Canada (TSB) found that ineffective crew resource management and an unstable approach led to the August 2015 hard landing of a Beechcraft King Air A100 in Margaree, Nova Scotia.

On 16 August 2015, a Beechcraft King Air A100 operated by Maritime Air Charter Limited was on a flight from Halifax Stanfield International Airport to Margaree Aerodrome, Nova Scotia, with two pilots and two passengers on board. While conducting a visual approach to Runway 01, the aircraft touched down hard approximately 260 feet beyond the runway threshold. Almost immediately, the right main landing gear collapsed, causing the right propeller and wing to contact the runway. The aircraft then slid along the runway for about 1350 feet before veering off the runway to the right. There were no injuries, though the aircraft was substantially damaged.

The investigation found that the crew did not anticipate that landing on a short runway at an unfamiliar aerodrome with high terrain nearby would increase their workload during the approach and landing phase. This increased workload led to the crew's reduced situational awareness. As a result, the crew did not recognize the aircraft's steep rate of descent as being indicative of an unstable approach condition. The aircraft crossed the runway threshold with insufficient energy to reduce the rate of descent immediately before touchdown, resulting in the hard landing.

The findings of this investigation are consistent with a lack of effective crew resource management (CRM). If CRM is not used and continuously fostered, there is a risk that pilots will be unprepared to avoid or mitigate errors encountered during flight. The TSB issued a recommendation (A09-02) which called for Transport Canada (TC) to require smaller commercial operators to provide its crews with modern CRM training. TC has proposed new standards, which should address the safety deficiencies once implemented, thus the Board has assessed TC's action as Satisfactory Intent.

Although not required, Maritime Air Charter had voluntarily implemented a safety management system (SMS). However, the SMS elements were primarily used as a reactive method to address potential safety concerns. If organizations do not use modern safety management practices, there is an increased risk that hazards will not be identified and risks mitigated. Safety management and oversight is on the TSB Watchlist.

Following the occurrence, Maritime Air Charter Limited introduced revised procedures to improve the safety of its operations. These include a preflight risk assessment checklist, a requirement to calculate accelerate-stop distance when taking off from shorter runways, and enhanced training, including increased emphasis on stabilized approach criteria and controlled flight into terrain avoidance.

See the investigation page for more information.

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Dartmouth, Nova Scotia, 6 April 2017 – The Transportation Safety Board of Canada (TSB) today released its investigation report (M16C0016) into the flooding of the fishing vessel Saputi, after it struck a piece of ice and was holed, while fishing in Davis Strait, Nunavut, in February 2016. The report highlights the risks when large fishing vessels are not designed to withstand the flooding of a main compartment and crews do not have access to a damage control plan.

On 21 February 2016, the fishing vessel Saputi, with 30 people on board, was fishing turbot in Davis Strait, Nunavut. At 1935 Atlantic Standard Time, the vessel struck a piece of ice that cracked the hull in the cargo hold. After pumping operations failed to keep up with the ingress of water, the cargo hold was sealed, and it subsequently flooded. The vessel developed a severe list but was able to proceed to Nuuk, Greenland, arriving on 24 February. No injuries were reported.

The investigation determined that, at 1840, the master sighted a single piece of ice on the port side that was not assessed to be of any danger to the vessel. While the master slowly altered the Saputi'scourse to avoid the piece of ice, a wave lifted the vessel, and as the vessel fell off the wave, it made contact with the ice. As a result, a vertical crack in the ship's hull was created, which led to a significant volume of water entering the vessel. The crew of the Saputi unsuccessfully attempted to seal the crack using available materials not specifically intended for damage control. They had also actioned all on board pumps to try controlling the incoming water. If fishing vessels operating in ice-infested waters do not carry a damage control plan and booklet on board, the master and crew may be inadequately prepared for an emergency situation where there is ingress of water, and may be unable to keep the vessel afloat until the arrival of rescue resources.

