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Transportation Safety Board of Canada

Transportation Safety Board of Canada (586)

Richmond Hill, Ontario, 11 July 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18O0002) on the January 2018 ground collision, fire and evacuation involving two Boeing 737-800 aircraft, on the Terminal 3 apron at Toronto/Lester B. Pearson International Airport in Toronto, Ontario.

The TSB conducted a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues.

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Québec, Quebec, 10 July 2018 – The Transportation Safety Board of Canada (TSB) released today its investigation report (M17C0035) into the April 2017 flooding aboard the fishing vessel L.K.C, near Sept-Îles, Quebec.

On 21 April 2017, at approximately 0330 Eastern Daylight Time, the engine room of the fishing vessel L.K.C flooded while the vessel was anchored 45 nautical miles east of Sept-Îles, Quebec. There were 4 crew members on board. The Canadian Coast Guard Ship Cap Rozier arrived on scene, helped pump out the water, and towed the vessel to Sept-Îles. There were no injuries or pollution.

The investigation found that the failure of the stern tube mechanical seal led to the flooding of the vessel. The high bilge-water alarm sounded only in the unmanned engine room. As such, the crew was unaware of the water ingress. Additionally, crew members did not detect the water ingress at an earlier stage, such as during an engine room inspection, as there was no consistent watchkeeping aboard the vessel while at anchor. Due to these factors, the water then rose to a level that rendered the vessel’s bilge pumps inoperative.

Following the occurrence, the owner of the L.K.C installed an additional warning device to sound in the wheelhouse when the high bilge-water alarm is triggered.

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Richmond Hill, Ontario, 9 July 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A17O0243) on the November 2017 hard landing of a Bombardier DHC-8-402 at Toronto/Billy Bishop Toronto City Airport in Ontario. There were no injuries.

The TSB conducted a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues.

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Dorval, Quebec, 5 July 2018 – The Transportation Safety Board of Canada (TSB) released today its investigation report (A17Q0050) into the April 2017 accident involving an aircraft that crashed about 3.5 nautical miles northwest of Schefferville Airport, Quebec. The report highlights the risks posed by low-altitude flying.

On 30 April 2017, a Piper PA-31 Navajo aircraft operated by Exact Air Inc. with two pilots on board was conducting its second survey flight of the day in an area 90 nautical miles northwest of Schefferville Airport, Quebec. These survey flights were conducted at 300 feet above ground level. During the return flight to Schefferville, the aircraft descended and flew over terrain at an altitude varying between 100 and 40 feet above ground level. The aircraft then struck power transmission wires and collided with terrain northwest of Schefferville Airport. Both pilots were fatally injured. There was no post-impact fire and no emergency locator transmitter (ELT) signal was detected.

The investigation found that sensation seeking, mental fatigue, and an altered risk perception very likely contributed to the pilot descending to an altitude of between 100 and 40 feet above ground level and maintaining this altitude until the collision with the wires. It is highly likely that the pilots were unaware that there were power wires 70 feet above the ground in their path. The pilot flying did not detect the power wires in time to avoid them, thus the aircraft collided with the wires.

Exact Air Inc. was unaware that the occurrence pilots had frequently flown at very low altitudes while transiting between survey areas and the airport. The occurrence aircraft was not equipped with a lightweight flight recording system, nor was it required to by regulation. In addition to providing investigators with information on the sequence of events prior to an occurrence, a lightweight flight recording system can also help a company conduct flight data monitoring and flight operation quality assurance programs, to ensure that pilots follow company procedures and operational limits. The TSB has recommended (A18-01) the mandatory installation of lightweight flight recording systems by commercial operators and private operators not currently required to carry these systems.

No ELT signal was detected following the accident, as the antenna and antenna cable were damaged. Current ELT standards do not require a crashworthy antenna system. As a result, there is a risk that potentially life-saving search-and-rescue services will be delayed if an ELT antenna is damaged. The TSB made recommendations to Canadian and international authorities (A16-02, A16-03, A16-04, A16-05) calling for rigorous ELT system crash survivability standards to improve the likelihood that ELT signals are received. The response to these recommendations has been assessed as “Satisfactory Intent.”

Following the occurrence, Exact Air Inc. conducted an awareness campaign and held meetings with company staff regarding the causes of the accident and the risks associated with low-altitude flying.

