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Transportation Safety Board of Canada

Transportation Safety Board of Canada (353)

Edmonton, Alberta, 24 February 2015 – In its investigation report (R13E0142) released today, the Transportation Safety Board of Canada (TSB) determined that numerous rail fractures led to the October 2013 derailment and fire involving a Canadian National (CN) train in Gainford, Alberta.

On 19 October 2013, a CN freight train, travelling from Edmonton, Alberta to Vancouver, British Columbia, derailed 13 cars, including 4 DOT 111 tank cars containing petroleum crude oil and 9 DOT 112 tank cars containing liquefied petroleum gas (LPG) in the siding at Gainford, Alberta. Two LPG tank cars were breached during the derailment and caught fire, and a third LPG car released product from its safety valve which ignited. About 600 feet of track was destroyed and a house located directly north of the derailment site was damaged by the fire. A total of 106 homes in the vicinity of the occurrence were evacuated. There were no injuries.

The investigation determined that the train derailed when one or more rail breaks occurred in the high rail as the train travelled through the curve in the Gainford siding. Numerous defects were found along the length of the high rail in the curve. A rail flaw detection test through the area 2 months earlier had not identified these defects. In March 2013, the low rail had been replaced with a new rail that reduced the curve’s superelevation. In this situation, more stress was placed on the high rail, increasing the risk of rail defect development and failure.

One of the DOT 112 tank cars carrying LPG was punctured in the underside by the coupler from another car. This caused it to release its load and explode. DOT 112 tank cars have increased protection on each end to withstand impacts and are equipped with double shelf couplers designed to keep derailed tank cars together during derailments. However, tank cars that come apart during a derailment and jackknife across the track are vulnerable to impacts from following cars. None of the DOT 111 tank cars, which were built to the CPC-1232 standard, released petroleum crude oil, as the cars derailed in a line on their sides and did not suffer secondary impacts.

Following the occurrence, CN conducted walking inspections and rail flaw detection re-testing on all 25 mph sidings. Speed was reduced to 15 mph in these sidings until they were retested. Rail grinding within these sidings was also programmed to remove rail surface defects.

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The occurrence

On 14 February 2015, a Canadian National (CN) crude oil unit train was proceeding eastward on CN's Ruel Subdivision near Gogama, Ontario. The train crew was composed of a locomotive engineer and a conductor. The train was equipped with 2 head-end locomotives hauling 100 Class 111 tank cars, 68 loaded with Petroleum Crude Oil (UN 1267) and 32 loaded with Petroleum Distillates (UN 1268). The train was 6089 feet long and weighed 14 355 tons.

At about 23:50, while travelling at 38 mph, the train crew felt a heavy tug on the train and a train-initiated emergency brake application occurred near Mile 111.6. Subsequently, the crew observed a fire about 10 cars behind the locomotives, so they detached the locomotives from the train. The temperature at the time was -31°C and a slow order (speed restriction) of 40 mph was in place.

The train was designated as a “Key Train”Footnote 1 operating on a “Key Route”.Footnote 2 The accident occurred in a remote area, and the CN Emergency Response Assistance Plan (ERAP) was implemented. There were no injuries reported, and no evacuation was required. The product in several cars was allowed to burn. All fires were extinguished by 20 February 2015.

What we know

Site examination determined that the 7th to the 35th cars behind the locomotives (29 cars in total) had derailed. During the derailment, a number of cars were breached, released product, and ignited a large fire that initially involved 7 of the derailed cars. Additional product was subsequently released, and a total of 21 cars sustained fire damage ranging from minor to severe. About 900 feet of track was destroyed.

While firefighters dealt with the fire, investigators from the Transportation Safety Board of Canada (TSB) were able to examine the site and recover a section of broken rail containing a rail joint and a broken wheel, that are of interest. All recovered rail components and the broken wheel were sent to the TSB Engineering Laboratory in Ottawa for further analysis.

