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Transportation Safety Board of Canada

Transportation Safety Board of Canada (644)

Calgary, Alberta, 4 March 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (R18C0076) on the main-track derailment that occurred near Stirling, Alberta, 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.

See the investigation page for further information.

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Richmond, British Columbia, 27 February 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A17P0170) into a collision with terrain involving a Mooney M20D aircraft near Revelstoke, British Columbia, in November 2017.

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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Richmond, British Columbia, 21 February 2019 – In its investigation report (R18V0016) released today, the Transportation Safety Board of Canada (TSB) found that a broken axle on a freight car led to the derailment of a Canadian National Railway (CN) train near New Hazelton, British Columbia.

On 19 January 2018, a CN freight train proceeding westward at 29 mph experienced a train-initiated emergency brake application near New Hazelton, British Columbia. A subsequent inspection determined that 27 gondola cars loaded with coal had derailed. Some of the product spilled into the nearby waterway. There were no injuries, and no dangerous goods were involved. The British Columbia Ministry of Environment and Climate Change Strategy monitored the site clean-up and recovery activities conducted by CN to ensure they met regulatory requirements.

The investigation found that the 52nd car in the train had sustained a broken axle, leading to the derailment of the 27 cars. The axle broke as a result of fatigue cracking in the journal fillet radius, the area between where the wheel and wheel bearing is mounted on the axle. While the exact cause of the fatigue cracking could not be determined, fatigue cracks are known to result from abnormal cyclic loading due to a number of reasons, such as a wheel tread defect, a general out-of-roundness, or uneven loading from railcar truck components.

Axle fatigue cracks in the journal fillet radius are not detectable during routine safety inspections, as this part of the axle is concealed by wheel bearing components. Visual inspection is only possible during wheel and bearing replacement, or during axle reconditioning. Without alternate strategies to identify fatigue cracks or to predict the likelihood of fatigue cracks developing, problematic axles might not be removed from service in a timely manner, increasing the risk of broken-axle derailments.

See the investigation page for more information.

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Québec, Quebec, 20 February 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (M18C0030) on the April 2018 liquefied natural gas fuel equipment failure of a passenger ferry in Matane, Quebec.

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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Dartmouth, Nova Scotia, 19 February 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18O0107) into the collision with water of a Found Aircraft Canada FBA-2C1 aircraft equipped with floats on Lake Muskoka, Ontario, 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.

See the investigation page for more information.

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Dorval, Quebec, 18 February 2019 – In its investigation report (A18Q0016) released today, the Transportation Safety Board of Canada (TSB) underscored the risks posed by insufficient recent experience flying with reference to instruments, particularly in the case of night flights when unfavourable weather conditions are encountered and pilots lose visual reference to the ground.

On 01 February 2018, at about 1945 Eastern Standard Time, a privately operated Robinson R44 Raven I helicopter departed Saint-Georges de Beauce, Quebec, with the pilot and 2 passengers on board, on a night visual flight rules (VFR) flight to Saint-Alexis-de-Montcalm, Quebec. At 2032, the Canadian Mission Control Centre received a distress signal from the helicopter’s emergency locator transmitter. At about 2135, the helicopter was found in a field in Saint-Joachim-de-Courval, near Drummondville. The helicopter was destroyed by the impact forces and a post-impact fire. All of the occupants were fatally injured.

The investigation determined that it is highly likely that the pilot encountered unfavourable weather conditions which led to a loss of visual references to the ground, and that he lost control of the helicopter as a result of spatial disorientation. Although the pilot held a valid pilot licence and a night rating, it is likely that, given his training and limited night flight experience, he did not have the necessary skills to handle a significant reduction in visual references to the ground.

The investigation highlighted several risk factors associated with night VFR flights. If pilots are not required by the Canadian Aviation Regulations (CARs) to maintain their instrument flying skills in order to use the privileges of a night rating, there is a risk that they will be unable to recognize spatial disorientation and react appropriately, increasing the risk of an accident resulting from a loss of control. Furthermore, if the CARs do not require pilots who conduct night VFR flights to undergo recurrent assessments in the form of dual instrument flights with a qualified instructor, there is an increased risk that, in the event of a loss of visual references, pilots may not be able to maintain control of the aircraft or to regain control in time to avoid an accident.

