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Transportation Safety Board of Canada

Transportation Safety Board of Canada (431)

Dartmouth, Nova Scotia, 5 May 2016 – In its investigation report (M15A0009) released today, the Transportation Safety Board of Canada (TSB) concluded that due to insufficient monitoring of the vessel’s navigation, the bridge team of the roll-on roll-off passenger ferry Grace Sparkes was unaware of the vessel’s position in the harbour channel and the vessel struck Burnside Rock. There were no injuries or pollution, but the vessel sustained damage to the hull and the bilge keel.

On 21 January 2015, at 1746 local time, the Grace Sparkes was voyaging with 8 crew and 4 passengers onboard along a route that deviated to the east-southeast of the course line specified in the standard passage plan. The master was steering the vessel and navigating, limiting his ability to use paper and electronic charts to monitor the vessel's position in relation to the planned route. Although the master navigated visually at night, the position of the vessel was not being cross-referenced by the bridge team using other navigational aids as was recommended by the company's safety management manual. After the striking, the vessel continued its voyage and docked at Burnside a few minutes later.

In addition to not cross-referencing navigational aids, the investigation found deficiencies in several areas. These included a delay in reporting the occurrence to the Canadian Coast Guard; a lack of crew training in bridge resource management; issues with the marine medical certification process for the master, and assessing fitness for duty; and a lack of signage for lifesaving equipment. Further, when the vessel struck the rock, the passengers and crew members were not properly informed. It was also determined that safety drills included only crew members and no passengers, and thus did not provide realistic training.

The investigation also identified a number of issues related to the TSB Watchlist: the operator's safety management system and Transport Canada's (TC) oversight. If TC oversight does not assess the effectiveness for passenger safety-related emergency procedures, there is a risk these will not achieve their intended purpose. Additionally, if there is no follow-up to verify that non-conformities raised during internal and external audits have been addressed, there is a risk that unsafe conditions may persist.

Following this occurrence, the operator, the Newfoundland Department of Transportation and Works, took a number of corrective actions which included providing chart correction procedures to all vessels; adding lifesaving equipment signage; repairing the public address system; and providing instruction to clarify procedures for obtaining accurate passenger counts.

Published in Transportation Safety Board of Canada
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Québec, Quebec, 28 April 2016 – In its investigation report (M15C0045) released today, the Transportation Safety Board of Canada (TSB) concluded that shortly after it departed Rimouski, Quebec, a fire broke out in the engine compartment of the Frederike. C-2, possibly due to a failure in the generator engine.

At 0145 on 28 April, 2015, the Frederike. C-2 left Rimouski with a master and three crew members onboard. At approximately 0230, charred wood could be smelled in the wheelhouse and a crew member went to the engine compartment to discover that it was filled with dense smoke. After the master decided to return to Rimouski, and after an unsuccessful attempt was made to put out the fire, the life raft was inflated and the crew abandoned ship at 0300. The crew was rescued by the fishing vessel Marie-Karine D around 0330. The Canadian Coast Guard (CCG) Cap Perce was dispatched to assist. The vessel burned to the waterline and sank by 1515. No injuries were reported.

The investigation uncovered a number of safety deficiencies. The master’s certificate had expired more than two years before the occurrence. The crew had not received onboard familiarization and safety training before starting their duties. Nor had steps been taken to ensure that the crew understood the use and location of the lifesaving and fire-extinguishing appliances onboard. Further, the master did not communicate the event in accordance with the Canadian Radiocommunication Regulations or use Standard Marine Communications Phrases. Instead of alerting the Marine Communications and Traffic Services (MCTS), the master believed no CCG intervention was required and called the master of the Marie-Karine D, who then reported the situation to the MCTS.

