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Transportation Safety Board of Canada

Transportation Safety Board of Canada (657)

Québec, Quebec, 3 June 2019 – Today, the Transportation Safety Board of Canada (TSB) welcomes the heads of independent safety investigation authorities from International Transportation Safety Association (ITSA) member countries to Québec City for the ITSA annual conference, which is taking place from 3 to 6 June 2019.

“As a leader in transportation safety investigations and founding member, the TSB is delighted to receive fellow ITSA members' representatives,” said Kathy Fox, Chair of the TSB. “We firmly believe in ITSA's mission, which relies on information sharing and cooperation to promote independent, non-judicial investigations of transportation accidents and thereby contribute to the safety of the public and industry.”

ITSA is a collaborative network of heads of 16 independent national safety investigation authorities, which seeks, among other things, to share best practices and learn from the experiences of others. The topics addressed during the conference may include safety deficiencies, safety studies, safety recommendations, investigation techniques, and training and recruiting strategies for investigators. The conference also provides an opportunity for members to identify common concerns, challenges, methods and solutions, and provides a platform for open, frank discussions among members on strategic issues and concerns.

For more information about ITSA and its members, please visit the ITSA website


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Gatineau Quebec, 29 June 2019 - The Transportation Safety Board of Canada (TSB) and the United States National Transportation Safety Board (NTSB) have deployed teams of investigators to the site of yesterday's Canadian National Railway (CN) train derailment in the St. Clair Tunnel which spans the Canada – US border.

Investigators from both agencies are working to determine the point of derailment. If the point of derailment is in Canada, the TSB will become the lead agency for the accident investigation.

Access to the site is restricted due to the limited space available and the potential hazards in the tunnel. We must ensure that the site is safe for investigators and those working to clear the accident site.

Once further information about the occurrence is available, both agencies will provide an update.


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Gatineau Quebec, 05 July 2019 - Today, the Transportation Safety Board of Canada (TSB) announced that it will be conducting the accident investigation into the June 28 Canadian National Railway (CN) train derailment that occurred in the St. Clair Tunnel between Sarnia, Ontario, and Port Huron, Michigan.

Following an initial assessment of the accident by both the TSB and the US National Transportation Safety Board, it was determined that the derailment was initiated in Canada.

The TSB would like to acknowledge the coordinated efforts of emergency response personnel, and the collaboration between multiple agencies from both sides of the border.


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Edmonton, Alberta, 9 July 2019 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (R18E0138) on the main-track derailment that occurred in Landis, Saskatchewan, in September 2018.

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, 10 July 2019 – In its investigation report (A18Q0069) released today, the Transportation Safety Board of Canada (TSB) found that short staffing and a deviation from standard procedures by air traffic controllers led to a May 2018 loss of separation between an Air Transat Airbus A310 and a Cessna 421 light twin-engine aircraft near the Montreal/Pierre Elliott Trudeau International Airport.

On 16 May 2018, both aircraft were inbound to land at the Montreal/Pierre Elliott Trudeau International Airport. The Airbus was coming from the west and was to fly north of the airport and land on Runway 24R, while the Cessna was inbound from the northeast and was to land on Runway 24L. A loss of separation between the two aircraft occurred when both aircraft were approximately 18 nautical miles northeast of the airport. At the closest point, the two aircraft came within 500 feet vertically and 1.7 nautical miles laterally of each other. Normally the aircraft should be separated by at least 1000 feet vertically or 3 nautical miles laterally.

Although seven controllers and a shift supervisor would have normally been scheduled to work that evening, absences and illness reduced that number to three controllers and a supervisor. As a result, six sectors of airspace normally divided among the controllers needed to be combined and controlled by just three—which in turn increased each of their areas of responsibility, as well as their workload and its complexity.

The TSB's investigation also found that, with the Cessna approaching from a sector to the northeast, control responsibility for it was not transferred to the next sector according to standard procedure. As a result, a controller-in-training responsible for the receiving sector, was not initially aware of the presence or intentions of the Cessna until it entered his airspace, and as a result did not have an opportunity to develop a plan to deal with the converging traffic. Also during this time, the instructor, who was both the shift supervisor and responsible for the trainee, was distracted by other tasks and wasn't able to accurately monitor the developing situation.

Shortly thereafter, the controller-in-training noticed the Cessna on the display and the required separation was re-established. Both aircraft then landed without incident.
The Board is not aware of any safety action taken following this investigation.

See the investigation page for more information.


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Richmond Hill, Ontario, 17 July 2019 — In its investigation report (R18T0006) released today, the Transportation Safety Board of Canada found that a lack of training on safe working practices when clearing snow at railway crossings led to a fatal collision between a snowplow and a Canadian National Railway (CN) train at a crossing in London, Ontario.

On the morning of 9 January 2018, a CN freight train proceeding eastward struck a snowplow on the sidewalk at the Colborne Street public crossing. The lone snowplow operator was fatally injured.

The investigation found that the accident occurred when the snowplow travelled onto the railway crossing while clearing snow from the sidewalk. Although the warning devices—which included flashing lights, a bell, and gates—activated while the plow was in the crossing, the combination of the plow’s position, the restricted visibility inside the cab, and the background noise of the plow itself made it difficult to detect these warnings, or to hear the train’s horn. A lack of experience with railway crossings, a lack of training on safe working practices when clearing snow at railway crossings, and tunnel vision exacerbated by fatigue inhibited the effectiveness of the snowplow operator’s visual scanning. As such, the operator did not detect the oncoming train.