Tank cars

The TSB conducted a preliminary damage assessment of all 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 cars have some enhancements which include half-head shields, improved top and bottom fitting protection, and normalized steel.

The preliminary assessment revealed that 2 tank cars 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 25 derailed tank cars sustained more significant damage. At least 19 of the 25 tank cars were breached or partially breached and released various amounts of product. It is estimated that a total of over 1 million litres of product was released, either to the atmosphere or to the ground. The amount of product released will be determined more precisely as site mitigation and clean-up continue.

The accident occurred at 38 mph. Initial impressions are that the Class 111 tank cars, which were compliant with the CPC-1232 standard, performed similarly to those involved in the Lac-Mégantic accident which occurred at 65 mph.

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 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. Consequently, until a more robust tank car standard with enhanced protection is implemented for North America, the risk will remain.

In response to the TSB’s recommendation, Transport Canada (TC) formalized the CPC-1232 standard in January 2014 as a requirement for all new tank cars built for the transportation of flammable liquids. The TSB has warned TC that this standard was not sufficient and that more needed to be done to provide an adequate level of protection. Preliminary assessment of the CPC-1232-compliant tank cars involved in this occurrence demonstrates the inadequacy of this standard given the tank cars’ similar performance to the legacy Class 111 tanks cars involved in the Lac-Mégantic accident.

“The TSB has been calling for tougher standards for Class 111 tank cars for several years,” said Jean L. Laporte, TSB’s Chief Operating Officer.“ Here is yet another example of tank cars being breached, and we once again urge Transport Canada to expedite the introduction of enhanced protection standards to reduce the risk of product loss when these cars are involved in accidents.”

Next steps

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

  • Examination of rail components and suspect wheel recovered from the derailment site
  • Sampling and testing of product from select cars
  • Review of Wheel Impact Load Detector records for subject train and 2 previous trains
  • Review of all track infrastructure maintenance records for the area
  • Review of CN Engineering Track Standards and cold weather policy
  • Review of TC-approved Track Safety Rules
  • Review and evaluation of ERAP and emergency response
  • Conducting 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. This may also include further failure analysis, testing and metallurgical examination at the TSB Engineering Laboratory.

Communication of safety deficiencies

Should the investigation team uncover safety deficiencies that present an immediate risk, the Board will communicate them without delay so they may be addressed quickly and the rail 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.


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 occurrence

On 14 February 2015, a Canadian National (CN) crude oil unit train was proceeding eastward on CN's Ruel Subdivision near Gogama, Ontario. The train crew was composed of a locomotive engineer and a conductor. The train was equipped with 2 head-end locomotives hauling 100 Class 111 tank cars, 68 loaded with Petroleum Crude Oil (UN 1267) and 32 loaded with Petroleum Distillates (UN 1268). The train was 6089 feet long and weighed 14 355 tons.

At about 23:50, while travelling at 38 mph, the train crew felt a heavy tug on the train and a train-initiated emergency brake application occurred near Mile 111.6. Subsequently, the crew observed a fire about 10 cars behind the locomotives, so they detached the locomotives from the train. The temperature at the time was -31°C and a slow order (speed restriction) of 40 mph was in place.

The train was designated as a “Key Train”Footnote 1 operating on a “Key Route”.Footnote 2 The accident occurred in a remote area, and the CN Emergency Response Assistance Plan (ERAP) was implemented. There were no injuries reported, and no evacuation was required. The product in several cars was allowed to burn. All fires were extinguished by 20 February 2015.

What we know

Site examination determined that the 7th to the 35th cars behind the locomotives (29 cars in total) had derailed. During the derailment, a number of cars were breached, released product, and ignited a large fire that initially involved 7 of the derailed cars. Additional product was subsequently released, and a total of 21 cars sustained fire damage ranging from minor to severe. About 900 feet of track was destroyed.

