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Transportation Safety Board of Canada

Transportation Safety Board of Canada (413)

Richmond, British Columbia, 1 February 2016 – In its investigation report (M15P0035) released today, the Transportation Safety Board of Canada (TSB) highlighted the lack of safety oversight as a significant risk in the foundering and abandonment involving the self-propelled barge Lasqueti Daughters. Although the vessel was declared a constructive total loss, there were no injuries.

On 14 March 2015, the self-propelled barge, with 17 people on board, departed Campbell River, British Columbia. Partway into the voyage, the sea and wind conditions deteriorated resulting in water pooling on board and making its way into the forward storage compartment. The vessel began foundering and was subsequently abandoned, however it remained afloat and was eventually towed to shore and intentionally beached.

The investigation determined that the weather and sea conditions encountered by the Lasqueti Daughters resulted in water being shipped onto the main deck via the spaces between the bow ramp, the bulwarks, and the main deck. Because the main deck, which had been recently replaced, was not watertight, it allowed water to downflood into the forward storage compartment. The investigation also found that the crew attempted to pump out the storage compartments using the on-board pumps; however, the emergency pump did not pump water, likely due to an air lock, and the remaining pumps could not cope with the ingress of water. As the water continued to enter, the vessel began to founder.

In this occurrence, the owner's safety program did not cover the marine transportation of workers and equipment required for silviculture operations. The investigation noted that if a company's health and safety program covers only some of its operations, there is a risk some hazards will not be identified or addressed. Further, if organizations with overlapping areas of responsibility, in this case, WorkSafeBC, the British Columbia Forestry Safety Council and Transport Canada (TC) do not share information and collaborate amongst themselves as well as with owners and masters, then there is a risk that gaps in safety oversight will occur. The investigation also determined that the vessel did not hold the required TC inspection certificate, nor was there any inspection or verification by TC of the vessel's condition; as such there was no opportunity to identify and address safety deficiencies. The vessel was not operating under a safety management system (SMS), nor was it required to.

The TSB has identified Safety management and oversight as a Watchlist issue. As this occurrence demonstrates, some marine operations are not effectively managing their safety risks. The TSB is calling for all operators in the marine industry to have formal safety management processes with oversight conducted by TC. When companies are unable to effectively manage safety, TC must not only intervene, but do so in a manner that succeeds in changing unsafe operating practices.

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Dorval, Quebec, 20 January 2016 – In its investigation report (A14Q0148) released today, the Transportation Safety Board of Canada (TSB) identified several factors which led to the September 2014 runway excursion in La Tabatière, Quebec. Although the aircraft sustained substantial damage, no occupants were injured.

On 28 September 2014, a de Havilland DHC-6-300 Twin Otter, operated by Air Labrador Limited, was on a charter flight from Lourdes-de-Blanc-Sablon to La Tabatière, Quebec, with 2 crew and 17 passengers on board. As the First Officer landed the aircraft, the captain determined that the aircraft would not stop before reaching the end of the runway, and took control and initiated a high-speed left turn onto the taxiway. The aircraft skidded to the right, and the right propeller struck a runway identification sign before the aircraft came to a stop.

The aircraft had floated for 6.3 seconds over the runway and touched down about 750 feet from the threshold, near the halfway point instead of the beginning of the runway, leaving not enough room to stop. The company has neither procedures nor a policy stating when to conduct go-arounds, and relies solely on pilot experience to determine when a go-around should be performed. If pilots are not prepared to conduct a go-around on every approach, there is a risk that they will not be ready to react to a situation that requires a go-around.

Crew resource management (CRM) training is specifically designed to address interactions between flight crew members. Neither pilot had received CRM training at Air Labrador, nor is it required by regulation. This training could have served as an aid by requiring crew members to monitor the other crew member's performance and to identify any deviation, bringing it to their attention as soon as practicable. The Board has an outstanding recommendation (A09-02) calling on contemporary CRM training for air taxi and commuter pilots. Transport Canada (TC) has recently developed CRM training standards for these operators and plans to publish them in 2016.

This accident highlights two issues on the TSB Watchlist: Approach-and-landing accidents and Safety management and oversight. The TSB publishes the Watchlist to focus the attention of industry and regulators on the safety issues posing the greatest risk to Canada's transportation system. As this occurrence demonstrates, landing accidents continue to occur at Canadian airports. The TSB has called on TC and operators to do more to reduce the number of unstable approaches that are continued to a landing. Additionally, a safety management system (SMS) is a comprehensive process for managing safety risks in an organization. In this case, the operator did not have an SMS, nor was it required to have one by regulation. However, if organizations do not use modern safety management practices, there is an increased risk that hazards will not be identified and mitigated. TSB also urges TC to implement regulations requiring all operators in the air industry to have formal safety management processes, and to oversee these processes.

