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Transportation Safety Board of Canada

Transportation Safety Board of Canada (631)

Winnipeg, Manitoba, 23 January 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18C0064) on the July 2018 stall and collision with terrain of a Cessna A188B aircraft operated by Clayton Air Service near Carrot River, Saskatchewan.

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

See the investigation page for further information.

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Dorval, Quebec, 22 January 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18Q0100) on the July 2018 collision with terrain of a de Havilland DHC-2 (Beaver) aircraft operated by Air Saguenay near the Manic-Cinq aerodrome, Quebec.

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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Winnipeg, Manitoba, 21 January 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (R18W0168) on the main-track derailment near Hudson Bay, Saskatchewan, in July 2018.

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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Edmonton, Alberta, 18 January 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18W0081) following a baggage compartment fire that occurred on WestJet flight 113 on 14 June 2018, shortly after the aircraft departed Calgary International Airport, Alberta.

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

This report highlights the hazard that lithium-ion batteries, such as those found in electronic cigarettes, pose to the safety of aircraft when stored in checked baggage. Passengers are reminded that these items must be carried in the cabin, where an incident can be immediately mitigated, and not in checked baggage.

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Richmond, British Columbia, 17 January 2019 – The Transportation Safety Board of Canada (TSB) today released its investigation report (M17P0400) into a November 2017 occurrence during which the ferry Seaspan Swift struck berth No. 2 at the Seaspan Ferries terminal located on Tilbury Island, British Columbia. The report identifies inadequate bridge resource management as a contributing factor to this occurrence.

In the early afternoon of 15 November 2017, the roll-on/roll-off ferry Seaspan Swift, with 10 crew members on board, departed the Swartz Bay terminal in Victoria, BC, for the Tilbury terminal, near Delta, BC. Prior to departure, after a brief handover, the relief master took over the command from the regular master. Upon approaching berth No. 2, the relief master attempted to slow the vessel's forward speed. Instead, the vessel's speed increased. Although he attempted a crash stop manoeuvre, the vessel struck the berth, injuring two crew members and damaging the vessel's bow and the berth's ramp. No pollution was reported.

The investigation found that inadequate bridge resource management reduced the crew's ability to help identify issues during the approach for docking. The crew began completing the pre-arrival checklist but stopped at the step requiring the relief master to switch the manual steering control from the steering wheel to the pod handles (pod handles are used for manoeuvring in restricted waters and docking). As a result, the relief master was not reminded to switch over the steering control.  When he turned the pod handle, the pod did not respond and remained thrusting in the ahead position. Realizing that the vessel's steering control was still set to the wheel, he quickly switched the steering control over to the pod handles and attempted a crash stop. As there was not enough time left, the vessel struck the berth at about 4.1 knots.

Moreover, one of the crew members was not required to obtain, and did not have, training in bridge resource management. If bridge members are not all required to take bridge resource management training and if they don't apply its key principles, they may not communicate and work effectively as a team, which increases the risk of accidents. In 1995, the Board issued two recommendations (M95-09 and M95-10) regarding bridge resource management training, both of which are still active.

The investigation also found that before arrival, a control console switch was inadvertently activated, causing a temporary power outrage and confusion on the bridge. If bridge switches are not designed optimally, there is a risk of accidental activation, which could contribute to an accident.

Following the occurrence, Seaspan Ferries Corporation introduced pre-arrival checklists for each of its terminals with explicit steering control instructions. It also made ergonomic improvements, including new visual and audible cues for the steering control system and thrust direction indicator.

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Richmond, British Columbia, 16 January 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18P0090) on the June 2018 collision with terrain of a privately operated Cessna 182P aircraft near Hope, British Columbia. The aircraft caught fire after impact and was completely destroyed. The two occupants were fatally injured.

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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Dartmouth, Nova Scotia, 14 January 2019 – In its investigation report (M17A0390) released today, the Transportation Safety Board of Canada (TSB) found that conflicting information about the location of a pilot boarding station and ineffective communication between the pilot and the bridge team led to the October 2017 grounding of the bulk carrier SBI Carioca near the Port of Belledune in Chaleur Bay, New Brunswick.

On 11 October 2017, while approaching the Port of Belledune, the SBI Carioca reached a nearby boarding station to meet the pilot responsible for guiding it to its destination pier. After the boarding got delayed by a few minutes, the pilot was on the bridge at 6:55 a.m. Atlantic Daylight Time (ADT) and, following a brief exchange of information with the master, initiated a series of manoeuvres to reposition the vessel for its approach to the pier. At 7:20 a.m. ADT, the vessel ran aground within the 10-metre depth contour near the port. With no sign of damage nor pollution, and no injuries to the 23 people on board, the vessel was refloated on the next high tide with the assistance of two tugboats.

The investigation determined that the absence of clear, published information about the position of the Port of Belledune's pilot boarding station contributed to the vessel being closer to the pier than was practical for a safe approach when the pilot boarded the SBI Carioca. As this occurrence demonstrates, bringing a pilot on board without sufficient time to manoeuvre may be detrimental to a vessel's safe approach to a pier.

The investigation also found that the pilot navigated the vessel using only visual references and did not request or receive feedback from the bridge team. An ongoing exchange of information and teamwork, which are key principles of bridge resource management, are essential to help create a shared mental model necessary to safely navigate. Since January 2014, the TSB has investigated three other marine occurrences where ineffective communication on the bridge was found to be a risk factor (M16C0005, M14C0193 and M14P0014).

