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Transportation Safety Board of Canada

Transportation Safety Board of Canada (301)

Whiteout conditions and loss of situational awareness led to February 2013 Cessna crash in Waskada, Manitoba

Winnipeg, Manitoba, 17 February 2014 – The Transportation Safety Board of Canada (TSB) today released its investigation report (A13C0014) into the February 2013 collision with terrain of a Cessna 210C in Waskada, Manitoba.

At approximately 1230 Central Standard Time on 10 February 2013, the privately-registered Cessna 210C departed Waskada with a pilot and 3 passengers on board for a sightseeing flight in the local area. Approximately 30 minutes after the aircraft departed, fog moved into the area. At 1317, an emergency locator transmitter signal was received in the area. A search was undertaken; the wreckage was located 3 nautical miles north of Waskada. All occupants suffered fatal injuries.

The investigation determined that the terrain, coupled with the reported meteorological conditions, was conducive to whiteout, a winter atmospheric optical phenomenon in which the observer appears to be engulfed in a uniformly white glow. Whiteout conditions may result in a poorly defined visual horizon that will reduce the pilot's ability to visually detect changes in altitude, airspeed and position. If visual cues are sufficiently degraded, the pilot may lose control of the aircraft or fly into the ground.

Furthermore, the investigation found that the accident occurred in an area of gently rolling hills, which were completely covered in snow. The Board therefore concluded that the pilot likely flew inadvertently into a whiteout, lost situational awareness and lost control of the aircraft, which resulted in an impact with terrain.

Collisions with land and water are a TSB Watchlist issue. Watch the TSB video!

Published in Transportation Safety Board of Canada
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Watchlist issue highlighted in 2012 runway overrun in St. John's, Newfoundland and Labrador

Dartmouth, Nova Scotia, 18 February 2014 – The Transportation Safety Board of Canada (TSB) today released its investigation report (A12A0082) into the August 2012 runway overrun of a Volga-Dnepr Airlines aircraft in St. John's, Newfoundland and Labrador. Landing accidents and runway overruns have been identified as an issue on the TSB Watchlist.

On 13 August 2012, an Ilyushin IL-76TD-90VD, a four-engine heavy-cargo transport aircraft, departed Prestwick, Scotland, for St. John's International Airport, Newfoundland and Labrador, with 10 crew members on board. Following touchdown on Runway 11, the crew was unable to stop the aircraft prior to the end of the runway. The aircraft came to rest in the grass, with the nose wheel approximately 640 feet beyond the end of the runway surface. There were no injuries, and aircraft damage was limited to cuts and localized rubber melting on the main landing gear tires.

The investigation found that a combination of factors contributed to the runway overrun. The tail wind and insufficient reduction of engine power on landing resulted in a longer than normal touchdown on the runway. The excessive tread wear on all 16 main landing gear tires and a wet runway resulted in hydroplaning, which reduced effective braking capability. An incorrect brake line installation further reduced the aircraft's braking capability, thereby increasing the distance required to stop the aircraft.

Following the occurrence, the St. John's International Airport Authority performed texture improvement work on runways 11/29 and 16/34 using specialized equipment to improve friction.

Volga-Dnepr Airlines is working with Tashkent Aircraft Production Company to resolve the discrepancy in the brake line installation. The airline also introduced requirements that flight crews monitor the heading and wind speed and that a go-around be carried out whenever the tail wind limitations have been exceeded. It also requires the captain to decide on using reverse thrust on all 4 engines in special cases.

Published in Transportation Safety Board of Canada
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Aircraft spin caused the 2012 Cessna crash in Moorefield, Ontario

Richmond Hill, Ontario, 20 February 2014 – The Transportation Safety Board of Canada (TSB) today released its investigation report (A12O0138) into the August 2012 collision with terrain of a Cessna 172S in Moorefield, Ontario.

At 1815 Eastern Daylight Time on 24 August 2012, a Cessna 172S, owned by the Waterloo-Wellington Flying Club (WWFC), departed the Kitchener/Waterloo Airport, Ontario. The aircraft flew to Niagara Falls, then to Toronto, and back to a practice area north of the Kitchener/Waterloo airport. At approximately 2016 Eastern Daylight Time, the aircraft crashed into a field, 25 nautical miles north of the airport. The aircraft was destroyed; the pilot and 3 passengers were fatally injured.

The investigation determined that the aircraft entered a spin in a configuration for which spins were not authorized and that the aircraft did not recover prior to ground impact. The investigation also found that there was a breach in the aerodynamic stall warning horn, but the effect on the operation of the horn could not be determined. A spin manoeuver is preceded by a stall, and a damaged horn may activate too late or not at all, increasing the risk that pilots are not warned of an impending aerodynamic stall in a timely manner.

