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Transportation Safety Board of Canada (390)
Dorval, Quebec, 13 August 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (A14Q0060) into the 13 May 2014 collision with wires involving a Eurocopter AS 350 BA helicopter north of Sept-Îles, Quebec. Both occupants of the helicopter were seriously injured.
The helicopter, operated by Héli-Boréal inc., with one pilot and a Hydro-Québec employee aboard, was on a flight to inspect vegetation encroachment along a power distribution line. While completing a right turn in a valley, the pilot noticed a larger power transmission line crossing perpendicular to the direction of flight. The pilot immediately turned right to avoid a collision; but one of the helicopter's main rotor blades struck one of the cables. While attempting an emergency landing in a nearby small clearing, the helicopter's skids impacted trees. The helicopter then rolled left and fell 50 feet through the trees, coming to rest on its left side. The two people aboard were able exit the helicopter, but sustained serious injuries. The helicopter was destroyed.
The investigation found that the power distribution line being surveyed did not have Hydro Quebec's standard triangular markings to warn the pilot of the upcoming intersection with a transmission line. The opportunity for the pilot to see the upcoming power line intersection in sufficient time to avoid the collision was reduced because the helicopter was following the distribution line around a hill. The investigation also found that deficiencies related to the collection and distribution of air navigation information adds risks to flight safety.
Following this occurrence, NAV CANADA clarified how aeronautical information products are to be used, and is working with Hydro-Québec to ensure accurate data regarding the location of power lines. For its part, Héli-Boréal inc. improved training for power line inspection flights.
Quebec, Quebec, 12 August 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (M14C0106) into the 12 June 2014 grounding of the bulk carrier Atlantic Erie near Port Colborne, Ontario. There were no injuries or pollution, but the vessel sustained damage.
The Atlantic Erie was on a voyage from Chicago, Illinois, to Sydney, Nova Scotia. While transiting toward Port Colborne to enter the Welland Canal, the crew experienced power interruptions on the bridge caused by voltage drops from attempting to use the bow thruster. While applying the vessel's blackout procedure, further power interruptions on the bridge caused navigational equipment, such as the gyrocompass, to provide inaccurate information. The vessel then proceeded off its intended course and when the crew became aware of the situation, corrective action was ineffective and the vessel ran aground.
The investigation found that the bow thruster circuit tripped and caused a voltage drop throughout the vessel that activated a number of power failure alarms on the bridge. The crew interpreted the situation as being a blackout. The chief engineer applied the vessel's blackout procedure; however, this caused additional power interruptions on the bridge. These led to the gyrocompass becoming misaligned and the vessel being placed off course. Because not all available bridge resources were being used to monitor the vessel's progress, the vessel continued off course for approximately 15 minutes and ran aground.
Following the grounding, the vessel operator incorporated the occurrence as a case study in its training for masters and chief engineers. Mentors have also been hired to sail in the fleet to observe and further coach vessel crew members.
Dartmouth, Nova Scotia, 11 August 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (M14A0348) into the August 2014 collision between a pilot boat and a small passenger vessel in Saint John, New Brunswick. There were no injuries or pollution, though both vessels sustained minimal damage.
On the evening of 01 August 2014, the pilot boat Captain A.G. Soppitt was returning to the Port of Saint John in dense fog. Meanwhile, the small passenger vessel Bayliner (with only the three crew on board) had departed the port of Saint John and was transiting the main channel proceeding outbound in dense fog to the anchorage area south of the main channel. As the pilot boat approached the main channel, the master contacted the Bayliner by radio to advise of their intention to transit towards the west side of the channel. However, the communication was taken by the crew of the Bayliner as an instruction or suggestion for the Bayliner to transit along the west side of the channel. Soon after, despite final evasive maneuvers by both vessels, they collided.