While firefighters dealt with the fire, investigators from the Transportation Safety Board of Canada (TSB) were able to examine the site and recover a section of broken rail containing a rail joint and a broken wheel, that are of interest. All recovered rail components and the broken wheel were sent to the TSB Engineering Laboratory in Ottawa for further analysis.

Tank cars

The TSB conducted a preliminary damage assessment of all 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 cars have some enhancements which include half-head shields, improved top and bottom fitting protection, and normalized steel.

The preliminary assessment revealed that 2 tank cars 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 25 derailed tank cars sustained more significant damage. At least 19 of the 25 tank cars were breached or partially breached and released various amounts of product. It is estimated that a total of over 1 million litres of product was released, either to the atmosphere or to the ground. The amount of product released will be determined more precisely as site mitigation and clean-up continue.

The accident occurred at 38 mph. Initial impressions are that the Class 111 tank cars, which were compliant with the CPC-1232 standard, performed similarly to those involved in the Lac-Mégantic accident which occurred at 65 mph.

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 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. Consequently, until a more robust tank car standard with enhanced protection is implemented for North America, the risk will remain.

In response to the TSB’s recommendation, Transport Canada (TC) formalized the CPC-1232 standard in January 2014 as a requirement for all new tank cars built for the transportation of flammable liquids. The TSB has warned TC that this standard was not sufficient and that more needed to be done to provide an adequate level of protection. Preliminary assessment of the CPC-1232-compliant tank cars involved in this occurrence demonstrates the inadequacy of this standard given the tank cars’ similar performance to the legacy Class 111 tanks cars involved in the Lac-Mégantic accident.

“The TSB has been calling for tougher standards for Class 111 tank cars for several years,” said Jean L. Laporte, TSB’s Chief Operating Officer.“ Here is yet another example of tank cars being breached, and we once again urge Transport Canada to expedite the introduction of enhanced protection standards to reduce the risk of product loss when these cars are involved in accidents.”

Next steps

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

  • Examination of rail components and suspect wheel recovered from the derailment site
  • Sampling and testing of product from select cars
  • Review of Wheel Impact Load Detector records for subject train and 2 previous trains
  • Review of all track infrastructure maintenance records for the area
  • Review of CN Engineering Track Standards and cold weather policy
  • Review of TC-approved Track Safety Rules
  • Review and evaluation of ERAP and emergency response
  • Conducting 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. This may also include further failure analysis, testing and metallurgical examination at the TSB Engineering Laboratory.

Communication of safety deficiencies

Should the investigation team uncover safety deficiencies that present an immediate risk, the Board will communicate them without delay so they may be addressed quickly and the rail 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.


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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Richmond Hill, Ontario – 12 February 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (A13O0098) into a May 2013 hard landing and tail strike involving a Porter Airlines Inc. aircraft at the Sault Ste. Marie International Airport. There were no injuries; however, there was substantial damage to the aircraft.

On 26 May 2013, a Porter Airlines Inc. Bombardier DHC-8-402 flew from the Billy Bishop Toronto City Airport to the Sault Ste. Marie Airport. At 2216 Eastern Daylight Time, during touchdown, the tail struck the runway. After landing, the aircraft taxied to the gate where the passengers were deplaned.

During the final approach to landing, the airspeed began to decrease and the descent rate began to increase. This profile put the aircraft in an unstabilized approach requiring a go-around, but the crew continued with the landing. As the aircraft rapidly approached the runway, instead of increasing engine power to reduce the rate of descent, the pilot pitched the nose up beyond the limits stated in the standard operating procedures and manufacturer's pitch awareness training. The investigation found that the high rate of descent coupled with the high nose-up attitude of the aircraft resulted in the hard landing compressing the struts and allowing the tail to contact the runway.

The investigation also drew attention to the need to clearly define the requirements for a stabilized visual approach, and to clearly define the duties of the pilot monitoring in order to mitigate the risk that unsafe flight conditions could develop.