Since this occurrence, WWFC has implemented some changes to its flight program. It has re-emphasized to pilots its policies regarding air manoeuvers, such as spins, to be conducted only with an instructor on board, and strengthened its ground school programs regarding airwork. Also, WWFC has indicated that it will have GPS trackers as well as cockpit voice recorders installed in its fleet of aircraft.

Published in Transportation Safety Board of Canada
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Loss of situational awareness contributed to 2012 aircraft crash near Pickle Lake, Ontario

Winnipeg, Manitoba, 27 February 2014 – The Transportation Safety Board of Canada (TSB) today released its investigation report (A12C0141) into a collision with terrain of a privately-registered aircraft near Pickle Lake, Ontario.

On 16 October 2012, the Aerofab Inc. Lake 250 aircraft was on a flight from Lac La Biche, Alberta, to Trois-Rivières, Quebec, with planned stops in The Pas, Manitoba, and Pickle Lake, Ontario. There were two pilots and two passengers on board. That evening, while conducting a visual approach landing in Pickle Lake, the aircraft entered a steep descent and struck terrain approximately one nautical mile east of the runway. Both pilots and one passenger were fatally injured. The surviving passenger sustained minor injuries. The aircraft was destroyed on impact and the emergency locator transmitter was activated. There was no post-crash fire.

The investigation found that the dark environment to the east of the airport, the lack of visual cues and the low intensity runway light setting likely contributed to a loss of situational awareness as to the aircraft's relative position from the runway and the rate of descent. This loss likely led to the pilots not taking measures to correct the aircraft's high rate of descent prior to its collision with terrain.

Published in Transportation Safety Board of Canada
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Direct approach and ineffective communication lead to 2012 striking of trestle in Roberts Bank, British Columbia

Richmond, British Columbia, 4 March 2014 – The Transportation Safety Board of Canada (TSB) today released its investigation report (M12W0207) into a terminal striking by bulk carrier Cape Apricot in Roberts Bank, British Columbia (BC).

At 0045 Pacific Standard Time on 7 December 2012, the bulk carrier Cape Apricot, while under the conduct of a pilot and assisted by two tugs, struck the causeway and conveyor system at the Roberts Bank terminal. As a result of the impact, the causeway and conveyor collapsed into the water, and the vessel's bow sustained damage. There was minor pollution and no injuries.

In this occurrence, the pilot and master discussed the vessel's passage and completed the necessary documentation for the pilot-master exchange. However, the investigation found that the Cape Apricot's course to Roberts Bank placed the vessel in a direct line of approach to the trestle. This path required a tight alteration of course to starboard, but given the vessel's speed and direct approach, the Cape Apricot's turn to starboard was neither timely nor sufficient, and the vessel struck the trestle.

As the vessel approached the basin, the master did not seek clarification or question the pilot. Nor had the pilot established or communicated any abort points. Without effective communication regarding their shared mental model during the approach, the master and the pilot did not identify the developing risk as the manoeuvre progressed, and did not take timely corrective action.

On the west coast of Canada, responsibility for the operation, maintenance and administration of pilot services for compulsory pilotage areas lies with the Pacific Pilotage Authority (PPA). However, the PPA does not directly employ pilots, other than those operating in the Fraser River. Rather, the PPA contracts the British Columbia Coast Pilots, Ltd. (BCCP) to provide pilotage services for vessels along the BC coast.

A safety management system (SMS) enables risks to be identified, analyzed and mitigated. Neither the PPA nor the BCCP has a comprehensive SMS. The investigation determined that neither the PPA nor the BCCP has:

  • a formal risk assessment process;
  • an accident/incident review process;
  • for pilots to ensure bridge resource management best practices are in place throughout a voyage.

Without an SMS in place, pilotage organizations may not properly identify hazards and mitigate them, thereby placing vessels at risk. Many TSB reports have emphasized the advantages of SMS in the marine industry.

Published in Transportation Safety Board of Canada
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TSB is concerned about TC oversight of new passenger safety regulations as part of Jiimaan grounding investigation

Gatineau, Quebec, 10 March 2014 – In its investigation report into the 2012 grounding of the passenger and vehicle ferry Jiimaan in Kingsville, Ontario, released today, the Transportation Safety Board of Canada (TSB) identified issues with the coordination of safety-critical activities in the port, the company's safety management system and passenger emergency preparedness, and with Transport Canada's (TC) oversight of recent regulatory amendments related to passenger safety.