Following the occurrence, Air Labrador issued a directive to all crews for modified procedures when landing on short runways. They also provided a landing-distance performance chart for each aircraft and amended their checklists.

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Richmond Hill, Ontario, 14 January 2016 – In its investigation report (A14O0178) released today, the Transportation Safety Board of Canada (TSB) found that a malfunctioning landing gear system led to the September 2014 landing accident at Timmins Victor M. Power Airport in Timmins, Ontario. The aircraft was substantially damaged but there was no post-impact fire, and no injuries to the occupants.

On 26 September 2014, at 1740 Eastern Daylight Time, a Beechcraft King Air A100 was operating as Air Creebec flight 140 on a scheduled flight from Moosonee, Ontario, to Timmins, Ontario, with two crew members and seven passengers on board. While on approach to Timmins, the crew selected the landing gear down, but did not get an indication light that the landing gear was down and locked. A fly-by at the airport provided visual confirmation that the landing gear was not fully extended. The crew attempted to lower the landing gear manually but was unable to do so. At approximately the same time, indicators illuminated to indicate that both the generators were not functioning. An emergency was declared, and the aircraft landed with only the nose gear partially extended. The aircraft came to rest beyond the end of Runway 28.

The investigation revealed that during the extension of the landing gear, a wire bundle became entangled around the landing gear rotating torque shaft, preventing full extension. The entanglement also prevented the alternate landing gear extension system from working. The investigation also determined that the wire bundle consisted of wiring for the generator control circuits, and when damaged, disabled both generators.

Following the occurrence, Air Creebec performed its own safety management system investigation and performed inspections on its two other Beechcraft King Air A100 aircraft, and found no faults. The operator submitted a safety deficiency report to Transport Canada, and also issued a maintenance advisory to its staff to check for proximity of wiring harnesses to surrounding rotating parts. In addition, Air Creebec contacted other operators with the same type of aircraft and made them aware of the potential for this type of event.

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Québec, Quebec, 5 January 2016 — In its investigation report (M14C0193) released today, the Transportation Safety Board of Canada (TSB) identified several factors which led to the striking of the breakwater by the tug Vachon while assisting—with the tug Brochu—the bulk carrier Orient Crusader in Port Cartier, Quebec. No pollution or injuries were reported, but the Vachon and the breakwater sustained minor damage.

On 12 September 2014, at 1907 EDT, the Orient Crusader departed from its anchored position approximately 3 nautical miles off Port Cartier and began proceeding toward the port. At 2012 EDT, the Brochu transferred a marine harbour pilot to the Orient Crusader, and the bridge team then consisted of the master, the pilot, a helmsman, and a third officer, who was also acting as officer of the watch (OOW). The pilot was navigating visually utilizing the harbor approach range lights. While entering the harbour with the assistance of the two tugs the Orient Crusader deviated from the recommended track due to the prevailing current. Although corrective actions were attempted to regain the approach track on the range lights, they were insufficient.

At the same time, the monitoring by the Orient Crusader bridge team did not detect the developing unsafe situation with respect to the Vachon’s proximity to the breakwater. When it became apparent that the Vachon would not clear the breakwater, the master on the Vachon activated the tow-abort mechanism in order to release the tow line; however, the tow-abort mechanism failed to operate and the tug struck the breakwater.

The investigation determined that in the case of the Orient Crusader, other than the pilot, it was unclear as to who on the bridge was monitoring the vessel’s position; therefore, the master and the OOW were likely unaware of the extent to which the vessels had deviated from the recommended track. Lack of monitoring by bridge teams when a pilot is on board, and inadequate communications between the pilot and the bridge team are serious issues the TSB has identified in previous investigations (M12L0147, M13L0123). If bridge team members do not continue to actively participate in the monitoring of the vessel’s progress when a pilot is on board, there is a risk that errors in navigation may go undetected.

In the case of the Vachon, the investigation ascertained that the company was not regularly testing the tow-abort mechanism to ensure it was fully operational under its maximum tension. Lloyd’s Register, which was delegated by Transport Canada (TC) to conduct inspections of the vessel, was not consistently inspecting the towing equipment. Further, these omissions were not detected by TC compliance inspections.