Immediately following this occurrence, Porter Airlines Inc. initiated an internal investigation as part of its Safety Management System. Part of the immediate corrective action involved a revision of the Pitch Awareness Training highlighting previous occurrences and the need to arrest high descent rates with power and not pitch. The company also conducted a review of training for captains and pilots, reviewed use of flap settings on approach, provided further clarification on the stabilized approach procedure, and re-emphasized hazards associated with night-time operations.

Approach-and-landing accidents are a TSB Watchlist issue. The Board is calling on Transport Canada and operators to do more to reduce the number of unstable approaches that are continued to a landing.

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Gatineau, Quebec, 03 February 2015 – The Transportation Safety Board of Canada today released its investigation report (A13Q0186) into the belt loader fire involving a Boeing 767 operated by Royal Air Maroc at Montréal-Pierre Elliott Trudeau International Airport (Québec) in November 2013. The fire led to smoke in the cabin and the evacuation of passengers.

On 04 November 2013, the Royal Air Maroc Boeing 767 carrying 243 passengers and 8 crew members parked at gate 61 after landing at Montréal-Pierre Elliott Trudeau International Airport (Quebec). During deplaning at 1645, a fire broke out under a belt loader that was positioned under the left rear cargo door. The smell of smoke created by the fire penetrated the cabin, prompting the captain to order the evacuation of the aircraft. Some passengers evacuated the aircraft through the jetway while others used the evacuation slides. Seven passengers suffered minor injuries. The airport firefighting service arrived on site at 1649 and brought the fire under control. The aircraft sustained no damage.

The investigation found that a connector in the fuel system on the belt loader disconnected while the engine was running. Consequently, fuel sprayed onto the hot surface of the exhaust and caused a fire.

In the weeks following the occurrence, all of the service provider's (Servisair Inc.) belt loaders at airports across Canada had their fuel systems inspected for connectors, and they installed an emergency switch on belt loaders that did not already have one. They also shared their observations with other service providers concerning the risks associated with the vulnerability of the fuel system for this engine model on ground handling equipment. Aéroports de Montréal has incorporated service providers such as ground handlers into their safety management system, and its firefighting service now offers training to employees working on the apron.

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Dartmouth, Nova Scotia, 29 January 2015 – In its report (M13M0287) released today, the Transportation Safety Board of Canada (TSB) found that maintenance deficiencies and lack of adequate emergency procedures led to the 7 November 2013 loss of electrical power and grounding of the passenger ferry Princess of Acadia in Digby, Nova Scotia. There were no injuries or pollution reported.

The Princess of Acadia was approaching the ferry terminal at Digby, Nova Scotia, with 87 passengers and crew aboard. In preparation for docking, as the bow thruster was started, the main generator blacked out causing a loss of electrical power and disabling the main propeller pitch control pumps. Once the pitch control pumps stopped, the propeller thrust defaulted toward full astern while the engines were still running, causing the vessel to slow down, stop and travel backwards towards the nearby shoreline until running aground.

The investigation found that a deteriorated generator component caused the failure of two main generators and the blackout of the main electrical switchboards, among other system failures. The investigation also identified that neither the bridge nor the engine room had effective procedures in place to respond to the blackout of the main switchboard. Because of this, the master was not informed that engine room personnel were having difficulty restoring power, and the engine room was not aware of the urgency of the situation. This impeded an effective response to the emergency. The vessel had voluntarily implemented a safety management system (SMS), but it did not provide the master with guidance to proactively identify risks or investigate hazardous occurrences.

There were also deficiencies with passenger-related duties in written evacuation procedures and with Transport Canada’s oversight to ensure compliance with regulations regarding passenger safety emergency procedures. As such, there is a risk that these procedures will not achieve their intended purpose. Previous marine investigations (M12C0058 and M13L0067) have found deficiencies in the oversight of passenger safety regulations.