The investigation also found that electrical and various other repairs were not reported to Transport Canada Marine Safety and Security (TCMSS) nor were two previous engine failures reported. Additionally, on 19 June 2012, a TCMSS inspector issued a Notice of Deficiency to the authorized representative (AR) of the Frederike. C-2 stating that the vessel required a safety familiarization and training manual onboard, specifically relating to firefighting and lifesaving equipment, and all tasks related to the safe operation of the vessel. The notice did not indicate any timeframe for rectifying the deficiency. On 25 March 2013, when TCMSS inspected the vessel again, there was still no familiarization and training manual on board. However, no further action was taken by TCMSS in this matter and the vessel was allowed to continue operating.

The TSB has identified safety management and oversight as a Watchlist issue. As this occurrence demonstrates, some transportation companies are not effectively managing their safety risks. The Board has been calling on Transport Canada (TC) to implement regulations requiring all operators in the marine industry to have formal safety management processes and for TC to oversee these companies' safety management processes.

In this occurrence, there were no fatalities; however, there continues to be approximately one fishing-related fatality per month in Canada. Loss of life on fishing vessels is also a Watchlist issue, and the TSB also conducted a Safety Issues Investigation (SII) into fishing safety. In this occurrence, two of the 10 safety significant SII issues: training and the cost of safety.

The SII emphasizes that the safety of fishermen will be compromised until the complex relationship and interdependency among safety issues is recognized and addressed by the fishing community. The Board continues to call for concerted and coordinated action by federal and provincial authorities and by leaders in the fishing community to improve the safety culture in fishing operations.

Following the occurrence, TCMSS inspectors at the Marine Safety Service Centre in Rimouski added compliance deadlines to Notices of Deficiency issued in relation to the familiarization and training manual. Failure to comply with this notice by the deadline will result in administrative monetary penalties.

Published in Transportation Safety Board of Canada
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Gatineau, Quebec, 19 April 2016 – The Transportation Safety Board of Canada (TSB) today released its assessments of the responses to its five recommendations arising from the investigation (R13T0192) into the collision between an OC Transpo bus and a VIA Rail train in Ottawa, Ontario, on 18 September 2013. These recommendations are aimed at reducing the risk of railway crossing accidents.

“There are a few good initiatives proposed by the regulator to address some of the safety deficiencies we identified in our investigation. But I'm concerned these efforts don't go far enough, fast enough,” said TSB Chair Kathy Fox. “To advance railway crossing and passenger safety even further, Transport Canada's research, review and consultation must lead to concrete action in a timely manner.”

Distracted driving guidelines (R15-01)

Recommendation R15-01 calls for Transport Canada (TC), in consultation with the provinces, to develop comprehensive guidelines for the installation and use of in-vehicle video monitor displays to reduce the risk of driver distraction. TC has indicated it will request that the Canadian Council of Motor Transport Administrators (CCMTA) Distracted Driver Working Group consider developing these guidelines. As co-chair of this group, TC will also suggest that experts and industry stakeholders be consulted to identify the challenges and effective strategies for limiting distracted driving due to video displays. Although meaningful results from the planned action will not likely occur in the short term, the Board is encouraged that TC will be taking a leadership role in the development of the guidelines. Therefore, the Board assesses the response to this recommendation as having Satisfactory Intent.

Bus crashworthiness (R15-02)

Recommendation R15-02 calls on TC to develop and implement crashworthiness standards for commercial passenger buses to reduce the risk of injury. TC has said it will conduct a review of accident data from urban centers around the world to evaluate the existing crashworthiness of commercial passenger buses. Beyond this commitment, there are no explicit plans to develop and/or implement crashworthiness standards for commercial passenger buses. Furthermore, no specific timeline has been provided for the planned review and analysis. Therefore, the Board assesses the response to this recommendation as being Satisfactory in Part.

Vehicle event data recorders (R15-03)

Recommendation R15-03 asks TC to require commercial passenger buses be equipped with dedicated, crashworthy, event data recorders (EDRs). TC has committed to researching EDR technologies and reviewing available international commercial vehicle EDR standards and recommended practices. TC will then review the results of the research and the review to evaluate the feasibility of developing an EDR standard or guideline for commercial passenger buses. While the Board is encouraged by TC's response, the work will take time and no specific outcome or timeline has been provided. In addition, there are no explicit plans for the development of EDR standards for commercial passenger buses. Therefore, the Board assesses the response to this recommendation as being Satisfactory in Part.