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Dorval, Quebec, 3 July 2018 – In its investigation report (A17Q0059) released today, the Transportation Safety Board of Canada (TSB) found that inadequate flight planning led to an aircraft colliding with runway lights after landing at the Montreal/St-Hubert Airport, Quebec.

On 15 May 2017, a U.S.-registered Bombardier Global Express aircraft was flying from Teterboro, New Jersey, to Montreal/St-Hubert Airport, Quebec, with three crew members and one passenger on board. The aircraft was cleared to land on Runway 06L at Montreal/St-Hubert Airport, which had been reduced in size to 75 feet wide and 5000 feet long due to construction work. At about 1055 local time, the aircraft touched down partially outside of the confines of the reduced-width runway, striking seven temporary runway edge lights. The pilot flying brought the aircraft back to the reduced-width runway centreline before coming to a stop 300 feet from the shortened runway end. There were no injuries but the aircraft sustained substantial damage.

The investigation found that the crew's flight planning did not adequately prepare them to ensure a safe landing. The flight crew believed that the entire width of the runway was available, despite notices to airmen (NOTAMs), communication with the air traffic controller and other information indicating the reduced runway size. Before landing, the flight crew misinterpreted the runway markings, and the pilot flying perceived the runway side stripe marking along the left edge of the runway as being the runway centreline. As a result, the aircraft touched down partly outside the limits of the available runway.

The approach briefing conducted by the flight crew did not include a review of the NOTAMs in effect at the airport, as required by the aircraft operator. This review could have made the crew aware of the reduced runway width prior to landing. If flight crews conduct incomplete approach briefings, there is a risk that information that is crucial for flight safety will be missed.

Following the occurrence, the operator of Montreal/St-Hubert Airport added a popup window to its website. It contained a message describing the construction work and specified that flight crews must read the notices to airmen in effect at the airport. Flight crews could also download a diagram of the construction work.

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Richmond Hill, Ontario, 27 June 2018 – Today, the Transportation Safety Board of Canada (TSB) is recommending that Transport Canada (TC) update the Railway Employee Qualification Standards Regulations to address existing gaps related to training, qualification and re-qualification standards, and regulatory oversight for employees in safety-critical positions. The Board's recommendation (R18-02) was issued as part of an investigation (R16T0111) into the June 2016 uncontrolled movement of rolling stock at MacMillan Yard located in Vaughan, north of Toronto, Ontario.

On the evening of 17 June 2016, a two-member crew employed by the Canadian National Railway (CN) was performing switching operations using a remote control locomotive system in MacMillan Yard. The crew had assembled a 9000-ton, 4500-foot-long assignment, consisting of 74 cars and 2 locomotives. As the switching operations required extra room, the crew received permission to move the cut of cars south along a slightly ascending grade toward the edge of MacMillan Yard and then downhill onto the main track of the York Subdivision. When the crew attempted to stop and reverse the cars back into the yard, they continued to move and rolled uncontrolled for about 3 miles, reaching nearly 30 mph before an ascending grade brought them to a stop. The foreman's quick emergency call to the rail traffic controller asking for assistance to protect the uncontrolled movement minimized the risk of collision and of a more serious outcome.

The investigation found that the crew had not charged air brakes on any of the freight cars, which left only the independent brakes on the two locomotives to control the movement. The crew members were qualified train conductors, but did not have sufficient operational experience to safely perform the tasks in this section of the yard. They had requested and received advance job briefings during which they reviewed operational requirements. However the briefings, job aid and procedures did not provide them with sufficient guidance. The crew was aware of the assignment's length and weight, but did not fully understand how these factors affected train handling on a descending slope using only the locomotives' independent brakes. As conductors, they had received little training in locomotive operation and train handling, as this was not required under existing regulations.

"Since the Railway Employee Qualification Standards Regulations came into force in 1987, the rail industry has changed tremendously and the technology has evolved, but qualification standards and training requirements have not," said Board member Faye Ackermans. "Consequently, railway employees in safety-critical positions may not be sufficiently trained or experienced to perform their duties safely."

Uncontrolled movements of railway cars are low frequency–high-risk events that can occur due to insufficient securement, switching without air, or loss of control as was the case in this occurrence. While most occur in rail yards, uncontrolled movements that affect the main track present the greatest risk of adverse outcomes, particularly if dangerous goods are involved. The number of occurrences involving uncontrolled movements has increased by about 10% in the past five years, compared to the 10-year average.

