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Transportation Safety Board of Canada

Transportation Safety Board of Canada (472)

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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Richmond, British Columbia, 25 January 2017 – The Transportation Safety Board of Canada (TSB) today released its investigation report (R15V0183) on the collision between two Canadian Pacific Railway (CP) trains at the Beavermouth siding near Golden, British Columbia. The investigation highlights deficiencies with following railway signal indications, a TSB Watchlist issue.

On 6 September 2015, an eastbound CP train collided with a westbound CP train that was entering the Beavermouth siding. Because the westbound train exceeded the length of the siding, some of its cars were still on the main track. As a result of the collision, two locomotives and the first car derailed on the eastbound train, as did one set of trucks on the 64th car of the westbound train. The conductor of the eastbound train sustained a serious injury. No dangerous goods were released.

The collision occurred when the eastbound train was operated past the Stop signal at the east siding switch at Beavermouth, and continued into the side of one of the cars from the westbound train that was still on the main track. Maintenance activities for a major track restoration project were underway in the vicinity of the occurrence location, and both trains traversed a number of work zones and slow orders before the collision. As the eastbound train was approaching the east siding switch, the crew realized that they had not complied with two previous slow orders during the trip.

The investigation determined that the crew on the eastbound train was not aware that the length of the westbound train exceeded the length of the siding. As such, the crew's expectation was that the westbound train would be clear of the east siding switch and that they would receive a permissive signal indication. Additionally, heavy radio use between work crews and rail traffic control precluded the sharing of information about the westbound train's length. Preoccupied with missing two previous slow orders during the trip, the crew was likely distracted as they approached the east siding switch. There is a risk that slow orders can be missed if they are not identified with trackside flags.

The lack of adequate defenses for ensuring railway signals are consistently followed were highlighted in this investigation. If signal systems do not include physical fail-safe capabilities, the risk of collisions and derailments from not following signal indications will persist. The Board has previously issued two recommendations for additional physical defenses (R00-04 and R13-01) to protect against missed railway signals. The Board has also indicated that on-board voice and video recorders could be used proactively and in a non-punitive way to enhance a railway's safety management system, helping to reduce risks.

Following the occurrence, Transport Canada issued a Notice and Order to ensure that trackside slow order flags are installed in a timely manner. For its part, CP enhanced its processes to ensure that slow order flags are installed as required by regulations.

See the investigation page for more information.

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Dartmouth, Nova Scotia, 19 January 2017 – Drawing attention to the wide range of safety risks that persist in the fishing industry, the Transportation Safety Board of Canada (TSB) today released its investigation report (M15A0348) into the November 2015 person overboard fatality near Clark’s Harbour, Nova Scotia.

On 30 November 2015, the opening day of lobster season, at about 0600 Atlantic Standard Time, the fishing vessel Cock-a-Wit Lady departed Shag Harbour, Nova Scotia, with five crew members on board. At 0911, the vessel reported that a deckhand had gone overboard while setting a first string of lobster traps. The crew recovered the deckhand and attempted resuscitation. After being airlifted to hospital, the crew member was pronounced deceased.

The investigation determined that while the crew was setting lobster traps, one of the traps got caught on the port guard rail. A deckhand attempted to free the caught trap with his feet, and while doing so, he stepped into the coils of rope attached to the traps. When he managed to free the trap, it quickly went over the stern, and the deckhand was hauled overboard and carried under water by the weight and momentum of the traps. The vessel's overhead block, which is mounted on top of the wheelhouse and used in conjunction with the trap hauler to pull traps aboard, was in stowed position as the crew was not planning on using it that day. In an attempt to save time, the crew tried to recover the deckhand using only the trap hauler but, given the angle of the line and additional strain of the submerged traps, the line parted. The crew then lowered the overhead block and was able to recover the deckhand. By that time, approximately 10 minutes had passed and the crew was unable to resuscitate the deckhand.

The investigation identified a number of risks related to emergency preparedness. These risks were also identified in a TSB Safety Issues Investigation (SII) into fishing safety that was published in 2012. If fishing vessel operations do not have a system for on-board risk management, such as safety meetings, there is a risk that crew members may not effectively mitigate on-board hazards. Furthermore, if vessel operators do not conduct drills that provide an opportunity for the crew to identify shortcomings in emergency response situations, such as a person overboard, there is a risk that fishermen will not be able to respond to an emergency effectively.