Grade separation guidelines (R15-04)

Recommendation R15-04 calls for TC to provide specific guidance as to when grade separation at railway crossings should be considered. TC has acknowledged that the new Grade Crossings Regulations (2014) do not specify when grade separation should be implemented at existing level grade crossings. TC has committed to working with the provinces and railways to develop guidelines to help determine when grade separation should be considered. The Board is encouraged that TC will work with key stakeholders to develop guidelines for determining when grade separation should be considered. Although no timelines have been established yet for this work, the Board assesses the response to this recommendation as having Satisfactory Intent.

Grade separation of Woodroffe Avenue, the Transitway and Fallowfield Road (R15-05)

Recommendation R15-05 calls on the City of Ottawa (the City) to reconsider the need for grade separations at the Woodroffe Avenue, Transitway, and Fallowfield Road level crossings. The City has responded that, in financial partnership with VIA Rail, it will conduct a feasibility study to review the technical requirements for providing grade separation at those crossings, as well as at two additional crossings. The action proposed by the City is a positive first step towards more effectively managing the risk of vehicle-train collisions at these five level crossings. The Board assessed the response to this recommendation as having Satisfactory Intent.

“The Board is pleased that the City of Ottawa has committed to conducting a feasibility study of grade separation at the recommended crossings, and commends the City for including Merivale and Jockvale roads in the study,” added Chair Fox. “The City's residents deserve the safest crossings on which to travel.”

The Board uses an Assessment Rating Guide to evaluate the responses and their overall effectiveness. Progress made to address TSB recommendations is re-assessed annually by the Board and is reported publicly.

Published in Transportation Safety Board of Canada
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Richmond, British Columbia, 18 April 2016 – The Transportation Safety Board of Canada (TSB) continues its independent investigation into the 11 September 2015 crossing collision between an ambulance and a Canadian National train in Langley, British Columbia.

The occurrence

On 11 September 2015, a northbound Canadian National (CN) train struck an ambulance travelling eastbound at the Crush Crescent–Glover Road, located at Mile 18.81 of the Canadian Pacific (CP) Page Subdivision in Langley, British Columbia. The occupants of the ambulance were two paramedics (one driving and one attending the patient) and one patient. The paramedics sustained injuries and the patient later succumbed to injuries sustained during the collision. The members of the train crew were not injured.

What we know

  • The train was travelling at 32 mph (maximum permissible track speed at the time of the occurrence was 35 mph).
  • During a post-occurrence examination, it was determined that there were no pre-existing mechanical deficiencies on the ambulance that would have contributed to the accident.
  • The main-track crossing is protected by automatic warning devices consisting of flashing lights, a bell, and gates, which were connected to the traffic lights at the intersection.

Progress to date

  • The ambulance was examined to determine whether any mechanical deficiencies might have contributed to the collision.
  • Investigators interviewed witnesses and downloaded information from the automatic warning devices installed at the crossing.
  • The locomotive event recorder and the ambulance data recorder were evaluated.
  • Investigators reviewed the crossing design and the interconnection of the traffic signals.
  • The TSB issued a rail safety advisory (RSA) to Transport Canada concerning safety issues at the Crush Crescent-Glover Road crossing. Further details on the RSA are included below.

Transport Canada Notice and Order

  • Transport Canada issued a Notice and Order on 11 February 2016, to the British Columbia Ministry of Transportation and Infrastructure, the Township of Langley, and the Canadian Pacific Railway.
  • The Notice and Order indicated that the current timing configuration for traffic light pre-emption and warning system gate delay was inadequate for longer vehicles to clear the crossing safely. It was also noted that roadway pavement markings were either absent or faded, such that drivers were not provided with adequate information.
  • As a result of the Notice and Order, some of the changes to the automatic warning devices included increasing the delay time of the crossing gate drop from 7 seconds to 12 seconds, and increasing the road traffic signal pre-emption time from 10 seconds to 15 seconds. These changes were made so that the crossing would be more suitable for use by longer vehicles.