A safety management system (SMS) is used to ensure safe practices in vessel operations and to promote a safe working environment. In this case, the Vachon did not have an SMS, nor was the vessel required to have one by regulation; therefore, certain potential hazards associated with the towing equipment had not been assessed. Safety management and oversight is an issue on the TSB’s Watchlist—which is a list of issues that pose the greatest risk to Canada’s transportation system. The Board has been calling on TC to implement regulations requiring all operators to have formal safety management processes and for TC to oversee these processes.

On 13 November 2015, TC issued a notice that was sent to all TC inspectors and recognized organizations reminding them of the regulatory requirements concerning tow-abort equipment. For their part, Lloyd’s Register has adjusted its inspection checklists requiring surveyors to examine the emergency release arrangements for towing equipment.

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Edmonton, Alberta, 22 December 2015 – In its investigation report (R14E0081) released today, the Transportation Safety Board of Canada (TSB) found that inadequate track conditions led to the June 2014 derailment of a Canadian National Railway (CN) freight train near Faust, Alberta. There was no release of product, and no injuries. Approximately 1200 feet of track was damaged.

On 11 June 2014, the last 20 cars of eastbound CN freight train 418 derailed at Mile 202.3 of the Slave Lake Subdivision. The 20 derailed cars included 17 Class 111A tank cars, which contained diesel fuel residue. The train was made up of 4 locomotives, one of which was isolated, and 126 cars (105 loaded cars, 4 empty cars and 17 residue tank cars). Among the 105 loaded cars were 20 loaded cars of petroleum crude oil (UN 1267).

The investigation determined that the derailment occurred when the track shifted laterally under the passing train due to irregular and insufficient rail anchoring, unstable subgrade and a build-up of stress in the rail generated by the train descending the grade. The investigation also highlighted that the stress had likely accumulated in the track due to repeated exposure to braking forces from previous eastbound trains on the long descending grade.

Following the July 2013 accident in Lac-Mégantic, Quebec, the TSB issued a recommendation (R14-02) pertaining to the need for the railways to do better planning and on-going risk assessments for the movement of dangerous goods. Subsequent to the recommendation, Transport Canada (TC) issued emergency directives with respect to the Rail Transportation of Dangerous Goods which defined “Key Train” and “Key Route”. The response to this recommendation is currently rated as Satisfactory Intent.

Since 2013, there had been a significant increase in traffic levels over the Westlock and Slave Lake Subdivisions. The Slave Lake and Westlock Subdivisions met the criteria established for Key Route; and in this occurrence, train 418 met the criteria for a Key Train.

During spring/summer 2014, there were 6 derailments in the area, including this occurrence, all of which involved track related failures. With the significant traffic increase on this corridor since 2013, in advance of the recommended infrastructure improvements, the condition of the track could not handle the increased traffic. If the impact of increased traffic levels on track infrastructure is not adequately assessed or mitigated, the risk of derailments will increase.

After the June 2014 derailment, CN performed a risk assessment for the Edmonton-Hay River Corridor, which includes the Slave Lake Subdivision. The number of ultrasonic and geometry testing programs were increased and 2 new hot box detectors were added to the Slave Lake Subdivision.

The transportation of flammable liquids by rail has been identified as a risk to Canada's transportation system and it is included on the TSB's Watchlist.

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Winnipeg, Manitoba, 21 December 2015 – The Watchlist issue of risk of collisions on runways is highlighted as the Transportation Safety Board of Canada (TSB) today released its investigation report (A14C0112) into the August 2014 runway incursion at the Winnipeg James Armstrong Richardson International Airport in Winnipeg, Manitoba. There were no injuries, and no damage to aircraft or airport property.

On 4 August 2014, the ground controller at the Winnipeg International Airport cleared a WestJet DHC-8 operating as WestJet Encore Ltd. to taxi for departure via Runway 31 and to hold short of Runway 36. The DHC-8 crew acknowledged the clearance to hold short of Runway 36. The tower controller then observed that the DHC-8 had entered the Runway 36 protected area at the intersection of Runway 31. The tower controller then instructed a WestJet Boeing 737, which was on final approach for Runway 36, to conduct a go-around. The Boeing 737 followed the instructions to conduct a go-around, and subsequently landed without further incident.

The TSB investigation found that the hold-short line painted on Runway 31 was significantly degraded, with 123 feet of the line missing. The crew of the DHC-8 was actively looking for the hold-short line as the primary reference for the hold-short position and was slowing the aircraft. They did not see it and stopped in the runway protected area. The investigation also concluded that the daily airport inspections did not identify the degraded condition of the hold-short line, allowing the continued use of the hold-short position. Further, the orientation of the runway holding position signs was optimized for traffic on Runway 31, which likely contributed to the pilots not identifying the hold-short position.