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Gatineau, Quebec, 14 February 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (P18H0034) into the Trans Mountain Pipeline ULC pipeline oil spill near Kamloops, British Columbia, in May 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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Richmond, British Columbia, 13 February 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18P0108) into the August 2018 loss of control and collision with water of a Cessna 180H aircraft, which occurred in Tyaughton Lake, British Columbia.

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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Rimouski, Quebec, 6 February 2019 – On 7 February, the Transportation Safety Board of Canada (TSB) in collaboration with the Standing Committee on Quebec Fishing Vessel Safety will host a panel discussion on fatigue and the consumption of alcohol and drugs during commercial fishing operations.

Although mostly conducted in French, the discussion will be facilitated in both official languages and will be live webcast at www.ustream.tv/channel/transportation-safety-board-of-canada

Anyone interested can participate in the question periods by teleconference (toll-free: 1-866-805-7923; access code: 6283969#), or submit questions or comments via Twitter @TSBCanada

Time

Thursday, 7 February 2019, 11 a.m. – 12 noon, Eastern Standard Time

Panelists

  • Denis Bélanger, moderator and marine inspector, Transport Canada
  • Alain Arseneau, lobster fisherman, Ȋles-de-la-Madeleine
  • Johanne Basque, director, fisheries management and elected councillor, Gespeg Micmac Nation, Gaspé
  • Tom Brocklehurst, director, Prevention Practices & Quality, WorkSafeBC
  • Michel Castonguay, expert, fisheries and vessels, Commission des normes, de l’équité, de la santé et de la sécurité du travail (Québec)
  • Vincent Dupuis, shrimp fisherman, Gaspésie’s North Shore
  • Capt. Christopher Hearn, director, Center for Marine Simulation, Memorial University of Newfoundland Terre-Neuve
  • Line Laroche, manager, Marine Operations, Central Region, Transportation Safety Board of Canada
  • Annie Larouche, senior marine inspector, Transport Canada
  • Bruce Logan, occupational safety officer, Prevention Field Services, WorkSafeBC
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Richmond Hill, Ontario, 31 January 2019 – Today, the Transportation Safety Board of Canada (TSB) is making four recommendations, following its safety issue investigation (A17O0038) into 27 runway incursions that occurred between two closely spaced parallel runways at Toronto/Lester B. Pearson International Airport, Ontario, between June 2012 and November 2017.

“Pearson International airport traffic is tightly controlled and monitored, and all 27 incursions examined involved flight crews who understood they needed to stop, and that they were approaching an active runway,” said Kathy Fox, Chair of the TSB. “Despite all the visual cues, including lights, signage and paint markings, professional crews were not stopping in time as required, thereby risking a collision with another aircraft on the other runway.”

The investigation found that all the incursions happened on the inner runway, after the flight crews involved had landed on the outer runway and were taxiing on a rapid-exit taxiway between the two runways. Several characteristics of the rapid exits in this area, known locally as the “south complex,” are different from almost every other major airport in North America. The exits lead directly to the “inner” parallel runway, the hold lines are located immediately following a 65-degree curve and, most notably, they are farther away from the protected runway than is commonly seen elsewhere. These uncommon features mean that the hold lines are not where crews are expecting to see them.

It was also determined that, although flight crews were aware of the increased risk for runway incursions in the area because they are designated as “hot spots” on the airport charts, that guidance did not bring crews' attention to specific strategies to mitigate the risk of incursion. Instead, crews followed their standard operating procedures and initiated their post-landing actions immediately after exiting the runway, taking their attention away from other more critical tasks—such as identifying the hold line. The timing of those tasks distracted the crew at a point when limited time was available to recognize the visual cues requiring them to stop, and contributed to their overlooking those cues.

Today, the TSB is making four recommendations to make these runways safer. The first one is that NAV CANADA amend its phraseology guidance so that safety-critical transmissions are more compelling to flight crews in order for crews to take the safest course of action. The next two recommendations are for Transport Canada and the United States Federal Aviation Administration (FAA) to work with operators to amend standard operating procedures so that crews only commence post-landing checks after a landing aircraft has cleared all active runways. Finally, the Board recommends that the Greater Toronto Airports Authority make physical changes to the taxiway layout at Pearson International's south complex to address the risk of incursions between the parallel runways.

“Fixing these complex issues won't be easy, which means all those involved must work together,” said Fox. “Because clearly, more needs to be done—so that all flight crews see the cues and react as required.”

More details about the Board's recommendations can be found in the backgrounder.

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