Following the occurrence, Bay Ferries Ltd., the vessel operator, instituted improved operating procedures for when the vessel prepares to arrive at Digby. They have also installed a simplified voyage data recorder, which records bridge audio and information navigation equipment and other available sensors. Llloyd’s Register, the vessel classification society, has increased the frequency for generator breaker testing.

Safety management and oversight is a TSB Watchlist issue. The TSB is calling on Transport Canada to implement regulations requiring all operators in the air and marine industries to have formal safety management processes and for effective oversight of these processes. When companies are unable to effectively manage safety, the regulator must not only intervene, but do so in a manner that succeeds in changing unsafe operating practices.

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Gatineau, Quebec, 28 January 2015 – While recognizing significant positive action taken by the regulator, the Transportation Safety Board of Canada (TSB) remains concerned about Transport Canada’s (TC) response to outstanding recommendations stemming from its investigation into the Montreal, Maine & Atlantic Railway (MMA) train that derailed on 6 July 2013 in Lac-Mégantic, Quebec.

“Transport Canada continues to take important steps to address the rail safety deficiencies we identified in our Lac-Mégantic investigation,” said Kathy Fox, Chair of the TSB. “With respect to preventing runaway trains, TC has introduced multiple layers of defences that, if fully implemented, will significantly reduce risks. But with respect to TC auditing and oversight activities, we are concerned that the department has not yet put in place an effective oversight regime that guarantees all railways will be audited in sufficient breadth and frequency to ensure safety issues are addressed in a timely manner.”

Prevention of runaway trains: Unattended equipment (R14-04)

The investigation determined that more robust defences are required to prevent runaways. Even if they have a low probability of occurrence, these events can have extreme consequences, particularly if they involve dangerous goods—as was seen in Lac-Mégantic. For this reason, the Board recommended that TC require Canadian railways to implement additional physical defences to prevent runaway equipment.

In October 2014, TC issued an Emergency Directive (which expires 29 April 2015) that addresses many of the weaknesses in the Canadian Rail Operating Rules pertaining to the securement of equipment. Along with a standardized hand brake chart and explicit instructions for hand brake effectiveness testing, additional physical securement measures must be used. TC also said it will hire additional specialized staff to strengthen oversight related to train securement and to monitor compliance with these additional levels of defence to prevent runaways. If the proposed measures are fully implemented on a permanent basis, the risk of runaway equipment will be significantly reduced; therefore, the Board assesses the response as having Satisfactory Intent.

Safety management systems audits and essential follow-up (R14-05)

Until Canada's railways make the cultural shift to safety management systems (SMS), and TC makes sure they have effectively implemented SMS, the safety benefits will not be fully realized. For this reason, the Board recommended that TC audit the SMS of railways in sufficient depth and frequency to confirm that the required processes are effective, and that corrective actions are implemented to improve safety.

TC has committed to bringing into force additional regulations and enforcement capabilities, hiring more auditors and strengthening its training programs. While significant progress has been made, TC has not yet demonstrated that it has implemented an effective oversight regime to ensure all railways will be adequately audited. Furthermore, TC has not committed to auditing every SMS component within a given time period. As a result, deficiencies within a railway's SMS may not be identified and addressed in a timely manner; therefore, the Board assesses the response as being Satisfactory in Part.

This issue has been identified as one of the key risks to the transportation system and it is included on the TSB's 2014 Watchlist.

“The Minister of Transport and the department have taken strong action to improve rail safety in the wake of the Lac-Mégantic tragedy, but more work needs to be done,” added Ms Fox. “We will continue to monitor the department and rail industry's progress in implementing new regulations and procedures introduced by TC. Canadians deserve no less than the safest transportation system.”

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Gatineau, Quebec, 21 January 2015 – The Transportation Safety Board of Canada today released its investigation report (R13D0077) into the derailment of a Canadian National Railway (CN) freight train in Taschereau Yard, Montréal, Quebec.

On 6 November 2013, at approximately 05:05 Eastern Standard Time, a CN freight train derailed 10 empty cars while travelling through a tight curve at Taschereau Yard in Montréal, Quebec. The derailed cars and the track were damaged. There were no injuries.

