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Transportation Safety Board of Canada

Transportation Safety Board of Canada (462)

Québec, Quebec, 7 December 2016 – Following its assessment of the collapse of the platform and gangway at the wharf in Sainte-Rose-du-Nord, Quebec, in September (occurrence number M16C0146), the Transportation Safety Board of Canada (TSB) is publishing a Marine Safety Information Letter today.

On 7 September 2016, at about 1130 Eastern Daylight Time, the passenger vessel Fjord Saguenay II docked at the marina in Sainte-Rose-du-Nord, Quebec, to board passengers for a cruise on the river. The vessel’s chief officer authorized the passengers, who were waiting on the dock, to begin boarding by using the platform and the gangway. At around 1140, the platform came away from the dock, taking the gangway with it and falling approximately eight metres. Several passengers who were standing on the gangway at the time of the occurrence sustained injuries.

The investigation revealed that the platform connecting the gangway to the dock had been fastened with lag screws to a piece of treated lumber, which was affixed to the dock with bolts. The piece of treated lumber holding the lag screws was in poor condition and, as a result, the screws were torn from their footings. No periodic maintenance or inspection of the platform or fastening system had been performed since it was first installed in 2011.

The assessment of the occurrence was unable to identify any existing municipal or provincial regulations referring to the periodic maintenance or inspection of this type of installation during its life cycle. The TSB has sent a Marine Safety Information Letter about this occurrence to the mayor of the municipality of Sainte-Rose-du-Nord. A copy of this letter has been sent to the Fédération québécoise des municipalités, the Union des municipalités du Québec, the Ordre des ingénieurs du Québec and the Federation of Canadian Municipalities to raise their awareness of the risks of such installations.

See the investigation page for more information.

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Dartmouth, Nova Scotia, 30 November 2016 – In its investigation report (A15A0045) released today, the Transportation Safety Board of Canada (TSB) determined that a degraded level of situational awareness contributed to the fatal helicopter accident near Rigolet, Newfoundland and Labrador, in July 2015. One passenger sustained fatal injuries, the pilot sustained serious injuries, and the other passenger sustained minor injuries.

On 30 July 2015, an Airbus Helicopters AS 350 BA, operated by Canadian Helicopters Limited (CHL), was flying to a remote microwave tower site approximately five nautical miles west-southwest of Rigolet, Newfoundland and Labrador, with a pilot and two passengers on board. The pilot had flown with these passengers often and they had been working together at other tower sites on the previous three days. After the passengers carried out the site maintenance as planned, the pilot began preparing for the return flight. At about 1609 Atlantic Daylight Time, the helicopter lifted off from the helipad and, while flying forward, struck one of the tower's outer guy wires with the main rotor. The helicopter struck the ground and settled on its upper right side. The helicopter was destroyed.

The investigation determined that the pilot did not note the outer guy wires and did not include them in the departure plan. The pilot's lower level of attention while conducting a routine flight led to an ineffective visual scan resulting in degraded situational awareness.

Following this occurrence, the helipad at Moliak was moved outside of the circumference of the outer guy wire anchor points. Bell Aliant also collaborated with CHL to conduct reviews of all Labrador tower sites to identify hazards. CHL has also adopted the policy of conducting an overhead inspection flight prior to landing at any Bell Aliant site.

See the investigation page for more information.

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Saskatoon, Saskatchewan, 16 November 2016 – In its investigation report (R14W0256) released today, the Transportation Safety Board of Canada (TSB) determined that a broken rail, due to an undetected defect, led to the October 2014 derailment of a Canadian National Railway (CN) freight train near Clair, Saskatchewan. There were no injuries, although a flash fire during the emergency response put CN emergency responders at risk.

On 7 October 2014, a CN freight train proceeding westward from Winnipeg, Manitoba, destined to Edmonton, Alberta, derailed 26 cars, including six Class 111 tank cars loaded with dangerous goods, near Clair, Saskatchewan. Two of the tank cars, which were loaded with petroleum distillates, released product that subsequently caught fire. As a precaution, 50 residents within a five-mile (8 km) radius were evacuated and Provincial Highway 5 was closed. Approximately 650 feet of track was destroyed.