The investigation found that the communications between both vessels in the channel led to a misunderstanding that resulted in the Captain A.G. Soppitt being maneuvered for a starboard-to-starboard passing and the Bayliner for a port-to-port passing. Both vessels continued along their intended route without additional radio communication, believing that the other vessel would take action to alter course towards the opposite side of the channel. The investigation also determined that further opportunities for collision avoidance were hampered by the navigational equipment on the Captain A.G. Soppitt not being optimally configured, and by both vessels not sounding the required signals while navigating in an area of restricted visibility.
Following the occurrence, the operator of the Bayliner fitted the vessel with a Class B automatic identification system (AIS). AIS transmits vessel data including the heading, GPS position, course over ground and speed over ground to other vessels equipped with AIS receivers, which can assist in collision avoidance.
Dartmouth, Nova Scotia, 10 August 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (M14A0289) into the capsizing of the small fishing vessel Sea Serpent 25 and subsequent loss of life in June 2014. Three crew members were rescued and one deceased crew member was recovered.
On 26 June 2014, at approximately 0900 Atlantic Daylight Time, the small fishing vessel took on water and capsized during fishing operations off Little Port Head on the west coast of Newfoundland. No distress call was made. The overturned vessel was sighted three hours later by a patrolling Department of Fisheries and Oceans vessel.
The TSB investigation determined that the vessel began taking on water in slight sea conditions, most likely due to water entering the vessel through the drain hole because the plug had not been inserted, or had not been inserted properly.
In November 2014, the TSB released its third Watchlist, which identifies critical safety issues that pose the greatest risk to Canada’s transportation system. One of these issues is the loss of life on fishing vessels, given that there continues to be approximately one fishing-related fatality per month in Canada. The Board remains concerned about vessel stability, the use and availability of lifesaving appliances on board, and unsafe operating practices. Although regulations have been proposed to address several deficiencies with respect to fishing safety, there have been significant delays in their implementation.
The Board is calling for concerted and coordinated action by federal and provincial authorities and by leaders in the fishing community to improve the safety culture in fishing operations, recognizing the interaction of safety deficiencies.
Dorval, Quebec, 6 August 2015 – Today, the Transportation Safety Board of Canada (TSB) issued its investigation report (R14D0011) into a collision between two Canadian National (CN) trains in Montreal, Quebec. There were no injuries; however, both trains sustained damages and approximately 4000 litres of diesel fuel was spilled.
On 23 February 2014, a Canadian National yard assignment train was travelling with 25 loaded cars on the freight track of the Montreal Subdivision. At about midnight, the train went through a stop signal and collided with the side of another CN train travelling on the north (adjacent) track in the opposite direction.
The investigation determined that, as the yard assignment train was approaching the junction between the freight track and the north track, the rail traffic controller (RTC) initiated a radio communication with the crew requiring them to copy instructions. During the following minutes, the crew prioritized the task of copying the RTC's instructions over the operation of the train and the observation of the track and applicable signals. Consequently, the stop signal was not identified resulting in the collision.
The locomotives of the yard assignment train were controlled using a remote control locomotive system called a “Beltpack.” An examination into CN's Beltpack practices revealed that CN does not limit the train tonnage, length, or territory characteristics for Beltpack operations. Furthermore, even though the Montreal Subdivision presents some unique characteristics and challenges, CN has not conducted a specific risk assessment for Beltpack operations on this subdivision. The investigation concluded that, if a thorough analysis of risks is not carried out for the operation of Beltpack trains on main track, the vulnerabilities involved in this type of operation will not be identified, and appropriate mitigation measures will not be implemented to protect the public.
Following railway signal indications is on the TSB Watchlist. The Board is calling for the implementation of additional physical safety defences to ensure that railway signal indications governing operating speed or operating limits are consistently recognized and followed.
Dorval, Quebec, 4 August 2015 – The Transportation Safety Board of Canada (TSB) today published its investigation report (A13Q0021) into an accident involving a helicopter training flight at the Sept-Îles Airport on 03 February 2013. The pilot instructor sustained serious injuries and the 2 pilots in training sustained minor injuries. The helicopter was heavily damaged.