Following the incident, CN conducted a risk assessment that included a review of topography and air brake use in all its switching yards in Canada. Based on the review, CN implemented new minimum braking requirements for each yard including how many cars require charged air brakes prior to accessing main track.

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Gatineau. Quebec, 26 June 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (M17P0406) on the 5 December 2017 collision of the dredger FRPD 309 with the barge EVCO 60 on the Fraser River in British Columbia. Both the dredger and the barge sustained damage.

The TSB conducted a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues.

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Richmond Hill, Ontario, 22 June 2018 - The Transportation Safety Board of Canada (TSB) will hold a news conference on 27 June 2018 to release its investigation report (R16T0111) on the uncontrolled movement of 2 locomotives and 74 railway cars that occurred in June 2016 at MacMillan Yard, located in Vaughan, north of Toronto, Ontario. The group of cars rolled uncontrolled for about 3 miles, reaching 30 mph before coming to a stop.

When:

27 June 2018
10:00 a.m. Eastern Time

Spokespersons:

Faye Ackermans, Board Member
Rob Johnston, Manager, Railway Investigations, Central Region & Headquarters
Nathalie Lepage, Senior Investigator

Where:

Transportation Safety Board of Canada
Richmond Hill Regional Office
23 East Wilmot Street, Richmond Hill, Ontario

The news conference will be broadcast live on Ustream at the following address: http://www.ustream.tv/channel/transportation-safety-board-of-canada

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


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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Richmond, British Columbia, 18 June 2018 – In its investigation report (M17P0052) released today, the Transportation Safety Board of Canada (TSB) determined that inadequate vessel stability information led to the capsizing and sinking of the fishing vessel Miss Cory in the Strait of Georgia, British Columbia, in March 2017. One of the vessel's crewmembers was reported missing.

On 6 March 2017, the fishing vessel Miss Cory was purse seining for herring with 5 people on board. After a successful catch, the crew lifted the net using the vessel's boom to transfer the fish from the net into a packing vessel. While waiting for additional packing vessels to arrive, the vessel leaned to starboard to the point where the vessel's rubbing strake was submerged. Water likely entered the vessel from behind the rubbing strake, making its way into the aft hold and causing further leaning to starboard. The crew unsuccessfully attempted to dewater the vessel, unaware that a capsizing situation was developing. The crew on deck abandoned the vessel in the final seconds before it capsized and sank. The engineer, who was below deck, was possibly unaware of the situation and was unable to escape the sinking vessel.

The investigation determined that the combined effects of the weight of the fish in the net and the progressive downflooding of the compartments in the Miss Cory caused it to heel over and capsize. The attention on the task of dewatering the vessel likely affected the master's ability to maintain situational awareness and make use of alternate strategies to manage the vessel's stability or initiate procedures to safely abandon ship.

The vessel had not undergone a stability assessment for operations using its boom. As such, there were no means for the master to recognize that the vessel would rapidly capsize with a boom load of 5-7 long tons. Fishing vessel stability information is a key concern in the TSB Watchlist issue of Commercial Fishing Safety. There are also two outstanding Board recommendations (M94-33 and M16-02) regarding the adequacy of fishing vessel stability information.

The investigation also found that there were no procedures for the safe operation of the vessel or for dealing with emergencies. The crew did not practice emergency drills on board the vessel, though they discussed the muster list and associated emergency duties. The

uncoordinated abandonment of the vessel led to one crewmember remaining in the engine room when the vessel capsized, who was subsequently reported missing. If formalized emergency procedures are not practiced in drills, there is a risk that an emergency response will be delayed or uncoordinated, potentially endangering the safety of the crew and the vessel.

Following the occurrence, Fish Safe facilitated the development of a code of best practices for the roe herring fishery to address unsafe work practices that continue to put fishermen and vessels at risk. WorkSafeBC will enhance inspections in the commercial fishing industry, focusing on vessel stability documentation, emergency drills and procedures.

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Québec, Quebec, 11 June 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (M17C0220) on the September 2017 mechanical failure and subsequent fire on board the tug Brochu in Port-Cartier, Quebec. No injuries or pollution were reported, but the fire caused extensive damage to the tug.

Early on, TSB investigators discovered a number of unsafe conditions that could potentially affect the crews and machinery operations of hundreds of other vessels worldwide having similar arrangements. Therefore in December 2017 the TSB issued a safety advisory to a wide range of Canadian and international stakeholders to inform them of the issue and encourage them to take appropriate action.

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