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Vancouver, British Columbia, 31 May 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (M16P0378) into the causes and contributing factors that led to the October 2016 grounding and sinking of the U.S.-registered tug Nathan E. Stewart in British Columbia. The report underlines the need to effectively and reliably manage the risk of fatigue in the marine industry.
On 13 October 2016, shortly after 1 a.m. Pacific Daylight Time, the articulated tug-barge composed of the tug Nathan E. Stewart and a tank barge went aground on Edge Reef near Athlone Island, at the entrance to Seaforth Channel, approximately 10 nautical miles west of Bella Bella, British Columbia, within the Heiltsuk First Nation territory. The tug's hull was eventually breached and approximately 110 000 litres of diesel fuel were released into the environment. The tug subsequently sank and separated from the barge.
The investigation determined that the second mate who, contrary to Canadian regulations, was keeping watch alone on the bridge at the time of the accident, had fallen asleep and missed a planned course change. For more than two days, he had been working a 6-on, 6-off shift schedule, alternating six hours of duty and six hours of rest. This schedule presents a number of challenges which have been well documented by various studies and experts internationally, notably the difficulty in obtaining sufficient restorative rest during the off-duty periods. There was no prior discussion with the master on the second mate's preparedness for the watch, and the watchkeeper wasn't aware of the sleep-conducive conditions he was facing on the bridge that night.
The TSB has identified fatigue as a causal or contributory factor in numerous marine investigations. "There is a compelling need for vessel operators and watchkeepers to recognize and to address the factors that contribute to fatigue," said Kathy Fox, Chair of the TSB. "If watchkeepers have a better understanding of those factors, and the actions they can take to reduce the risks, then we should see a reduction in the number of fatigue-related occurrences in the marine industry."
The Board has made two recommendations following this investigation. Firstly, it is recommending that Transport Canada require that watchkeepers receive mandatory education and awareness training to help identify and prevent the risks of fatigue. Secondly, it is recommending that vessel owners implement comprehensive fatigue-management plans, tailored specifically for their individual operations.
The investigation also determined that the spill response and the recovery efforts of both the Western Canada Marine Response Corporation and the Canadian Coast Guard were in accordance with the prescribed time standards. However, because other responding agencies and some Canadian Coast Guard personnel were not familiar with the incident command system in use, there was confusion about roles and responsibilities and who had final authority. A coordinated and comprehensive evaluation of the response involving all organizations may have provided more insight to identify deficiencies and improve Canada's spill response regime.
Vancouver, British Columbia, 29 May 2018 - The Transportation Safety Board of Canada (TSB) will hold a news conference on 31 May 2018 to make public its investigation report (M16P0378) into the October 2016 grounding and subsequent sinking of the tug Nathan E. Stewart in the Seaforth Channel, 10 nm west of Bella Bella, British Columbia.
When: 31 May 2018, 10:00 a.m. Pacific Daylight Time
Who: Kathy Fox, Chair of the TSB and Glenn Budden, Investigator-in-charge
Where: Vancouver Maritime Museum, T.K. Gallery, 1905 Ogden Avenue, Vancouver, British Columbia
The event will be broadcast live on Ustream at the following address: http://www.ustream.tv/channel/ZK7R3XaGbPP
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
Edmonton, Alberta, 29 May 2018 – The Transportation Safety Board of Canada (TSB) investigation (A16W0092) into an occurrence where the nose wheel failed to extend on an Air Georgian flight found several maintenance-related deficiencies that went undetected by the company's safety management system (SMS). These issues also went undetected by Transport Canada oversight activities.
On 12 July 2016, an Air Georgian Ltd. Beechcraft 1900D turboprop aircraft was operating as Air Canada Express flight 7212 from Lethbridge, Alberta, to Calgary, Alberta, with 2 flight crew members and 15 passengers on board. When the flight crew lowered the landing gear for the approach into Calgary, they noticed that there was no gear-safe indication for the nose landing gear. The flight circled for about one hour while the flight crew attempted to fix the problem. An emergency was declared and the aircraft landed with the nose gear partially extended. There was minimal damage to the aircraft, no fire, and there were no injuries.