TSB rail safety advisory

On 17 March 2016, the TSB issued a rail safety advisory (RSA) to Transport Canada concerning safety issues arising from conflicting information given by the railway crossing and road traffic signals at the Crush Crescent–Glover Road crossing. The RSA suggested that Transport Canada, British Columbia’s Ministry of Transportation and Infrastructure, and the Canadian Pacific Railway (CP) might wish to review the design and functionality of the Crush Crescent–Glover Road crossing, including the interconnection of the automatic warning devices on the crossing and the road traffic signal system, to ensure that the risks to motorists at this crossing are minimized.

The British Columbia Ministry of Transportation and Infrastructure responded to the RSA on 13 April 2016. Its response indicates that:

  • Ministry traffic engineers have reviewed the design and operation of the railway interconnection with the traffic signal and determined that it is operating as designed.
  • The Ministry is working with CP to ensure the ongoing safe operation of this crossing and further enhancements are planned. These enhancements include an upgrade to the signal bungalow, relocation of the gate arm, and the addition of an active warning LED sign on Crush Crescent.
  • The Ministry is considering the suitability of pre-signals or other means to prevent the movement of road traffic towards the grade crossing.

Follow-up with other stakeholders

When TSB followed up with Transport Canada, it noted the following:

  • There are actually two separate crossings at this location: the automatic warning devices protect the main track while crossbucks protect the Milner storage track.
  • As currently configured, the Milner Storage track crossing must meet the sightline requirements of the Grade Crossings Regulations.
  • The location of the two separate warning devices—one active and one passive—in a single place confuses road users, who think that it is safe to approach the gates when they are active.
  • Because of the interconnection of the crossing warning system and the road traffic signals at this location, the systems can send a conflicting message to road users when a train is approaching: the traffic signals indicate green for go while the crossing warning system indicates stop.

When TSB followed up with Canadian Pacific, it indicated that it would:

  • Install a new crossing warning system, and that British Columbia’s Ministry of Transportation and Infrastructure would install a new traffic signal controller capable of launching the gate-down process;
  • Relocate the crossing gate controlling eastward traffic to the west side of the Milner storage track. Construction on these changes will start in early July 2016.

Railway crossing safety

Railway crossing safety has been identified as one of the key risks to the transportation system, and it is included on the TSB's 2014 Watchlist. The rate of crossing accidents per million main-track train-mile decreased between 2006 and 2010 but it has been stable over the last 5 years, and the TSB is concerned that the risk of trains and vehicles colliding remains too high.

Next steps

  • The TSB continues to investigate the crossing design and the automatic warning devices, their interconnection with the traffic signals, and their timing at this location. It continues to monitor for any further safety action that may be taken.
  • The investigation will continue to examine the crossing and its operation; driver distraction and motor vehicle operation; driver training and supervision; and the operation of the trains approaching the crossing.

Railway Investigation R15V0191

Published in Transportation Safety Board of Canada
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Edmonton, Alberta, 6 April 2016 – In its investigation report (A14W0177) released today, the Transportation Safety Board of Canada (TSB) found that excessive vibrations from a failed tire led to the collapse of the right main landing gear on a Jazz Aviation Bombardier DHC-8-402 in Edmonton, Alberta, in November 2014. Three passengers suffered minor injuries.

On 6 November 2014, Jazz Aviation Flight 8481 departed from Calgary International Airport destined for Grande Prairie, Alberta, with 71 passengers and four crew members onboard. During takeoff, one of the tires on the right landing gear failed. The flight was diverted to the Edmonton International Airport. Shortly after touchdown on landing, the right main landing gear collapsed. The right side propeller blades sheared off on impact with the ground and one of the blades penetrated the cabin wall. All passengers and crew evacuated the aircraft. There was no post-occurrence fire.