This investigation identified risk factors related to the transportation of flammable liquids by rail, and safety management and oversight as outlined in the TSB Watchlist. Two of the Class 111 tank cars released product, and the damage to these cars was consistent with failures noted by the TSB in other investigations. The TSB made recommendations (R14-01 and R14-02) to address these issues as part of the Lac-Mégantic investigation.

The investigation determined that the train derailed when a sudden and catastrophic failure of one of the rails occurred under the train, due to the presence of an undetected defect. Poor rail surface conditions had masked the presence of this defect and reduced the effectiveness of visual inspections and ultrasonic inspections. Including this occurrence, the TSB has investigated seven occurrences in the past 10 years involving a rail break due to a pre-existing rail defect that was not detected by ultrasonic testing.

During the emergency response, CN emergency responders were flaring (igniting) the contents of one of the breached tank cars that had overturned and released product which pooled on the soil below the tank car. A flash fire occurred when the vapors inside the tank car ignited, sending a large fireball towards the two emergency responders who were carrying out the flaring activity. Both emergency responders took immediate evasive action to avoid the flash fire, which quickly extinguished itself.

The investigation found that CN emergency responders, who were likely fatigued, did not consider all the risks associated with the flaring activity prior to igniting the pool of product released from the tank car. CN did not document the close-call during the flaring activity or proactively share the information with any outside agencies, highlighting gaps in CN's reporting and/or procedures.

The investigation also identified deficiencies in provincial incident commander training, emergency response activity monitoring and post-response follow-up.

“If company and industry guidance is not followed and close-calls during emergency response activities are not properly documented and openly shared among all responding agencies, similar circumstances could occur, putting emergency response personnel at risk,” said TSB manager and lead investigator Rob Johnston.

Following the occurrence, CN improved procedures for flaring tank cars and enhanced its documentation requirements for emergency response activities. The Saskatchewan Ministry of the Environment enhanced its procedures for ensuring that incident commanders are appropriately trained and site monitoring activities are established when responding to emergencies involving dangerous goods.

See the investigation page for more information.

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Richmond, British Columbia, 3 November 2016 – According to a Transportation Safety Board of Canada (TSB) investigation report (A15P0147) released today, the engine of a Beechcraft A36 Bonanza that force-landed on Highway 97 northeast of Osoyoos, British Columbia, in July 2015 lost power, likely because of fuel starvation due to vapour lock.

On 7 July 2015, at approximately 1645 Pacific Daylight Time, the privately operated Beechcraft A36 Bonanza (C-GPDK) departed Oliver Municipal Airport, British Columbia, with only the pilot on board for a flight to the Boundary Bay Airport. Approximately six minutes after takeoff, the aircraft suffered an engine power loss, and the pilot carried out a forced landing on Highway 97. The aircraft struck a truck and a power pole, and came to rest on the edge of the road. A post-impact fire consumed most of the aircraft. The pilot was able to get out of the aircraft, but sustained serious burns.

The investigation determined that the aircraft's engine was likely starved of fuel due to vapour lock, and lost power as a result. Vapour lock occurs when fuel, normally in liquid form, changes to vapour while still in the fuel delivery system. This change causes a reduction in pressure to the fuel pump, disrupts fuel flow, and can result in temporary or complete loss of engine power. The pilot had experienced fuel-flow fluctuations and power losses on previous flights with C-GPDK, but was able on those occasions to successfully regain normal power and engine operation. Those previous successes in regaining full engine power may have delayed the pilot's selection of a forced landing area. The nearest airport was then not an option, and Highway 97 was chosen as the next best emergency landing area.

Post-impact fires have been documented as a risk to aviation safety in previous TSB investigation reports. In 2006, the TSB issued a recommendation to reduce the number of post-impact fires in impact-survivable accidents. C-GPDK did not have, and was not required to have, any of the technologies, materials, or components identified in Recommendation A06-10. If aircraft are not fitted with crashworthy fuel-system components that retain fuel or with systems that eliminate ignition sources, the risk of injury or death due to post-impact fire is increased.