On 11 October 2012, the Jiimaan was travelling from Pelee Island to Kingsville, Ontario with 18 passengers and 16 crew aboard. The crew planned to sail parallel to and east of the charted channel leading to Kingsville Harbour to avoid an obstruction in the channel marked by a buoy. They had intended to sail very close to the buoy, alter to port and then make a sharp turn to starboard to dock the vessel; however, winds pushed the vessel to starboard, further from the buoy, and the vessel ran aground 130 metres from the Kingsville Harbour entrance. The Canadian Coast Guard was dispatched to assist the Jiimaan, but an evacuation could not be safely carried out due to weather. The following day, the Jiimaan was refloated and escorted to Leamington, where the passengers were disembarked. There were no injuries, no pollution and no damage to the vessel.

The investigation found that the company’s safety management system (SMS) did not include a risk assessment process. As such, the risks associated with deviating from the charted channel to avoid the obstruction were not adequately identified and mitigated. It also found that there was a lack of coordination between the organizations involved in safety-related port activities, specifically with regards to communicating information about the buoy’s position and the extent of the channel obstruction due to silting with those responsible for maintaining charts and aids to navigation.

In addition, investigators identified deficiencies with passenger emergency preparedness in this occurrence. TC enacted new regulations in 2010 requiring vessels to have procedures in place to account for all passengers during an emergency and to conduct realistic emergency drills. The Jiimaan’s emergency procedures did not have the measures required by the new regulations.

The investigation also found that TC inspectors are not required to assess the passenger emergency preparedness procedures, nor are there any guidelines published to help the industry and inspectors interpret and comply with the new regulations. Because of this, the Board is concerned that the potential safety benefits of the new regulations may be negated.

Since the occurrence, the TSB issued a safety advisory letter to the Department of Fisheries and Oceans regarding the accuracy of the chart for the Port of Kingsville. It also issued a safety advisory letter to the Jiimaan’s operator concerning the implementation of passenger safety procedures and drills aboard its vessels. The vessel’s operator has since implemented improved passenger emergency procedures, new water level monitoring procedures and improved navigation procedures.

Published in Transportation Safety Board of Canada
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TSB modernizes transportation safety regulations

Gatineau, Quebec, 12 March 2014 – The Transportation Safety Board of Canada (TSB) today announced modernized regulations governing the reporting and investigation of occurrences in Canada's transportation sector. The Transportation Safety Board Regulations, published today in the Canada Gazette, Part II, are clearer and easier to understand.

TSB factsheets

“The transportation industry and its legislation have evolved a great deal since the Regulations were first introduced 22 years ago,” explained Wendy Tadros, Chair of the TSB. “The changes announced today bring the Regulations up-to-date and take better advantage of electronic information sharing.”

The Regulations strengthen the rules governing accident reporting in Canada, introducing additional requirements for railways, the release of dangerous goods, and lighter aircraft. Among key changes are measures to:

  • Re-organize the Regulations from six sections to two;
  • Modernize and introduce definitions that are harmonized with other federal legislation, international agreements and standards;
  • Clarify provisions that had been subject to misinterpretation;
  • Formalize existing investigation policies and procedures; and
  • Allow witnesses to be accompanied by one representative of their choice during TSB interviews.

In developing these Regulations, the TSB consultedwith the public, regulators, provincial governments, industry associatio ns and transportation companies. Part I, which addresses accident reporting, comes into effect on 1 July 2014. Part II of the Regulations takes immediate effect.

Consult TSB factsheets for further details about the Transportation Safety Board Regulations.

Published in Transportation Safety Board of Canada
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The Transportation Safety Board of Canada will hold a news conference to release its investigation report into the accident involving First Air flight 6560 in Resolute Bay, Nunavut

Gatineau, Quebec, 21 March 2014 – The Transportation Safety Board of Canada (TSB) will hold a news conference to release its investigation report into an accident involving First Air flight 6560, which struck a hill about 1 mile east of the runway at Resolute Bay, Nunavut, on 20 August 2011. The Board and the Investigator-in-Charge will make public the findings of the investigation.

Tuesday, 25 March 2014, 11 a.m.
Library Room, 1st floor
John G. Diefenbaker Building (former Ottawa City Hall)
111 Sussex Drive
Ottawa, Ontario
Kathy Fox, Board Member
Joseph Hincke, Board Member
Brian MacDonald, Investigator-in-Charge

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

Copies of the report will be available electronically on a USB key.

The news conference will be webcast live.

