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Transportation Safety Board of Canada

Transportation Safety Board of Canada (457)

Edmonton, Alberta, 20 October 2016 – The limitations of the “see-and-avoid” principle in preventing collisions were illustrated once again in the Transportation Safety Board of Canada (TSB) investigation report (A15W0087) into a June 2015 mid-air collision between two small aircraft near Fort McMurray, Alberta.

On 21 June 2015, a Cessna 172 was conducting a training flight in the practice area northeast of the Fort McMurray airport with a student pilot and flight instructor on board. At the same time, a privately operated Cessna 185 on amphibious floats was descending through the practice area on its way to the Fort McMurray airport. Both pilots were conducting visual flight rules (VFR) flights and relying primarily on the see-and-avoid principle to avoid collisions with other aircraft operating under VFR. This principle is based on active scanning, and the ability to detect conflicting aircraft and to take appropriate measures to avoid such aircraft. The two aircraft collided at 2800 feet, leading to the left float separating from the Cessna 185, and the in-flight breakup of the Cessna 172. The occupants of the Cessna 172 were fatally injured. The Cessna 185 pilot was uninjured, though the aircraft sustained substantial damage.

The investigation found that neither pilot saw the other aircraft in time to avoid a mid-air collision, because of the inherent limitations of the see-and-avoid principle as the primary means of preventing collisions between aircraft flying in uncontrolled airspace. This is due to factors such as the limitations of human vision, restricted visibility from the aircraft cockpit, pilot workload, and difficulties in spotting small aircraft at a distance. These limitations have been of concern in previous investigations to the TSB and other investigative bodies.

There are other measures pilots flying in uncontrolled airspace can take to mitigate the risks of collision. These include flying along published VFR routes, actively providing and listening for traffic advisories on the radio, and using aircraft collision avoidance systems to detect aircraft flying nearby. If these measures are not taken, there is an increased risk of collision between aircraft.

Following the occurrence, NAV CANADA published additional information about the flight training practice area northeast of the Fort McMurray Airport in its aviation publications.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
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Richmond, British Columbia, 19 October 2016 – The Transportation Safety Board of Canada (TSB) is wrapping up the on-site operations of its investigation (A16P0186) into the 13 October 2016 accident north of Kelowna, British Columbia, involving a Cessna Citation aircraft.

The examination and documentation of the wreckage scene is complete and investigators have collected the data they needed from the accident site. The wreckage will be removed by helicopter and transported to a facility for further analysis.

Next steps

With the conclusion of the Field Phase begins the Examination and Analysis Phase. TSB investigators from across Canada are involved in helping with this ongoing investigation. While there are no definitive findings to report at this time, there are some important next steps.

In the coming days and weeks, the team will:

  • Review drone images—filmed with the assistance of the RCMP
  • Examine components such as instrumentation and any device that contains non-volatile memory
  • Send selected wreckage to the TSB Laboratory in Ottawa 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 witnesses, the aircraft operator and others
  • Review operational policies and procedures
  • Examine the regulatory requirements
  • Create simulations and reconstruct events to learn more about the accident sequence (i.e., to validate data, test hypotheses, and verify assumptions)

“We will be thorough in our analysis of the data we have collected, and will continue to gather information as the investigation progresses”, said Beverley Harvey, TSB's Investigator-in-Charge.

Working with others

The TSB conducts independent investigations. However, we would like to recognize the contribution of other organizations:

  • The RCMP protected the site and provided essential family liaison services.
  • The BC Coroners Service secured the site and provided TSB investigators access so that investigation work could start right away.
  • The BC Coroners Service and the RCMP Forensic Search and Evidence Recovery Team conducted extremely meticulous recovery work.
  • A Transport Canada Minister's Observer was assigned and present at the accident site.
  • The National Transportation Safety Board (NTSB) of the United States, as State of Design and Manufacture of the aircraft, appointed an Accredited Representative to the TSB investigation.
  • Representatives from the aircraft manufacturer assisted on site as technical advisors to the US Accredited Representative.
  • Technical experts from the engine manufacturer also assisted on site.

If at any stage during the investigation the TSB identifies safety deficiencies that require immediate attention, it will communicate directly with Transport Canada and the industry, and will inform the public.