Early the following day, the master advised Joint Rescue Coordination Centre (JRCC) Halifax that the vessel was unable to keep up with the ingress of water using the pumps on board, and requested additional pumps. Almost six hours later, a Hercules aircraft, tasked by JRCC Halifax, arrived at the Saputi and dropped off four gasoline-powered search and rescue (SAR) pumps to the vessel, which allowed the crew to remove a large volume of water. Shortly after, crew members advised the master that they were having suction issues with all four SAR pumps. Since the situation had deteriorated drastically, all pumping operations were stopped, leaving the cargo hold to flood completely. Large fishing vessels are not required to be designed to withstand the flooding of a main compartment. A naval architect who had completed stability calculations advised that the vessel could remain afloat and stable with the cargo hold flooded. If fishing vessels operating in ice-infested waters are not designed and constructed to withstand the complete flooding of any one of the main compartments, there is a risk that vessels will not be able to remain afloat if they lose their watertight integrity.

In this occurrence, the gasoline-powered pumps provided by SAR resources did not perform efficiently, and therefore did not control the ingress of water. To effectively address an emergency, it is critical that the equipment provided to a vessel in distress by SAR resources perform adequately.

Commercial fishing safety is a TSB Watchlist issue. Although regulations have been published and will likely lower some of the risks associated with outstanding safety deficiencies, gaps remain and these new regulations apply only to small fishing vessels up to 24.4 metres. Future phases of the regulations will address large fishing vessels over 24.4 metres; however, no work has commenced.

See the investigation page for more information.

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Dorval, Quebec, 3 April 2017 – In its investigation report (A15Q0126) released today, the Transportation Safety Board of Canada (TSB) found that a loss of directional control led to the September 2015 fatal helicopter accident near Sept-Îles, Quebec. Two passengers sustained fatal injuries, while the pilot and two other passengers suffered serious injuries.

On 2 September 2015, a Bell 206B helicopter operated by Héli-Nord was flying from the airport in Sept-Îles, Quebec, with one pilot and four passengers on board. The purpose of the flight was to inspect a salmon pass on Nipissis River, approximately 20 nautical miles north of Sept-Îles. During the final approach to the landing site at a river camp, a few feet from the ground, the helicopter began an uncommanded rotation to the right. After turning a few times, the helicopter crashed heavily into a rock on its front right side. A fire started in the engine tailpipe, and was immediately extinguished by persons on site.

The investigation determined that the helicopter was operating at a weight and in a flight regime that led to a loss of directional control at an altitude that did not allow any recovery. During the final approach, the pilot noticed that the engine torque had exceeded its limits and that the nose of the helicopter was starting to turn to the right. To counteract the uncommanded turn, the pilot reduced the engine torque while applying full left anti-torque pedal. However, the nose of the aircraft continued turning to the right and the helicopter kept losing altitude. The pilot increased the torque to reduce the rate of descent and tried to gain airspeed, but the right turn rate increased. Realizing that control of the aircraft was lost, the pilot cut the engine power and prepared for impact. The helicopter was in a nose-down position to the right before it collided with terrain. The investigation determined that the pilot's lack of experience on a Bell 206B helicopter with a shorter tail rotor than the one he had previously trained on prevented him from recognizing the loss of tail rotor effectiveness and counteracting it in a timely manner. The TSB also found that, if occupants do not wear safety belts correctly during a flight, there is an increased risk of serious injuries or death in the event of an accident.

See the investigation page for more information.

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Winnipeg, Manitoba, 29 March 2017 – In the release of its investigation report (R16W0004) today, the Transportation Safety Board of Canada (TSB) determined that a broken wheel, caused by a service-related failure, led to the January 2016 derailment of a Canadian National Railway Company (CN) freight train near Webster, Ontario.

On 9 January 2016, a CN freight train proceeding westward on the Redditt Subdivision experienced a train-initiated emergency brake application at Mile 21.74, near Webster, Ontario. A total of 26 cars had derailed, including six Class 111 residue tank cars that last contained diesel fuel. There were no injuries and no product was released.

The investigation revealed that a progressive fracture on a wheel of the second car from the head end eventually allowed the wheel to move inboard on the axle and derail. The train proceeded on the track for approximately eight more miles before cars derailed, setting off the train-initiated emergency brake application.