The investigation determined that a high rotational imbalance was created on the tire that failed during takeoff, resulting in a significant vibration as the tire began to spin up during touchdown. As this vibration was the same or very close to one of the natural frequencies of the right main landing gear, it falsely triggered a sensor within the main landing gear. This resulted in a reduction of hydraulic pressure to the locking mechanism of the landing gear. In this condition, the excessive vibration then caused the mechanical locking system to release, leading the landing gear to collapse. The investigation concluded that the lack of specific requirements for dynamic vibration testing of aircraft components during certification was a risk factor, as similar systems could fail during high-vibration conditions.

Following the occurrence, Jazz Aviation decided to no longer use retreaded tires on the main landing gear of their DHC-8-402 fleet. Further, the operator made changes to its DHC-8-402 operating procedures to reduce stress on the main landing gear tires when manoevring on the ground. Other operators using this aircraft have adopted similar procedures to reduce main landing gear tire stress.

Published in Transportation Safety Board of Canada
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Dartmouth, Nova Scotia, 1 April 2016 – The Transportation Safety Board of Canada (TSB) continues its independent investigation into the 29 March 2016 aircraft accident in les Iles-de-la-Madeleine, Quebec.

What we know

  • Moncton Air Traffic Control cleared the aircraft for an instrument approach to Runway 07 at les Îles-de-la-Madeleine Airport.
  • Preliminary observations indicate that the aircraft was near wings level in a slight nose-high attitude at impact. More analysis of the aircraft attitude at impact is required.
  • The wreckage is contained in a 150m x 150m field. The aircraft came to rest approximately 91m from the initial point of impact.
  • Initial assessments indicate that the engines were producing power at the time of impact.
  • The investigation will examine previous occurrences with this type of aircraft, and subsequent safety action taken in Canada, the United States (U.S.) and other jurisdictions.
  • It is believed that there is a GPS tracking device installed in the aircraft. The team will recover the device for further analysis.
  • Approach-and-landing is a phase of flight during which a high number of accidents take place. The investigation will be paying close attention to this Watchlist issue.

Progress to date

There are currently seven TSB investigative team members on site. So far, the team has:

  • Almost completed the examination and documentation of the accident site;
  • Obtained initial witness statements from the Sûreté du Québec. The team may do follow-up interviews with selected eyewitnesses;
  • Taken photographs of the wreckage and obtained aerial images from the Canadian Coast Guard;
  • Appointed a TSB team member as a family liaison person.


The TSB conducts independent investigations in collaboration with numerous agencies. In this investigation:

  • The Canadian Coast Guard has provided high-resolution aerial imaging of the accident site.
  • The Sûreté du Québec is responsible for ensuring that there was no criminal activity surrounding the occurrence. They secured and surveyed the site, conducted initial witness interviews and provided site documentation. Information collected will be provided to the TSB for the investigation.
  • A Transport Canada Minister’s Observer has arrived at the accident site.
  • Contacts have been established with the Coroner’s Office to coordinate our activities.
  • The U.S. National Transportation Safety Board (NTSB) has an accredited representative on site, as the aircraft was registered in the U.S. This is granted under international conventions and the purpose is to facilitate the transfer of information between both countries.
  • The NTSB accredited representative is accompanied by a second NTSB investigator and technical advisors from the U.S. Federal Aviation Administration (FAA), the aircraft manufacturer, and the manufacturer of the engines.

Next steps

The Field Phase of the investigation will be concluding, and the Examination and Analysis Phase will commence. In the coming days and weeks, the team will:

  • Transport the aircraft to the TSB Laboratory in Ottawa for further analysis;
  • Examine components such as instrumentation and any device that contains non-volatile memory;
  • Gather additional information about weather conditions;
  • Gather information on air traffic communications and radar information;
  • Obtain and examine aircraft maintenance records;
  • Obtain and examine pilot training, qualifications and proficiency records;
  • Interview family, witnesses, the aircraft operator and others;
  • Review operational policies and procedures;
  • Examine the regulatory requirements;
  • Examine survivability issues such as cabin and cockpit crashworthiness and emergency response; and
  • Examine the MU-2 aircraft design and previous safety communications and studies in Canada and elsewhere.

Additional updates will be provided as required.