The investigation found that the nose landing gear did not fully extend because of a lack of lubrication to certain landing gear components. These components were not properly lubricated because maintenance personnel were not adequately trained on lubrication techniques and the use of lubrication equipment. The company's quality control program also contributed to ineffective lubrication activities going undetected for an extended period of time prior to the occurrence.
Safety management and oversight is a TSB Watchlist issue. This investigation found that Air Georgian's SMS was ineffective at identifying and correcting improper and unsafe practices related to nose landing gear lubrication tasks.
Transport Canada's (TC) surveillance of Air Georgian focused primarily on its SMS rather than on regulatory compliance. As a result, ineffective lubrication processes went undetected during three TC inspections prior to the occurrence. If TC does not adopt a balanced approach to oversight that combines inspections for compliance with SMS audits, there is a risk that improper maintenance practices will not be identified, which may lead to incidents and accidents.
Following the occurrence, Air Georgian carried out a fleet campaign to address the greasing issue and reduced the inspection interval for the affected component. The company also hired a manager for maintenance training, and provided human factors training to its staff on distraction, including the need to track and document steps in the workflow.
Richmond, British Columbia, 15 May 2018 – The Transportation Safety Board of Canada (TSB) released today its investigation report (M17P0098) into the April 2017 fatal accident involving the commercial sports fishing vessel Catatonic, near Tofino, British Columbia. The report highlights the risks posed by vessel modifications, which may compromise the safety features of the original design and increase the risk that the vessel will not be adequate for the intended voyage.
On 30 April 2017, at approximately 9:30 a.m. PDT, the sports fishing vessel Catatonic left Tofino, for nearby fishing grounds with one operator and four passengers on board. During the next few hours as the vessel anchored at various fishing spots, it was observed to take on water from the stern due to shipping seas. By 1303 PDT, as the vessel was preparing to return to the dock, the operator was unable to re-start the starboard engine. Subsequently the port engine stopped and bilge pumps, navigation equipment, and communications equipment also ceased functioning. Using a personal cellphone, the operator called the Canadian Coast Guard to report the emergency and give their approximate location. Eventually, the vessel could not maintain its upright aspect, and everyone on board abandoned the vessel into the water. Search and Rescue (SAR) vessels recovered the operator and passengers from the water and took them to a local hospital where two of the passengers were pronounced dead.
The investigation found that the Catatonic's stern sank primarily due to water ingress into the vessel's pontoons and stern buoyancy compartments. Modifications made to the vessel allowed the water shipped on deck to first enter the fish boxes and then drain into the pontoon bilges. Holes that had been made in the shipside and the bulkhead also allowed the water to enter the pontoons and into the stern buoyancy compartments and contributed to the stern's sinking.
Significant components of the vessel had also been modified, including its powering arrangement. The vessel's original design for two batteries operating separately was modified to allow both batteries to be charged and drained simultaneously, and act as the only power source to the entire vessel. When the battery unit drained, the vessel was without a power supply for critical equipment such as the engines, bilge pumps, and VHF radiotelephones. If vessel modifications compromise the safety features of the original design, then there is an increased risk that the vessel will not be adequate for its intended voyage.
The investigation also determined that, at the time of the occurrence, the vessel's manual emergency position indicating radio beacon (EPIRB) was not the approved type and was defective. The operator's personal locator beacon (PLB) was not activated since the operator was not familiar with its operation. Additionally, because the vessel's power supply was depleted, the very high frequency (VHF) radios and global positioning system were not functional; the operator was therefore unable to relay the vessel's exact location to the Joint Rescue Coordination Centre. Because the vessel's exact location could not be provided to SAR authorities, 1 hour and 40 minutes elapsed from the time the stern sank to the time everyone was recovered from the water. If accurate position information is not provided in an emergency, there is a risk that valuable time will be lost while SAR resources try to locate the vessel.