See the investigation page for more information.

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Ottawa, Ontario, 31 October 2016 — The Transportation Safety Board of Canada (TSB) released its latest safety Watchlist today, at the same time announcing a more proactive approach to engage government and industry leaders in dialogue and action that leads to safety improvements across Canada’s transportation network.

“No longer is it enough to point out a problem and wait for others to take notice,” said TSB Chair Kathy Fox. “In the next few days and weeks, we'll meet with key stakeholders to push for concrete action, and then we'll report publically on the results.”

This year's edition of the Watchlist, which identifies the key safety issues that need to be addressed in the air, marine, and rail sectors, features the addition of two new issues. “Fatigue has been a factor in numerous railway investigations, most notably regarding freight train operations,” said Fox. “Too many train crews aren't getting the rest they need, whether its shifts that are too long or irregular scheduling that interferes with normal sleep times. It's time for the railway industry to start applying fatigue science to crew scheduling, instead of calling for more studies.”

Fox said the second new issue is Transport Canada's slow progress addressing previous TSB recommendations, something that affects all aspects of the transportation network, with potentially adverse outcomes. “There are currently 52 TSB recommendations that have been outstanding for ten years or more. Over three dozen of those have been outstanding for more than twenty years,” she said. “There is no reasonable excuse for taking that long—especially in cases where TC agrees that action is needed.”

Fox added that “good intentions” on the part of the government aren't enough to reduce the very real safety risks that must be addressed. “If that were enough, the same accidents wouldn't keep happening and we wouldn't need a Watchlist.”

Eight of the ten issues on this year's Watchlist are holdovers from previous years. One previous issue, railway crossing safety, was removed from the list thanks to significant action on the part of Transport Canada, the railways and road authorities —including new grade-crossing regulations and a decline in the number of crossing accidents.

Of the other issues on this year's Watchlist, Fox said safety management systems have not yet been mandated in all sectors of the transportation industry, and TC must oversee them effectively. The safety culture in the fishing industry needs to change to prevent needless loss of life and injuries. In spite of strong safety measures taken by TC regarding transportation of flammable liquids by rail, the risk will persist in the system until the new tank car standards and effective risk controls are fully implemented. There still isn't a plan in place to implement physical defenses against railway signal indications not being followed. The railway industry is not reaping the safety benefits of on-board voice and video recorders in locomotive cabs. Airlines need to better track unstable approaches that continue to a landing to prevent accidents. While some airports are making runway ends safer to reduce the risk of runway overruns, there is no requirement to do so for all major airports. Lastly, the number of runway incursions is too high, which could lead to a catastrophic accident.

Watchlist 2016 issues

Multi-modal

Marine

Rail

Air

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

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

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

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

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

See the investigation page for more information.

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

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

Next steps

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

In the coming days and weeks, the team will:

  • Review drone images—filmed with the assistance of the RCMP
  • Examine components such as instrumentation and any device that contains non-volatile memory
  • Send selected wreckage to the TSB Laboratory in Ottawa for further analysis
  • Gather additional information about weather conditions
  • Gather information on air traffic control communications and radar information
  • Examine aircraft maintenance records
  • Examine pilot training, qualifications, proficiency records and medical history
  • Continue interviews with witnesses, the aircraft operator and others
  • Review operational policies and procedures
  • Examine the regulatory requirements
  • Create simulations and reconstruct events to learn more about the accident sequence (i.e., to validate data, test hypotheses, and verify assumptions)

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

Working with others

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

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

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

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

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

What we know

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

Work to date

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

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

So far, the team has:

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

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

Next steps

In the coming days, the team will also:

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

Communication of safety deficiencies

Investigations are complex and we take the time needed to complete a thorough investigation. However, should the investigation team uncover safety deficiencies that present an immediate risk, the Board will communicate them without delay.

Further, it is important not to draw conclusions or speculate as to causes at this time. There are often many factors that can contribute to an accident.

Additional updates will be provided as required.

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

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

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

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

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

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

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

See the investigation page for more information.

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

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

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

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

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

See the investigation page for more information.

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