Visit the active investigation page for more information about this investigation.

Published in Transportation Safety Board of Canada
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Richmond, British Columbia, 15 October 2016 – Today, the Transportation Safety Board of Canada (TSB) began the Field Phase of its investigation (A16P0186) into the 13 October 2016 accident north of Kelowna, British Columbia involving a Cessna Citation aircraft. The TSB offers its condolences to the families and friends who lost loved ones in this accident.

What we know

  • A Cessna Citation departed Kelowna, British Columbia (CYLW) at 21:32 (Pacific Daylight Time), destined for Calgary/Springbank Airport, (CYWB).
  • The aircraft struck terrain approximately 11 km north of Kelowna Airport at approximately 21:40 local time (Pacific Daylight Time).
  • At this time we believe there was one pilot and 3 passengers on board, all of whom sustained fatal injuries.
  • The aircraft was not equipped with, nor was it required to carry, a Cockpit Voice Recorder (CVR) or a Flight Data Recorder (FDR); however, the team will be reviewing any electronic components on the aircraft from which they can retrieve data to help understand the flight profile.
  • The air‎craft was destroyed from high deceleration forces after a vertical descent.
  • There were no emergency or distress calls made. No emergency locator transmitter signal was received.

Work to date

The occurrence site is currently under the control of the BC Coroners Service. The TSB has been granted access to the site. There are currently 5 investigators on site.

The RCMP is providing an unmanned aerial vehicle for site survey and documentation. This data will be provided to the BC Coroners Service and to the TSB.

So far, the team has:

  • examined the site (preliminary walk-around)
  • taken photographs of the wreckage
  • been collaborating with the BC Coroners Service
  • given Observer status to Transport Canada, the aircraft manufacturer, and the RCMP.

The team will continue taking measurements and documenting the site into the evening.

Next steps

In the coming days, the team will also:

  • Examine, document and photograph the aircraft wreckage
  • Make arrangements to transfer relevant aircraft components to the TSB Laboratory in Ottawa for further analysis
  • Examine the occurrence site and surrounding terrain features
  • Gather additional information about weather conditions
  • Gather information on Air Traffic communications and radar information
  • Obtain aircraft maintenance records and pilot records
  • Interview witnesses and next-of-kin
  • Review operational policies
  • Examine the regulatory requirements

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.

Published in Transportation Safety Board of Canada
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Richmond Hill, Ontario, 5 October 2016 – According to its investigation report (R15T0245) released today, the Transportation Safety Board of Canada (TSB) has determined that incomplete communication and improper signal blocking were causal in the risk of collision between a VIA Rail train and work equipment at a Canadian National Railway (CN) work site in October 2015 in Whitby, Ontario.

On 25 October 2015, before a crew started work on a CN track of the Kingston Subdivision, near Whitby, Ontario, the foreman called the CN rail traffic controller (RTC) and asked for—and received—exclusive use of the south track (which meant that trains would be operating on the north track only) between Mile 304 and Mile 305. However, the RTC inadvertently entered improper signal blocking that would still permit trains to operate on the south track past Mile 304.

Meanwhile, westbound VIA train 65 was travelling on the south track, and the crewcomplying with the rules and the signals, contacted the foreman for permission to proceed through the work site. The foreman permitted the train to proceed on the north track. The train crew, recognizing that the train was routed and would remain on the south track, contacted the foreman again to indicate that the train would be crossing over at Whitby. The train crew did not, however, specify that the train was still on the south track. The foreman responded affirmatively, still not realizing that the train was to continue on the south track. When the train crew saw the work equipment ahead, the train was brought to a stop, about a quarter of a mile past the entrance to the work area.

The investigation determined that because of incomplete communications between the foreman and the train crew, the foreman was not aware that the train had inadvertently been routed onto the south

track. In its report, the TSB underscores that if standard communication protocols are not in place, the desired routing of trains may not be clearly understood.

The report makes the observation that if foremen do not have real-time display tools to help them determine which tracks are active for their work areas, improper train routing may not be identified soon enough to avoid the risk of a train entering a work area without adequate permission.