Commercial fishing safety is a TSB Watchlist issue as it is recognized nationwide that the loss of life on fishing vessels is simply too great. Although regulations have been published and will likely lower some of the risks associated with outstanding safety deficiencies, gaps remain with respect to, among other things, unsafe operating practices and crew training.

See the investigation page for more information.

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Winnipeg, Manitoba, 17 January 2017 – In its investigation report (A15C0130) released today, the Transportation Safety Board of Canada (TSB) found that deteriorating weather and departure under conditions of near darkness led to the fatal September 2015 crash of a Robinson R44 helicopter near Foleyet, Ontario.

On 8 September 2015, at approximately 2015 Eastern Daylight Time, an Apex Helicopters Inc. Robinson R44 departed a camp on Horwood Lake, Ontario, for the Foleyet Timber Camp with one pilot and one passenger on board. Sometime after liftoff, northwest of the Foleyet Timber Camp, the helicopter struck trees on elevated terrain and was destroyed by impact forces. There was no post-impact fire, and the occupants sustained fatal injuries.

The investigation determined that the flight was conducted in deteriorating weather and departed under conditions of near darkness. The helicopter was not equipped for flying at night or in instrument conditions, and the pilot was not certified for conducting such operations. It is likely that the pilot was unable to determine the helicopter’s height above the forest canopy and to notice the rising terrain ahead before striking trees. Because a number of hazards are associated with night flights, the TSB issued Recommendation A16-08, calling for regulations to clearly define the visual references required to reduce the risks associated with flying at night.

The helicopter was equipped with an emergency locator transmitter (ELT) that activated upon impact; however, it did not transmit its position because the antenna had broken off during the accident. The aircraft was not reported missing until the following day at approximately 1500, which resulted in search and rescue operations being delayed by approximately 20 hours. In 2016, the TSB issued four safety recommendations (A16‑02, A16‑03, A16‑04, and A16‑05) related to ELT crash survivability. If existing ELT design and certification standards do not ensure that the currently manufactured systems provide a reasonable degree of survivability from fire or impact forces, there is a risk that potentially life-saving search-and-rescue services may be delayed.

The investigation also found that the helicopter was not equipped with a flight data recorder or a cockpit voice recorder, nor was either required by regulation. In 2013, the TSB issued Recommendation A13-01, pushing for the installation of lightweight flight recording systems by all commercial operators. This occurrence demonstrates once more that if cockpit and flight data recordings are not available to an investigation, this may preclude the identification and communication of safety deficiencies to advance transportation safety.

Following the accident, Apex Helicopters Inc. has reviewed and emphasized the importance of timely reporting of overdue aircraft with all newly hired pilots and ground crew.

See the investigation page for more information.

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Richmond Hill, Ontario, 10 January 2017 – In the release of its investigation report (A14O0218) today, the Transportation Safety Board of Canada (TSB) determined that flight crew deviation from standard landing procedures led to the October 2014 risk of a runway excursion, and that the aircraft was not stabilized during a portion of the approach phase.

On 3 October 2014, the Bombardier DHC-8-400, operating as Sky Regional Airlines flight 7519, departed Montréal/Pierre Elliott Trudeau International Airport, Quebec, for a regularly scheduled flight to Billy Bishop Toronto City Airport, Ontario. During the landing, the aircraft touched down approximately 800 feet from the threshold of runway 26 but did not slow down in a timely manner. As the aircraft approached the end of the runway, the flight crew steered the aircraft toward the last taxiway to prevent an overrun. The aircraft came to a stop on the taxiway, shortly after exiting the runway. There were no injuries and no damage to the aircraft.

During the landing roll, likely in an attempt to make a smooth landing, the flight crew did not adhere to standard landing technique, and only light braking was initially applied, leading to the risk of overrun. It was also determined that during a portion of the approach phase, the aircraft did not meet stabilized approach criteria as a result of being well above the desired approach path. The investigation also highlights deficiencies in training for flight crews in recognizing unstable approaches, as well as the lack of mandatory company reporting of unstable approaches, as risk factors.

Unstable approaches are one of the key safety issues on the 2016 TSB Watchlist. When continued to a landing, unstable approaches are known to increase the likelihood of a landing accident. There is also an outstanding Board recommendation (A14-01) calling for Transport Canada to require airlines to monitor and reduce unstable approaches that continue to a landing.

Following this occurrence, Sky Regional Airlines conducted an internal Safety Management System (SMS) investigation. It identified and took steps to mitigate the risks associated with portions of its flight operations. This included updating initial and recurrent training of landing procedures and equipping its DHC-8-400 fleet with enhanced quick access flight recorders for accurate flight data analysis.