The investigation also found that, although the City of London provided training to its employees who operate snowplows, the contractor and subcontractor involved in this occurrence did not provide formal training to their employees on safe working practices when clearing snow at railway crossings. Oversight by the contractor and the City of London did not ensure that employees had the skills and knowledge to perform their duties safely. If snow-clearing contract companies do not have safe work procedures and related training in place for work at railway crossings, there is an increased risk of crossing accidents.

Following this occurrence, the City of London required snowplow operators employed by its sidewalk snow-clearing contractors to participate in a City-led review of safe operating practices at railway crossings. Guidance documents on clearing snow at crossings were distributed to snowplow operators at this review session.

See the TSB investigation page for further information.


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Richmond Hill, Ontario, 24 May 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18O0153) on the collision with terrain involving a Piper PA-28R-200 aircraft that occurred at the Brantford Municipal Airport, Ontario, in November 2018

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, 6 May 2019 — In its investigation report (R17D0123) released today, the Transportation Safety Board of Canada (TSB) found that the lack of a risk assessment following a significant change in operations, in addition to fatigue and task interruption, were factors that led to a 2017 employee fatality in St-Luc Yard in Montréal, Quebec.

On 8 November 2017, during the hours of darkness, a Canadian Pacific Railway (CP) yard assignment (a crew operating with 2 locomotives) was performing switching operations in St-Luc Yard. The crew consisted of a locomotive engineer, a yard foreman and a yard helper.

While the assignment was switching cars into their designated tracks, the yard helper briefly left his position near a crossover switch and entered a nearby building. When he returned to continue his duties, he instructed the locomotive engineer by radio to stop the assignment north of the crossover switchwhich wasfurther than necessary for the next switching movement. The yard helper then incorrectly placed the crossover switch in the reverse position, inadvertently aligning the movement away from the intended destination track. He then placed the destination track’s switch in the reverse position and instructed the locomotive engineer to move the yard assignment into the destination track. Because the crossover switch was in the incorrect position, the assignment diverted onto the crossover track. The assignment struck and fatally injured the yard helper and collided with a cut of cars on the track.

The investigation found that when switching operations in St-Luc Yard were changed significantly in 2012, with most switching moved to the diamond area, a risk assessment of the changes had not been conducted. As CP’s safety management system (SMS) had not considered a risk assessment necessary, the opportunity to identify and mitigate any new hazards created by the changes was missed. If risk assessments are not completed when a change to railway operations occurs, new hazards might not be identified, increasing the risk of accidents. Safety management and oversight is an issue on TSB Watchlist 2018.

The existing levels of lighting in the diamond area of the yard made it more difficult for the yard foreman to visually determine the location of the yard helper and to distinguish the direction of travel of the yard assignment. If railway yards are not adequately illuminated for night switching operations, the visibility of employees, yard tracks and railway equipment can be compromised, which can lead to accidents.

Furthermore, the short absence of the yard helper created a task interruption that shifted the yard helper’s focus away from his duties. This led to the yard helper incorrectly aligning the yard assignment away from the destination track. It is likely that the yard helper’s fatigue also contributed to the incorrect alignment of the crossover switch.

Following the occurrence, Transport Canada (TC) conducted an investigation into the employee fatality. As a result, TC issued a direction regarding lighting at St-Luc Yard. CP has until May 2019 to address the items in the direction. CP conducted employee awareness campaigns focusing on the hazards present when working on or near tracks and the associated risk mitigation processes.

See the investigation page for more information.


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Ottawa, Ontario, 2 May 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18O0150) on the mid-air collision that occurred near the Ottawa/Carp Airport, Ontario, in November 2018.

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 more information.


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Richmond, British Columbia, 29 March 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (R17V0220) on the 2017 collision of a Canadian Pacific Railway (CP) freight train with a backhoe conducting track work, near Fraine, BC. The investigation found that the misapplication of CP’s planned protection procedures in a track work area resulted in misunderstandings among team members and important information being missed.

On 31 October 2017, at about 0600 Pacific Daylight Time, during the hours of darkness, a CP freight train, authorized to proceed eastward through work limits on the Connaught track of the Mountain Subdivision, struck a backhoe conducting track work. The backhoe operator suffered serious injuries. The backhoe and the lead locomotive sustained damage.

At the time of the accident, track work was being conducted in the area under Canadian Rail Operating Rules (CROR) Rule 42 (Planned Protection). The foreman had established with the rail traffic controller (RTC) that trains requiring passage would operate through the Macdonald track only. This information was transmitted during the job briefings. Later, the foreman realized that an eastbound train had been routed toward the work limits on the Connaught track. Although he told the supervisor and all sub-foremen and contract workers under his protection of the change in track routing, a formal job briefing was not conducted to inform all employees and contractors. Before authorizing the eastbound train through the work limits on the Connaught track, the foreman verified with and received confirmation from the employees under his immediate supervision, from the sub-foreman, and from the supervisor that all workers and track equipment had been cleared off the track.

The investigation found that the supervisor had assumed the responsibility of sub-foreman to protect some of the track workers without having acquired formal sub-foreman designation from the foreman. This adaptation created an ambiguity in the chain of command within the work limits that created an unsafe condition and contributed to the backhoe operator being instructed to resume work activities on an active track.

The investigation also determined that the foreman and sub-foreman had been using various ad hoc methods to keep track of employees. Reliance on working memory, rather than the use of the formal sub-foreman protection process, contributed to the foreman and the supervisor having a different understanding of the track on which the train would operate, the location of the backhoe, and the protection required for the backhoe operator.

Following the accident, CP issued a Safety Flash stating that all employees must ensure there is clear communication when clearing a movement through protected limits. This includes validating that all parties understand the direction and are aware of the limits being provided.

See the investigation page for more information.

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