The risk of collisions on runways has been identified as one of the risks to Canada's transportation system and is included on the TSB's 2014 Watchlist. The Board is calling for the implementation of improved procedures and enhanced collision warning systems at Canada's airports.

Following the occurrence, the Winnipeg Airport Authority Inc. (WAA) repainted the degraded hold-short line on Runway 31 and realigned the runway guard lights. The WAA has also incorporated new procedures for return to service inspections and computer-based inspection tracking software that contains checklists and intervals for inspections.

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Québec, Quebec, 7 December 2015 – In its investigation report (A13H0002) released today, the Transportation Safety Board of Canada (TSB) determined that a strong probability of a lack of visual cues to judge altitude led to the fatal September 2013 crash of a Canadian Coast Guard (CCG) Messerschmitt-Bölkow-Blohm BO 105 helicopter in the M’Clure Strait, Northwest Territories.

On 9 September 2013, at 1638 Mountain Daylight Time, the helicopter took off from the CCG vessel Amundsen for a combined ice measurement and reconnaissance mission in the M'Clure Strait, with the pilot, ship's master and a scientist aboard. At 1738, the helicopter informed the Amundsen that it would return to the vessel in 10 minutes; however the helicopter did not arrive at its intended time. At 1805, the helicopter's position was checked on the flight following system, which displayed it as being 3.2 nautical miles from the vessel. At 1818, the Amundsen's crew attempted several times to communicate with the helicopter without success and soon after proceeded to the helicopter's last position. Debris was spotted and the three occupants were recovered. None survived. The helicopter sank in 458 metres of water and was recovered 16 days later.

The investigation found that there was a strong probability that a lack of visual cues to judge altitude while flying low over open water, combined with the possibility of pilot distraction, resulted in the loss of altitude and the collision with the water. The three occupants likely drowned due to cold incapacitation, as none of them were supported in a way to keep their airways above the water line. Further, the search and rescue operation from the Amundsen was delayed, as the vessel's crew was inadequately trained to use and interpret information from the flight following system. The flight following system also did not provide an aural warning to alert the vessel's crew immediately that the helicopter was no longer transmitting position reports. The investigation also found numerous factors as to risk, including deficiencies related to the proper usage and wearing of survival suits by flight crews, packing of personal flotation devices, egress training, and operational and regulatory oversight.

The helicopter was not equipped with a flight data recorder or cockpit voice recorder, nor was it required to by regulations. Had the aircraft been equipped with these systems, investigators would have been able to better understand the circumstances and events that led to the accident. The Board has an outstanding recommendation (A13-01) for the implementation of flight data monitoring and the installation of lightweight flight recording systems by commercial air operators not currently required to carry these systems. The current Board assessment is Satisfactory Intent.

Following the occurrence, Transport Canada Aircraft Services Directorate introduced additional risk management measures for low-level helicopter flights and shipboard operations. New survival equipment including survival suits and personal flotation devices were also introduced. Additionally, a new fleet of helicopters to replace the BO 105 was acquired. The new fleet is equipped with automatic float deployment, externally mounted life rafts, cockpit voice recorders and flight data recorders, among other safety enhancements. For its part, the CCG revised and clarified instructions for the flight following system and introduced new policies requiring the use of dry-type immersion suits with appropriate thermal protection for helicopter operations in the Arctic.

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Ottawa, Ontario, 2 December 2015 – The Transportation Safety Board of Canada (TSB) investigation (R13T0192) into the September 2013 collision between an OC Transpo bus and a VIA Rail train in Ottawa, Ontario, identified numerous contributory factors including company practices, work-related driving distractions, speed, the configuration of the Transitway, and bus crashworthiness. As a result of the collision, the train derailed and the bus was extensively damaged. Six people, including the bus driver, died, and 34 passengers sustained injuries. There were no injuries to the crew or passengers on the train.

On September 18, 2013, at 0847:27, OC Transpo double-decker bus No. 8017, operating as Express Route 76, left the Fallowfield Bus Station in South Ottawa enroute toward downtown Ottawa along the Transitway. Around the same time, the automatic warning devices, consisting of flashing lights, bells and gates at the Woodroffe Avenue and Transitway railway crossings were activated and fully functional.