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

Published in Transportation Safety Board of Canada
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TSB highlights worldwide problem with unstable approaches and calls for improved crew communications following 2011 crash in Resolute Bay, Nunavut

Gatineau, Quebec, 25 March 2014 – During today's release of its investigation report (A11H0002) into the August 2011 fatal accident involving First Air flight 6560 in Resolute Bay, Nunavut, the Transportation Safety Board of Canada (TSB) called on Transport Canada and the airline industry to reduce unstable approaches that are continued to a landing, and to improve crew communications.

On 20 August 2011, a Boeing 737-210C, operated by First Air, was being flown as a charter flight from Yellowknife, Northwest Territories, to Resolute Bay, Nunavut, when it struck a hill about 1 nautical mile east of the runway. The accident claimed the lives of all 4 crew members and 8 of the passengers, and left 3 passengers seriously injured.

The investigation concluded that a combination of factors contributed to the accident. The aircraft did not intercept the runway localizer (alignment) beam, and instead diverged to the right, and ultimately hit a hill. Fundamental to the Board's findings is the fact that an unstable approach was continued to a landing. “Too many unstable approaches continue to a landing, and this is an international problem,” said Board Member Joseph Hincke. “If we want to see fewer landing accidents, we have to tackle this issue now.”

Central to the TSB findings was that, although the 2 pilots were aware they were off course, they each had a different understanding of the situation and did not take corrective action in time. Effective crew resource management (CRM) training and procedures help crews manage workload in the cockpit and communicate effectively to make better decisions and solve problems. “Although Transport Canada is taking steps to update the CRM training standards, the Board is concerned that a comprehensive and integrated approach to monitoring and reinforcing best practices is still needed,” added Board Member Kathy Fox. “To advance aviation safety in Canada, the TSB is seeking stronger defences to reduce unstabilized approaches, and measures to improve crew communications.”

This accident involves one of the issues on the TSB Watchlist: Collisions with land and water. The Watchlist is a list of transportation safety issues that pose the greatest risk to Canadians. In each case, action to date has been inadequate, and concrete steps must be taken on the part of the regulator and industry to eliminate these risks.

An animation of the sequence of events has been released as part of this investigation. See the active investigation page for complete details of this investigation.

Published in Transportation Safety Board of Canada
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Partially obstructed view and other driver challenges at passive level crossing contributed to 2012 vehicle–train collision in Broadview, Saskatchewan

Winnipeg, Manitoba, 26 March 2014 – Citing concerns that the risk of accidents at passive public railway crossings will continue in the absence of advance warning systems, the Transportation Safety Board of Canada (TSB) today released its investigation report (R12W0182) into a fatal crossing accident in Broadview, Saskatchewan.

At 1835 Central Standard Time on 9 August 2012, a Canadian Pacific Railway freight train 205-09 was proceeding westward at 53 mph when it struck a southbound camper van at a passive public crossing, equipped only with standard reflectorized railway crossing signs (SRCS), near Broadview, Saskatchewan. As a result of the collision, the camper van was destroyed, 4 of the 6 vehicle occupants were fatally injured, the novice driver was seriously injured, and the supervising driver sustained minor injuries. The train crew was not injured, and the locomotive sustained minor damage.

The investigation determined that the train approached the crossing from the east with the locomotive headlights, ditch lights and horn all activated as required. The train and van approached the crossing on roughly parallel, albeit opposing, paths. Vegetation along the railway right-of-way limited the view of the van from the train crew and the train from the vehicle occupants. The collision occurred when the westbound van turned south onto Airport Road, approached the crossing, proceeded into the path of the train, and was struck broadside. A partially obstructed view, the position of the sun, the vehicle characteristics, the driver's limited experience with the risks associated in negotiating a passive public crossing protected solely by SRCS, and the fatigued state of the supervising driver likely contributed to the accident.

Over the last 10 years in Canada, there have been 658 accidents involving vehicles at passive public crossings, which resulted in 59 fatalities and 107 serious injuries. While the crossing was not equipped with a stop sign, studies have demonstrated that stop signs do not always provide an effective defence because compliance is subject to frequent enforcement. Research indicates that a key to improving safety is to equip these crossings with lower-cost advance active warning devices, such as those using GPS, magnetic flux and radar to detect approaching trains, in order to attract driver attention and provide them with advance warning of the need to stop.

Considering the serious consequences that can result from a crossing accident, and the technological advancements that have been made, the Board is concerned that, in the absence of timely implementation of low-cost alert systems, the risk of accidents at passive crossings will continue.

Published in Transportation Safety Board of Canada
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