The TSB is not aware of any safety action taken as a result of this occurrence.
Richmond, British Columbia, 14 May 2018 – In its investigation report (R16V0195) released today, the Transportation Safety Board of Canada (TSB) determined that inadequate safety watch training contributed to an employee injury at the Roberts Bank Yard in Delta, British Columbia in December 2016.
On 18 December 2016, a Toronto Terminals Railway (TTR) locomotive engineer and a conductor were shoving 66 empty intermodal platforms onto the east leg track at the Roberts Bank Yard in Delta, BC. The conductor was driving a vehicle beside the lead platform while providing instructions to the locomotive engineer who was positioned at the opposite end of the movement. At the same time, two track workers employed by a track maintenance contractor (PNR RailWorks) were clearing snow from a switch on the same track. As the movement approached the switch, the conductor saw the workers and activated the oscillating beacon on top of the vehicle to alert them to the approaching movement. When no reaction was observed, the conductor attempted to sound the vehicle's horn, but it was inoperative. The conductor then instructed the locomotive engineer to stop the movement. However, the movement was unable to stop before the leading platform struck and seriously injured one of the track workers.
The investigation found that the conductor's instruction to the locomotive engineer to stop was not made in time to allow the movement to be stopped before reaching the switch. The attentional focus required to monitor the movement's progress while driving the vehicle, combined with the expectation that the track workers would clear the track, likely contributed to the late call to stop the movement.
Deficiencies with the use of safety watch protection by the track workers were also identified in the investigation. Safety watch is a form of track protection that requires one of the members of a track work crew to be assigned with the sole task of continuously monitoring the work site for oncoming trains or other on-track equipment. In this occurrence, neither of the track workers was solely performing the duties of safety watch. The track workers had not been adequately trained in its use and did not have an accurate understanding of how to apply such protection. In addition, as the use of safety watch and the associated processes were not specifically audited, the inadequate application of this form of track worker protection was not apparent.
Safety management and oversight is a TSB Watchlist issue. As demonstrated in this occurrence, gaps in training, supervision, and efficiency testing of employees can decrease the effectiveness of a company's safety management system (SMS).
Technical Safety BC (formerly BC Safety Authority) issued a Safety Advisory to notify all provincially certified railways operating in BC of the risks associated with shoving equipment. It recommended that railways review their processes to ensure compliance with all applicable rules and regulations regarding shoving equipment.
BCR Properties Ltd., the owner of the Roberts Bank Yard, completed a risk assessment and incorporated a number of protection measures into its SMS. BCR also followed up with the contractor to ensure its employees receive appropriate training and certifications.
Gatineau, Quebec, 14 May 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (M17C0061) into the 20 May 2017 capsizing of the small fishing vessel Emma Joan that occurred off the coast of Grosse-Île, Îles-de-la-Madeleine, Quebec.
The TSB is releasing this limited-scope investigation report to raise awareness of the importance for fishermen to have comprehensive information regarding navigational hazards and safe passages.
Gatineau. Quebec, 9 May 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (M17C0108) into the 15 June 2017 grounding of the tanker Damia Desgagnés that occurred in St. Lawrence Seaway, near Morrisburg, Ontario. There were no injuries and no pollution reported.
The TSB is releasing this limited-scope investigation report to raise awareness of the need for crew members to be familiarized with all operational aspects of safety critical equipment on board a vessel so that they can operate it proficiently and regain control during an emergency.
Winnipeg, Manitoba, 3 May 2018 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A17C0147) into the 15 December 2017 collision with terrain of a privately operated Piper PA-23-250 aircraft that occurred near Baldur, Manitoba. The pilot, who was the sole occupant, sustained fatal injuries.
The TSB conducted a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues.