The investigation also highlighted that implementation of existing technology, such as proximity detection devices and advance warning devices, can be an effective means to warn train crews and track workers that they are approaching one another.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
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Richmond Hill, Ontario, 3 October 2016 – In the release of its investigation report (A15O0031) today, the Transportation Safety Board of Canada (TSB) cited expired qualifications, a lack of recent experience, and an elevated level of fatigue as the likely causes of the loss of control which resulted in an in-flight breakup of an aircraft that occurred near Sudbury, Ontario, in March 2015. All three people on board were fatally injured and a post-crash fire destroyed most of the wreckage.

On 17 March 2015, a privately registered Piper PA-32RT-300T, with the pilot and two passengers on board, departed Sudbury, Ontario, on an instrument flight rules flight to Winston Salem, North Carolina. Approximately 30 nautical miles south of the Sudbury Airport, at an altitude of 10 000 feet above sea level, the pilot advised air traffic control that there was a problem and that the aircraft was returning to Sudbury. Air traffic control cleared the aircraft to a lower altitude, and observed it turning and descending on radar.

During the descent, the aircraft disappeared from the radar. A search for the aircraft was initiated, and wreckage was located the following morning. The aircraft had broken up in flight, and debris was found as far as 6500 feet from the main crash site.

The investigation found that the pilot's qualifications had expired, that he had flown very little in the period leading up to the accident, and that he had been experiencing levels of chronic stress and fatigue, and consequently that he was neither qualified nor fit to undertake the flight. The pilot, who was no longer proficient at flying in instrument meteorological conditions, likely became spatially disoriented after entering cloud in a descending turn, and lost control of the aircraft. While in a spiral dive, the wings broke due to extreme forces, causing an in-flight breakup of the aircraft.

Having concluded that the aircraft was likely overweight and outside balance limitations at takeoff, the investigation noted that if aircraft are loaded outside of approved operating limits, there is increased risk that pilots will experience difficulties maintaining control of the aircraft during flight.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
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Richmond Hill, Ontario, 29 September 2016 – The Transportation Safety Board of Canada (TSB) determined that a passenger’s unsafe behaviour and intoxication led to him falling overboard from the vessel Northern Spirit I in Toronto, Ontario, and subsequently drowning. The investigation also found that the crew’s emergency response efforts were not coordinated. The findings are in the investigation report (M15C0094) released today.

On 13 June 2015, the Northern Spirit I was on an evening cruise when security guards near the bow of the vessel observed that one of the passengers was behaving erratically and appeared to be intoxicated. When the passenger was seen leaning over the upper deck railing on the starboard side, two security guards rushed over to him and attempted to prevent him from falling, but he went overboard. A guard advised the master of the situation, search and rescue authorities were alerted, and the vessel was maneuvered to return on a reverse track in an attempt to locate the passenger. Numerous first-responder organizations joined the search effort as the evening progressed, but the search was unsuccessful. The passenger's body was recovered 18 days later.

The investigation found that the passenger was intoxicated, and that he had been drinking before boarding and while on board the vessel. Security guards and crew members had not detected this during pre-boarding screening or on board the vessel, and the passenger had not been denied alcoholic beverage service. The passenger's high blood alcohol concentration affected motor skills and increased the risk of hypothermia, which decreases the chance of survival in the water.

Because the signal to initiate the man-overboard procedure was not sounded, the crew's response to the emergency was not coordinated and did not align with the company emergency procedures. In addition, there were delays in launching the vessel's emergency boat owing to its position on the vessel's stern. The investigation also found that if emergency procedures in the safety management system or muster list lack key details and do not fully account for all contingencies, there is a risk that opportunities to recover a person who has fallen overboard may be missed.

Although the crew had performed some emergency drills, they had not performed any man-overboard drills, which may have prevented the crew from being able to easily recall the steps to take during a person-overboard situation. There is a risk of increased death or injuries during emergencies if crew members do not practise drills for emergency procedures.

See the investigation page for more information.

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

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

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

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

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

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

See the investigation page for more information.

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

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

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

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

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

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

See the LVVR study page for more information.

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

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

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

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

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

See the investigation page for more information.

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

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

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

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

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

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

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

Published in Transportation Safety Board of Canada
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