Moreover, if formal passage plans are not devised and shared among bridge team members, there is a risk that members will be unable to effectively monitor the vessel's track and progress. This is why the Board has long recommended that Transport Canada require that pilotage authorities publish official passage plans to enable close and continuous monitoring by ship's personnel. The Board has assessed the Atlantic Pilotage Authority's response to Recommendation M94-34 as Unsatisfactory. The recommendation is still active.

Following this occurrence and at the request of the Atlantic Port Authority, a pilot boarding station symbol was added to Canadian Hydrographic Services charts. The TSB advised the Canadian Department of Fisheries and Oceans and the United Kingdom Hydrographic Office to prompt them to update their respective sailing directions.

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Vancouver, British Columbia, 10 January 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (M17P0244) into a July 2017 occurrence during which the tug Ocean Monarch made bottom contact while transiting the Princess Royal Channel south of Kitimat, British Columbia. The report underlines the need to effectively manage the risk of fatigue in the marine industry.

On 9 July 2017, at 4:36 am Pacific Daylight Time, the tug Ocean Monarch, with three crew members on board, made bottom contact while towing the loaded cement barge Evco No. 15. No pollution or injuries were reported, but the tug's hull, starboard propeller and nozzle were damaged. After a damage assessment and actions taken to prevent fuel from leaking, the tug resumed its voyage to Kitimat, B.C., using the port engine. It then returned to the Fraser River and a shipyard in Vancouver for repairs.

The investigation determined that the mate, alone on watchkeeping duties, fell asleep while the tug and barge transited on autopilot through the channel's confined waters. At the time of the occurrence, the mate had been on duty for at least 8 hours. The master and deckhand were asleep below deck. All navigational alarms were disabled. The mate fell asleep likely as a result of acute fatigue from previous night shifts, chronic sleep disruptions, circadian rhythm desynchronization, combined with the low and monotonous workload in the wheelhouse.

The investigation also found that the tug's operator had no strategies in place to mitigate crew fatigue, despite a previous occurrence in 2011 where fatigue played a role (M11W0091). Given the tug's 24-7 operations, a three-member crew made it challenging, and at times impossible, to maintain two people on the bridge every night while also ensuring the crew was sufficiently rested. If an operator does not have a fatigue management plan and is not required to have one, there is a risk that crews will work while fatigued, increasing the likelihood of an error that leads to an occurrence.

Fatigue management is on the TSB Watchlist 2018 as a multimodal issue. In the marine sector, the Board made two recommendations in May 2018 following its investigation into the sinking of the tug Nathan E. Stewart (M16P0378) in British Columbia. The first recommendation (M18-01) calls for mandatory education and awareness training for watchkeepers whose work and rest periods are regulated by the Marine Personnel Regulations to help them identify and prevent the risks of fatigue. The second recommendation (M18-02) calls on Transport Canada to require that vessel owners implement comprehensive fatigue-management plans, tailored specifically for their individual operations.

Following this investigation, the operator installed a navigational watch alarm on the bridge of the Ocean Monarch, and ordered that all alarms be enabled and monitored at all times. New safe operating procedures were developed and implemented on the vessel. The Pacific Pilotage Authority revoked the pilotage waiver for the master and required him to become informed of the waiver requirements before reinstating his waiver.

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Richmond, British Columbia, 9 January 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18P0091) on the Piper PA-28-140 aircraft that collided with trees near the Sechelt Aerodrome, British Columbia, in July 2018.

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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Winnipeg, Manitoba, 8 January 2019 – The Transportation Safety Board of Canada (TSB) today released its investigation report (R17W0190) into a hi-rail crane boom failure and employee injury that occurred in Brandon, Manitoba, in September 2017. The crane boom failed due to undetected cracks in the crane column. Deficiencies with the crane operator’s seatbelt and seat locking mechanism contributed to the employee injury.

On 2 September 2017, a Canadian Pacific Railway (CP) Engineering Services work crew was using a truck-mounted boom crane to unload tie plates in Brandon Yard, Manitoba. The crane operator was sitting in an elevated basket secured to the crane’s column. During a lift operation, the crane column failed and the crane boom dropped, throwing the crane operator onto the track about 12 feet below. The crane operator sustained serious injuries.

The investigation found that multiple fatigue cracks had originated near a weld on the interior of the crane column, and had propagated outward through the rear and side column walls. The impact from a 2015 collision with a train likely initiated these cracks. If these cracks were present on the inner surface of the column when the crane was recertified following the collision and during subsequent annual inspections, they would have been difficult to detect given the limitations of the magnetic particle inspection technique used for crane inspection and the location of the cracks.

The seatbelt and seat-locking mechanism in the crane operator’s basket were inoperative, resulting in the operator being thrown out of the seat onto the track when the crane column failed, contributing to the operator’s injuries. CP’s daily crane inspection checklist included a requirement to check all safety devices for proper operation. However, at the time of the accident, some of the safety features of the crane operator’s seat and basket were inoperative, suggesting that they were not being inspected. If the basket, the operator seat securement and seatbelt of a boom crane are neither regularly inspected nor appropriately maintained, there is an increased risk of operator injury in the event of an accident.

Following the occurrence, CP inspected all boom cranes across its system. No defects were reported. CP also revised its crane inspection procedures to include the crane operator’s seat.

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