Calgary, Alberta, 26 April 2018 – The Transportation Safety Board of Canada (TSB) is recommending the mandatory installation of lightweight flight recording systems by all commercial and private business operators not currently required to carry them. The TSB is also concerned with Transport Canada's reactive approach to oversight of private business aircraft operations. The details are in the investigation report (A16P0186) released today into the 2016 fatal loss of control and collision with terrain of a Cessna Citation 500 near Kelowna, British Columbia.
On 13 October 2016, a Cessna Citation 500 that was privately operated by Norjet Inc. departed Kelowna Airport, British Columbia, on a night instrument flight rules flight to Calgary/Springbank Airport, Alberta. The pilot and three passengers were on board. Shortly after departure, the aircraft departed controlled flight, entering a steep descending turn to the right until it struck the ground. No emergency call was made. All of the occupants were fatally injured. Impact forces and a post-impact fire destroyed the aircraft.
Because there were no flight recording systems on board the aircraft, the TSB could not determine the cause of the accident. The most plausible scenario is that the pilot, who was likely dealing with a high workload associated with flying the aircraft alone, experienced spatial disorientation and departed from controlled flight shortly after takeoff. The investigation also determined that the pilot did not have the recent night flying experience required by Transport Canada for carrying passengers at night. Pilots without sufficient recent experience flying at night or by instruments are at a greater risk of loss of control accidents.
"We don't like having to say 'We don't know' when asked what caused an accident and why," said Kathy Fox, Chair of the TSB. "We want to be able to provide definitive answers—to the victims' families, to Canada's aviation industry, to the Canadian public. This is why we are calling today for the mandatory installation of lightweight flight recording systems on commercial and private business aircraft not currently required to carry them."
The Board also raised a concern with the way Transport Canada (TC) had conducted oversight of private business aviation in Canada. During the course of its investigation, the TSB found no record that the operator of this aircraft had ever been inspected by TC. As such, TC was unaware of safety deficiencies in its flight operations, such as the failure to obtain approval for single-pilot operation of the aircraft and the pilot's lack of recent night flying experience required to carry passengers at night. Since this occurrence, TC has said that it will conduct targeted inspections of private business operators starting in April 2018. The Board will continue to monitor this safety issue.
Toronto, Ontario, 25 April 2018 – The Transportation Safety Board of Canada (TSB) released its investigation report (A17O0025) into the runway excursion of Air Canada flight 623 at Toronto/Lester B. Pearson International Airport, Ontario. The investigation determined that weather conditions and lack of runway centreline lighting reduced the cues available to recognize the aircraft's drift in time to correct the trajectory or to execute a safe go-around.
On 25 February 2017, the Airbus A320 was completing an evening flight to Toronto from Halifax/Stanfield International Airport, Nova Scotia, with six crew members and 119 passengers on board. Just before touchdown, the aircraft began to deviate to the right of the runway centreline. It deviated further to the right after touchdown and entered the grassy area to the west of the runway. It then travelled approximately 2390 feet through the grass parallel to the runway before returning to the pavement. During the excursion, the aircraft struck five runway edge lights, causing minor damage to the left outboard wheel and the left engine cowling. There were no reported injuries.
The investigation found that during the final approach phase, while the aircraft was less than 30 feet above ground and on the runway centreline, a right roll command input caused the aircraft to enter a shallow right bank and start drifting to the right. The crew had limited visual cues to accurately judge the aircraft's lateral position because of rain, reduced windshield wiper capability and lack of runway centreline lighting. The severity of the drift was not recognized until the aircraft was less than 10 feet above ground and rapidly approaching the runway edge, which left limited time to correct the aircraft's trajectory before contacting the surface. Given the risks involved in executing a go-around from a low level in response to significant drift, the pilot continued the landing sequence while attempting to minimize the extent of the excursion.
Following the accident, Air Canada instituted a program for inspections of windshield wiper tension, developed a drift training scenario for the simulator, and issued further flight crew guidance on lateral drifts and lateral runway excursions.