The investigation determined that about 14 minutes prior to the accident, the train passed a wayside inspection system (WIS) where a wheel impact load detector (WILD) recorded the impact load of the defective wheel. While the reading exceeded the Association of American Railroads (AAR) condemning limits, CN WILD guidelines permitted the wheel to remain in service without restriction until it reached its certified car inspection location. The development and implementation of WILD technology has been an industry initiative to enhance rail safety by proactively identifying wheels with defects that can cause derailments or damage to track infrastructure. However, if railway WILD guidelines do not provide adequate guidance for dealing with wheel impacts that are condemnable under AAR rules, there is an increased risk that wheels with emerging defects will not be identified and removed from service before progressing to failure.

In response to a 2011 TSB Rail Safety Advisory, Transport Canada (TC) had indicated that it would create a joint TC-industry forum to conduct a comprehensive review of WIS and WILD criteria. However, there has not been any progress by TC relating to guidelines, standards or rules for the use of WILD technology. In the absence of WILD condemning limits within the TC-approved Railway Freight Car Inspection and Safety Rules and/or other related TC guidance, WILD company guidelines may not be sufficiently robust to consistently protect against wheel failures.

See the investigation page for more information.

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Dorval, Quebec, 28 March 2017 – The Transportation Safety Board of Canada (TSB) investigation report (A14Q0155) into the 7 October 2014 runway excursion of an Air Canada Airbus A330 at Montréal/Pierre Elliott Trudeau International Airport illustrates the risks posed when conducting approaches and landings in the presence of thunderstorms.

On 7 October 2014, the Air Canada Airbus A330 was operating as flight ACA875 from Frankfurt, Germany, to Montréal-Pierre Elliott Trudeau International Airport with 217 people aboard. There was a thunderstorm north of the airport as the aircraft was on approach to Runway 24R in daytime visual conditions. Runway 24R was the only runway in operation, and the flight crew had been advised that the runway lights were out of service. During the final approach, the aircraft entered a heavy rain shower and encountered a strong right crosswind. It then deviated from its path before touching down to the left of the runway centreline. Soon after, the outboard tires of the left main landing gear departed the runway surface for a distance of approximately 600 feet. The aircraft returned to the centreline before taxiing to the terminal gate, where the passengers disembarked without further event.

The investigation determined that during the approach in the presence of a thunderstorm, a pilot-induced aircraft rolling movement resulted in the aircraft being in a left bank as it crossed the runway threshold, which, combined with a strong right crosswind, caused it to drift rapidly to the left. After crossing the runway threshold, the intensity of the rain suddenly increased, causing the pilot flying to have very few visual references. The rain and the absence of runway lighting made it difficult to detect the aircraft's lateral movement and prevent the runway excursion. In addition, during the final approach, weather conditions had changed rapidly to those requiring runway lighting. As the runway lights were not working, that runway should not have been used under those weather conditions.

This occurrence demonstrates how flight conditions near thunderstorms can change dramatically and abruptly, posing a risk to flight safety. As part of its investigation (A05H0002) into the 2005 Air France runway overrun in Toronto, the TSB issued a recommendation (A07-01) calling on Transport Canada (TC) to establish clear standards for limiting approaches and landings in convective weather. TC issued an Advisory Circular to alert Canadian air operators to the hazards associated with flight operations in or near convective weather conditions and did propose that this issue be addressed at the international level. However, it stopped short of issuing the recommended standards. If TC does not take action to develop clear standards for avoiding thunderstorms during approach and landing, approaches in the presence of thunderstorms will continue, exposing aircraft to multiple, unpredictable hazards.

The report also notes that Montréal-Pierre Elliott Trudeau International Airport is not equipped with a low-level wind shear alert system, nor is it required to by regulation. If airports are not equipped with a low-level wind shear alert system, crews landing may not be aware of the presence of rapidly changing wind direction and speed, and therefore are exposed to the risk of approach-and-landing accidents.

Following the occurrence, Aéroports de Montréal, the operator of Montréal-Pierre Elliott Trudeau International Airport, reviewed conditions for closing a runway when approach and runway lighting is out of service. Air Canada also developed new guidance for its flight crews regarding approach and visibility requirements.

See the investigation page for more information.

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