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

Published in Transportation Safety Board of Canada
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Dorval, Quebec, 30 March 2016 – In its investigation report (R14Q0045) released today, the Transportation Safety Board of Canada (TSB) determined that the derailment of the Quebec North Shore and Labrador Railway (QNS&L) ore train near Tellier, Quebec, in November 2014, occurred when the train collided with fallen boulders that were blocking the track.

On 6 November 2014, at approximately 0540, Eastern Standard Time, the QNS&L train, which consisted of three locomotives and 240 empty ore cars, was proceeding northward when it struck a rock slide. The collision caused the two lead locomotives and the first nine cars to derail. The lead locomotive rolled down the slope and came to a stop at the bottom of the Moisie River, completely submerged. The locomotive engineer was fatally injured. About 1000 litres of diesel fuel spilled from the locomotive. About 100 feet of railway track was destroyed.

The investigation determined that the derailment could not have been prevented because the locomotive engineer received no alarm or prior indication that an obstacle was blocking the track. In addition, because it was still very dark and the train was coming out of a curve, the distance of visual perception provided by the locomotive headlights did not allow the locomotive engineer to apply the emergency brakes in time to avoid the collision.

Following the accident, QNS&L implemented several measures aimed specifically at managing ground hazards and improving railway safety. These included having a geotechnical specialist conduct a rock face inspection; setting up a database for compiling information on ground hazards and employee observations; drafting directives for speed reductions during periods of freezing or thawing; and having an independent consultant conduct audits of its programs.

Published in Transportation Safety Board of Canada
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Edmonton, Alberta, 24 March 2016 – In its investigation report (A14W0181) released today, the Transportation Safety Board of Canada (TSB) found that not using all available weather information and inadequate awareness of aircraft limitations in icing conditions led to the severe icing encounter and forced landing of an Air Tindi Cessna 208B Caravan west of Yellowknife, Northwest Territories (NWT). There were no injuries to the pilot and 5 passengers, but the aircraft was substantially damaged.

On 20 November 2014, in morning darkness, an Air Tindi Cessna Caravan was on a flight from Yellowknife to Fort Simpson, NWT. During the climb to 8000 feet, the flight encountered severe icing conditions, requiring a return to Yellowknife. While on the return, the pilot was unable to maintain altitude and eventually the aircraft contacted the frozen surface of Great Slave Lake. The aircraft sustained substantial damage after striking a rock outcropping. The pilot and passengers were rescued approximately 4 hours after the forced landing.

The investigation determined that the pilot underestimated the severity and duration of icing conditions to be encountered during the flight. Additionally, as a result of incomplete weight and balance calculations, the aircraft was found to be 342 pounds above its certified maximum weight for flight into known icing conditions, and the aircraft's centre of gravity was also not within limits. These factors led to a condition that increased the aircraft's stall speed and reduced its ability to climb.

The investigation also found that although passengers were briefed on how to open the cabin door, it did not enable them to do so following the forced landing and they were required to exit through one of the cockpit doors. Further, due to the collision with terrain, access to survival equipment and winter clothing loaded in the belly pod was limited. As such, the investigation concluded that ineffective passenger briefings and stowage of survival equipment in an inaccessible location were additional risk factors.

Following the occurrence, Air Tindi temporarily suspended Cessna Caravan operations, conducted a safety management system investigation and undertook a number of safety actions. These included enhanced oversight of aircraft dispatch procedures, more thorough weather monitoring, improved training for operations in icing conditions, and updating the company's emergency response plan.

Published in Transportation Safety Board of Canada
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Richmond Hill, Ontario, 16 March 2016 – In its investigation report (R14W0137) released today, the Transportation Safety Board of Canada (TSB) determined that poor track conditions and delays in maintenance activities led to the derailment of a Canadian National (CN) train near Fort Frances, Ontario. There were no injuries, and 500 feet of track was destroyed.