Meanwhile, VIA Rail passenger train No. 51 was approaching these crossings. The train was within normal operating parameters and slowing down to approach the Fallowfield train station. When the train crew realized that the bus would not stop in time, the emergency brakes were activated. About 3 seconds before impacting the train, the bus driver released the throttle and applied the brakes 35.6 metres away from the point of collision. The accident occurred at 0848:06, just 39 seconds after the bus left the passenger terminal.

“This complex investigation identified 15 inter-related findings that played a part in this tragedy,” said Kathy Fox, Chair of the TSB. “Remove even one, and this may have had a very different outcome. But because of this accident, we are calling for concerted action to reduce the risk of railway crossing accidents.”

The main question focused on “Why didn’t the bus driver see the train and stop in time?” The investigation determined that, while accelerating toward the railway crossing, the bus was negotiating a significant left curve in the road. The driver’s view of the crossing was obstructed, and there was only a short time when the activated crossing signals were visible to the driver. During this critical time, the driver was also distracted by surrounding conversations about seating on the upper deck, and by the perceived need to monitor the upper deck on a small screen that was positioned up and to the left of the driver’s seat and to make an announcement about no standing on the upper deck. At the speed the bus was travelling, the driver was unable to stop in time, even after passengers began to shout “stop”.

“Given the same circumstances, this accident could have happened to just about any driver,” said Rob Johnston, the Investigator-in-charge.

To address the major safety deficiencies identified in the investigation, today, the Board is issuing five recommendations aimed at reducing the risks. The recommendations deal with the installation and use of in-vehicle video displays, crashworthiness standards, data recorders for commercial passenger buses, and grade separations at busy railway crossings, both in Ottawa and across Canada.

“Every day, vehicles and trains interact at thousands of railway crossings across Canada,” added Chair Fox. “The number of crossing accidents remains too high; that’s why it’s on the TSB’s Watchlist. Whether it’s a busy street or a country road, people need to understand that railway crossing safety is a responsibility shared by the regulator, transit operators, road authorities, bus manufacturers, and also vehicle drivers. Drivers need to slow down and be prepared to stop as if there were always a train approaching.”

See investigation page for more information.

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Ottawa, Ontario, 30 November 2015 - The Transportation Safety Board of Canada (TSB) will hold a news conference on 2 December 2015, to make public its report (R13T0192) on the investigation into the September 2013 collision between an OC Transpo bus and a VIA Rail train in Ottawa, Ontario.

When:

Wednesday, December 2, 2015 at 11:05 a.m. ET

Where:

Poliquin Room, 1st floor
John G. Diefenbaker Building (former Ottawa City Hall)
111 Sussex Drive
Ottawa, Ontario

Who:

Kathy Fox, TSB Chair
Hélène Gosselin, TSB Board Member
Rob Johnston, Investigator-in-Charge

This event is for media only. Media representatives will need to show their outlet identification.

The news conference will be live on WebEx. To access the broadcast of the news conference, click the following address:

Join TSB news conference online
Meeting Number: 556 403 309
Meeting Password: TSBBST1

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
Telephone: 819-994-8053
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

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Edmonton, Alberta, 26 November 2015 – In its investigation report (R14C0142) released today, the Transportation Safety Board of Canada (TSB) determined that a broken heel block assembly led to the derailment of a Canadian Pacific Railway (CP) freight train that destroyed the bridge over 40 Mile Creek near Banff, Alberta, on 26 December 2014. Derailed cars loaded with fly ash, soybeans and lentils were breached, spilling product into the waterway. No initial injuries were reported; however, a crew member sought medical attention for fly ash inhalation.

The investigation revealed that the westbound CP train derailed 15 cars at Mile 82.1 on the Laggan Subdivision, when the end of the north switch point rail fractured in the heel block assembly. The heel block assembly had been weakened due to looseness in the joint, occurring over time under train traffic. Although the regular, detailed, and visual track inspections were performed in compliance with regulatory and railway requirements, they did not specifically identify the deteriorating condition of the heel block assembly.

The investigation determined that if loose joints cannot be identified in a timely manner, particularly in the vicinity of switches (i.e., heel block area), the resulting relative movement in the joint will increase over time, increasing the risk of cracks in the rail leading to broken-rail derailments. It also highlighted the need for crew members to discuss hazards associated with the commodities carried, prior to, or during, an inspection of derailed cars, in order to address the risk to crew members and other emergency responders.

Following the accident, Transport Canada requested that the railway industry formulate rules with regards to joint bar inspections and repairs in continuous welded rail territory.

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