The Eurocopter AS350 BA, operated by Héli-Excel Inc, was practicing various types of landings in unprepared areas. The aircraft then headed to the Sept-Îles Airport to undertake various simulated emergency exercises. At 0959 Eastern Standard Time, as the helicopter began its third hydraulic systems failure exercise, the flight instructor flew a short pattern at low altitude and low speed without hydraulic power. In the moments following the start of the final approach, the cyclic control stick moved sharply forward and to the left. The flight instructor gripped the cyclic stick to try and re-establish level flight. The main rotor blades struck the runway, and the aircraft came to a stop on its left side.
The investigation found that the approved procedure to complete this manoeuver was not followed. As a result, the helicopter's flight profile deviated from the flight profile recommended by the manufacturer when the hydraulic system is depressurized. The investigation also found that in the absence of specific instructions for pilots regarding restoration of hydraulic pressure in the event of deviation from the flight profile, there is a risk that pilots will not be able to re-engage the hydraulic system while applying considerable effort to the helicopter controls.
The investigation made some other significant findings as to risk. First, the TSB has documented a number of cases where wearing a helmet would likely have reduced or prevented pilot injuries. Therefore, helicopter pilots who do not wear helmets are at increased risk of incapacitation, serious injuries or loss of life in the event of an accident. Secondly, the investigation revealed that there was no coordination of the emergency response. When emergency vehicles drive on an active runway without coordination between the airport operator and emergency response units, and with no means of communicating with the flight service station, there is a risk of collision on the runway.
Winnipeg, Manitoba, 28 July 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (P14H0011) into the 25 January 2014 rupture of a TransCanada PipeLines Limited pipeline. A 30-inch natural gas pipeline, Line 400-1, ruptured and ignited at the site of Mainline Valve 402 near Otterburne, Manitoba. The escaping gas burned for approximately 12 hours. Five residences in the immediate vicinity were evacuated until the fire was extinguished.
The investigation determined that Line 400-1 failed due to a fracture that occurred at a pre-existing crack that had remained stable for over 50 years prior to the occurrence. This crack had formed at the time of the pipeline's construction likely due to an inadequate welding procedure and poor welding quality. There was no requirement for inspections of every weld by radiography at the time of the pipeline's original construction.
The fracture was caused by incremental stresses to the pipeline, which were likely due to a combination of factors. These included: weakened soil support in the area due to maintenance activities over the years; record low temperatures that winter; recent work at and around the valve site that may have driven frost deeper into the ground; and thermal contraction that may have occurred when the pipeline cooled due to the absence of gas flow for 20 days prior to the occurrence.
Following the occurrence, the National Energy Board required TransCanada to perform several engineering assessments along Line 400-1. TransCanada performed numerous excavations, inspections and repairs along Line 400-1 before returning it to service. Following the pipeline's return to service, TransCanada performed in-line inspections to rule out other threats to the pipeline's integrity.
Gatineau, Quebec, 16 July 2015 – The Transportation Safety Board of Canada (TSB) released today its investigation report (A13H0003) into the December 2013 runway incursion at the Ottawa/MacDonald-Cartier International Airport, in Ontario. There were no injuries and no damage to aircraft or airport property.
On 1 December 2013, a Piaggio P-180 turboprop aircraft with 2 pilots aboard was authorized to taxi across Runway 14 on its way to Runway 07 at the Ottawa/MacDonald-Cartier International Airport. At the same time, a Jazz de Havilland DHC-8 with 3 crew and 15 passengers aboard was also taxiing to Runway 14 for takeoff. After being cleared for takeoff, the DHC-8 was on its takeoff roll when the P-180 crossed Runway 14, approximately 4400 feet in front of it. Neither aircraft was aware of the runway incursion and continued their flights without further incident.