On 23 May 2014, a CN freight train was travelling from Winnipeg, Manitoba, to Chicago, Illinois, along the Fort Frances Subdivision. While operating on a descending grade approaching Fort Frances, the train crew observed a track misalignment at Mile 93.38. The train crew made a full service application of the automatic train air brakes and moved the locomotive dynamic brake (DB), a secondary electrical braking system that provides resistance against the rotation of the locomotive axles, to position 5 just prior to reaching the track misalignment. The crew further increased DB as the train passed over the misaligned track. About 40 seconds later, a train-initiated emergency brake application occurred and the train slowed to a stop. Subsequent inspection determined that 35 freight cars had derailed. The derailed equipment included two tank cars loaded with molten sulfur, one of which was punctured, released product and started a small grass fire which burned itself out.

The investigation determined that the derailment occurred when the track misalignment at mile 93.38 buckled sharply beneath the train. The track structure near the derailment was in poor condition with defective ties, fouled ballast, and ineffective rail anchoring. The train brake applications imparted additional compressive forces into an already weakened track structure. A significant increase in traffic and tonnage had accelerated track deterioration and maintenance programs were delayed. At the derailment location, freight trains were operating at 50 mph on track that only met the standards for 25 mph operation.

The investigation also identified that CN did not consistently apply its Engineering Track Standards while Transport Canada’s (TC) inspection and enforcement activities did not ensure timely maintenance action. Despite CN company maintenance and TC’s regulatory inspection activities prior to the accident, the weakened track structure had not been adequately addressed and speed reductions were not applied.

Following the occurrence, TC issued a Notice and Order to limit speeds and increase track inspections between Mile 90.1 and 1142.8 of the Fort Frances Subdivision. For its part, CN conducted additional track inspections with professional engineers and installed new ties between Mile 87.0 and 143.6 of the same track. Once TC was satisfied with the corrective measures taken, the Notice and Order was revoked.

Finally, this track met the criteria for a key route which was subject to additional safety measures, including a formal risk assessment. Following the Lac-Mégantic investigation, the TSB Board recommended that “the Department of Transport set stringent criteria for the operation of trains carrying dangerous goods, and require railway companies to conduct route planning and analysis as well as perform periodic risk assessments to ensure that risk control measures work” (R14-02). While CN’s risk assessment for this corridor and its engineering processes took into account a number of factors, the mitigating strategies in place were insufficient.

Published in Transportation Safety Board of Canada
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Richmond Hill, Ontario, 15 March 2016 – In its investigation report (A14O0217) released today, the Transportation Safety Board of Canada (TSB) determined that a faulty navigation receiver and difficulty holding aircraft heading while flying in conditions of limited visual reference, led the pilot of an aircraft to become lost, and eventually collide with terrain near Whitney, Ontario. Both occupants were fatally injured.

On 11 November 2014, at 1803 Eastern Standard Time, a Cessna 150M with two people on board departed from the Ottawa/Rockcliffe Airport under night visual flight rules for a flight to the Toronto Buttonville Municipal Airport. At 2025, the pilot transmitted a mayday indicating that he was lost and that the aircraft was low on fuel. The aircraft was below radar coverage, and air traffic control (ATC) attempted to assist the aircraft in locating a suitable aerodrome. At 2127, the pilot made a final radio transmission, and the aircraft crashed shortly thereafter.

The investigation determined that the aircraft was being operated in darkness, below a layer of clouds with limited visual reference, and over an area with few ground lights. The pilot was navigating by relying solely on aircraft heading and the information provided by an onboard navigation instrument (VHF omnidirectional range (VOR) receiver). A component within the receiver had deteriorated and was overheating, causing it to periodically display incorrect information. The pilot relayed this incorrect location information to ATC, rendering ATC assistance ineffective. Further, because the pilot was uncertain of the amount of fuel remaining in the aircraft, ATC attempted to route the aircraft to the perceived nearest airport with runway lighting rather than to one slightly more distant in a better lit, more populated area.

Shortly before the accident, the pilot entered a shallow descent, possibly in an effort to maintain visual flight in deteriorating weather, and as a result, the aircraft struck a heavily treed area.

Published in Transportation Safety Board of Canada
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