The investigation determined that, as the train began to accelerate from a stop, the empty cars occupying the curve were pulled over the lower (inside) rail and derailed. The first car to derail, the 29th car, was an empty, long car equipped with end-of-car cushioning devices. These cars are susceptible to high lateral/vertical (L/V) forces, especially in curves. With a block of empty cars marshalled ahead of a block of loaded cars, the empty cars experienced a significantly higher L/V force than the loaded cars.

In the weeks following the derailment, CN issued instructions aimed at minimizing in-train forces in the curve of track CX01. Yard and train personnel must ensure that the train brakes are fully released before initiating a movement and must limit the force applied to the train by the locomotive consist.

CN will continue to ensure compliance with these instructions by reviewing locomotive event recorder downloads.

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Calgary, Alberta, 14 January 2015 – In its investigation report (R13C0087) released today, the Transportation Safety Board of Canada (TSB) determined that a Canadian Pacific train derailed when a wheel flange struck and climbed a switch point and then fell between the switch point and the rail.

On 11 September 2013, the freight train departed from Alyth Yard in Calgary enroute to Red Deer, Alberta. As the train crossed over the switch, it derailed seven tank cars loaded with natural gasoline condensate (a product commonly used to dilute bitumen so that it can flow through a pipeline). During the derailment, approximately 600 feet of track was destroyed and a natural gas line supplying a switch heater was severed, prompting an evacuation in the vicinity. There were no injuries or product loss from the tank cars.

The investigation determined that wheel flanges striking the switch point had caused overstress impacts on the tip of the switch point, creating a ramp for the wheels to climb up and derail the seven cars. Given the track layout, including a combination of curves, the transition from empty to loaded cars entering the crossover likely resulted in the wheels of the loaded cars tracking more towards the standard switch point.

Following the occurrence, Canadian Pacific made improvements to the track infrastructure, including removing the switch points involved in this occurrence, upgrading the rails and installing a new turnout.

The transportation of flammable liquids by rail is a Watchlist issue. The TSB is calling for railway companies to conduct route planning and analysis, and perform risk assessments to ensure that risk-control measures are effective. Additionally, flammable liquids must be shipped in more robust tank cars to reduce the likelihood of a dangerous goods release during accidents.

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Vancouver, British Columbia, 13 January 2015 – The Transportation Safety Board of Canada today released its investigation report (A13P0166) into the crash of an air taxi near Hesquiat Lake, British Columbia. The float plane, with 6 on board, crashed shortly after take-off. Everyone aboard survived the crash; however, the pilot and one passenger died when they were unable to exit the aircraft before it was consumed by flames in a post-crash fire.

At 1015 Pacific Daylight Time, a de Havilland Beaver floatplane, operated by Air Nootka Ltd., left Hesquiat Lake for Air Nootka Ltd.'s water aerodrome base near Gold River, B.C. with a pilot and 5 passengers on board. Visibility at Hesquiat Lake was about 2 ½ nautical miles in rain and the cloud ceiling was about 400 feet above lake and sea level. Approximately 3 nautical miles west of the lake, while over Hesquiat Peninsula, the aircraft struck a tree top at about 800 feet above sea level and crashed. Shortly after the aircraft came to rest, the fire started.

The accident investigation identified flight at low level in poor weather as causal. It also found that Air Nootka did not have effective methods to monitor its pilots' in-flight decision-making and associated practices. As a result, Air Nootka had no way to detect and correct unsafe behaviour or poor decision making. Further, the investigation found that risks still persist in the area of post-crash survivability. The lack of a requirement for shoulder harnesses on all passenger seats, the lack of technology to reduce fuel leakage or to eliminate ignition sources, and the lack of alternate means of escape such as push-out windows, all increase the risk of tragic results in the event of a crash. These issues have all been highlighted in previous TSB accident investigations.

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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