The investigation determined that the NAV CANADA ground controller issued instructions to the P-180 to taxi unrestricted from the apron to Runway 07, across Runway 14, despite the frequent use of Runway 14 for departing aircraft. Additionally, after issuing taxi instructions to the P-180, the ground controller did not transfer the information to the airport controller. While operating procedures require that this be done, they do not indicate exactly when the transfer must be performed. As such, the airport controller’s display did not indicate that the P-180 was taxiing for Runway 07 when take-off clearance was issued to the DHC-8. The investigation also found that the Tower was staffed below unit guidelines at that time.
Following the occurrence, the Ottawa Tower issued a directive instructing controllers to indicate that a vehicle or aircraft was cleared to cross a runway by activating a runway crossing indicator (RCI) on the flight data entry. The RCI can only be deactivated once the aircraft or vehicle has left the protected area on the other side of the runway. NAV CANADA also made changes to its procedures when operating short-staffed.
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 improved procedures and enhanced collision warning systems to be implemented at Canada's airports.
Ottawa, Ontario, 15 July 2015 – Today the Transportation Safety Board of Canada (TSB) released its investigation report (A14H0002) into the June 2014 runway incursion and risk of collision at the Macdonald-Cartier International Airport. There were no injuries.
On 5 June 2014, Ornge's Agusta AW 139 helicopter, operating as Life Flight 4 Medevac (LF 4 Medevac), was departing Ottawa's Macdonald-Cartier International Airport destined for Pembroke, Ontario, on an Instrument Flight Rules (IFR) flight plan. As instructed, LF 4 Medevac contacted the tower when holding short of Runway 25. The airport controller amended LF 4 Medevac's IFR clearance, and then observed LF 4 Medevac taxiing across the hold line while a Federal Express Airbus 300 was landing on Runway 25. The airport controller instructed LF 4 Medevac to stop. The runway incursion and risk of collision occurred when LF 4 Medevac crossed the hold line on Taxiway Echo at the intersection of Runway 25, after the Airbus had landed.
The TSB investigation found that Air Traffic Control used non-standard phraseology when issuing instructions to the pilot and that LF 4 Medevac taxied across the hold line on Taxiway Echo without authorization. It also found that, if flight crews do not follow company standard operating procedures before taxiing onto a runway, there is an increased risk of collision between aircraft.
Immediately after the incident, Ornge issued two bulletins reminding flight crews to be diligent when receiving and acknowledging air traffic control clearances. For its part, NAV CANADA reviewed the occurrence during Ottawa tower refresher training in November 2014, with emphasis on the importance of using standard phraseology.
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 TSB is calling for improved procedures and enhanced collision warning systems must be implemented at Canada's airports.
Winnipeg, Manitoba, 14 July 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (R14W0041) into the 15 February 2014 derailment of a Canadian Pacific (CP) freight train near Keyes, Manitoba.
The freight train originated at Bredenbury, Saskatchewan and was destined for St. Paul, Minnesota. The train consisted of 2 locomotives, 50 loaded cars and 22 empty cars. It was 4403 feet long and weighed 7363 tons.
At about 2211, the train was travelling eastward on the Minnedosa Subdivision at 42 mph when the crew reported encountering a rough section of track near Mile 43.0. Shortly thereafter, the train experienced an unintended emergency brake application indicating that the train air brake line had become disconnected. Subsequent inspection revealed that 25 loaded covered hopper cars and 2 empty cars had derailed. There were no dangerous goods involved and no injuries. At the time of the accident, the sky was clear and the temperature was -21°C.
The TSB investigation determined that the derailed train was the second train through the area, and it derailed after encountering a broken rail that had likely failed under the passage of a previous train approximately 6 hours earlier.
The rail had failed catastrophically, likely due to high wheel impacts imparted on the rail by defective wheels from a car on a previous train which had large flat spots on its wheel treads. The flat spots occurred as a result of brake equipment which had failed enroute. The investigation also identified that risks exist when there are no explicit protocols in place to inspect the track after a train with known high impact wheels passes through non–signaled territory.