See the investigation page for more information.

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Richmond Hill, Ontario, 9 January 2017 – In its investigation report (A14F0065) released today, the Transportation Safety Board of Canada (TSB) determined that an unstable approach led to the 10 May 2014 hard landing of an Air Canada Rouge Airbus 319 at the Sangster International Airport in Montego Bay, Jamaica. There were no injuries and no structural damage to the aircraft.

The Air Canada Rouge Airbus A319 was operating as flight AC1804 from Toronto, Ontario, to Montego Bay, Jamaica, with 131 passengers and 6 crew members on board. At approximately 14 minutes before touchdown, the aircraft was cleared for a non-precision approach to Runway 07 at the Montego Bay airport. The approach became unstable and the aircraft touched down hard. The landing subjected the main landing gear to very high loading. The aircraft was subsequently inspected and the main landing gear shock absorbers were replaced as a precaution.

The investigation determined that the approach became unstable as a result of inconsistent airspeed management and delayed configuration of the aircraft for landing. The flight crew did not adhere to standard operating procedures, which required the monitoring of all available parameters during approach and landing.  The investigation also found that simulator training to recognize an unstable approach leading to a missed approach had not been provided. As such, the flight crew did not recognize the instability of the approach and continued it well beyond the point at which a missed approach and go-around should have been initiated.

If flight crews do not follow standard procedures and best practices that facilitate the monitoring of stabilized approach criteria and excessive parameter deviations, there is a risk that undesired aircraft states will be mismanaged. 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 airlines to monitor and reduce unstable approaches that continue to a landing.

Following the occurrence, Air Canada Rouge refined its stable-approach policy, modified its training to include more manual flying scenarios and incorporated simulator training for unstable approaches leading to a missed approach.

See the investigation page for more information.

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Richmond, British Columbia, 14 December 2016 – Another fatal commercial fishing accident that occurred in September 2015 off the West Coast of Vancouver Island, British Columbia (M15P0286), has led the Transportation Safety Board of Canada (TSB) to issue five new recommendations.

On 05 September 2015, at approximately 15:30 Pacific Time, the Caledonian, a large, 100-foot fishing vessel with four crew members on board, capsized 20 nautical miles off the west coast of Vancouver Island. The crew had been fishing for two days. After the final catch was hauled aboard, and as the crew prepared to stow it, the vessel began to list. Within a couple of minutes, water covered the deck and the vessel rolled over. No distress call was sent and none of the vessel's emergency signaling devices activated. The vessel sank about six hours later. Only one crew member was wearing a personal flotation device (PFD), and this crew member was the only one who survived.

"At the TSB, we have seen similar circumstances occur far too often. In fact, on average, 10 fishermen die each year somewhere in Canada's commercial fishing industry. These deaths are nearly all preventable, and this why this issue is still on our Watchlist," said Kathy Fox, Chair of the TSB. "We are asking that all commercial fishing vessels have a stability assessment appropriate for their size and operation, that this assessment information be kept current, and that it be used to determine safe vessel operating limits."

The investigation determined that the capsizing of the Caledonian was caused by a combination of factors. The most significant ones were the operating practices, such as where the fuel was stored and the way fish and seawater were loaded, and the tendency of vessels to grow heavier with time. These factors caused the vessel to float lower in the water and reduced its stability, which changed its safe operating limits. The crew, however, did not recognize that the vessel had grown heavier over the years or that their operating practices were putting them and the vessel at risk.

"Here in British Columbia, roughly 70 percent of all fishing-related fatalities in the past decade came while not wearing a PFD. Yet many fishermen still don't wear them," said Chair Fox. "It's no longer acceptable to think of fishing as just a dangerous job and that nothing can be done about it. There are steps that we can take; there are steps that we must take.”

Including this occurrence, the TSB has investigated 28 occurrences in the past 10 years resulting in 26 fatalities in commercial fishing in Canada. This investigation is similar to many other investigations and that is why the TSB is recommending that:

All commercial fishing vessels, large and small, have their stability assessed; and that this stability information be kept up to date and be presented in a way that is clear and useful for the crew.
(Recommendations M16-01, M16-02, and M16-03)
Both regulators, WorkSafeBC and Transport Canada, require crews on fishing vessels to wear suitable PFDs at all times on deck and develop ways to confirm that they are complying.
(Recommendations M16-04 and M16-05)

See the investigation page for more information.

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