Annual Report to Parliament 2004-2005

RAIL

Occurrence Statistics and Investigations

ANNUAL STATISTICS

A total of 1129 rail accidents were reported to the TSB in 2004, a 9% increase from last year's total of 1032 and a 7% increase from the 1999-2003 average of 1054. Rail activity has been relatively constant over the last six years, averaging 89.7 million train-miles annually. The accident rate increased to 12.5 accidents per million train-miles in 2004, compared to 11.5 in 2003 and the 1999-2003 average rate of 11.8. Rail-related fatalities totalled 100 in 2004, compared to 79 in 2003 and the five-year average of 94. This increase consisted mainly of trespasser fatalities, with 67 in 2004, up from 45 in 2003 and the five-year average of 53.

There was a significant increase in accidents in two areas. First, trespasser accidents showed a 52% increase over 2003, from 65 to 99, and a 27% increase over the five-year average of 78. Second, non-main-track derailments showed a 14% increase over 2003, from 389 to 444, and a 16% increase from the five-year average of 382.

Five main-track collisions occurred in 2004, compared to six in 2003 and the five-year average of eight. In 2004, there were 152 main-track derailments, comparable to the 149 in 2003, but a 21% increase from the five-year average of 126. Non-main-track collisions numbered 114 in 2004, up from 104 in 2003 and from the five-year average of 103.

In 2004, crossing accidents decreased to 237 from the 2003 total of 250 and the five-year average of 267. Crossing-related fatalities numbered 25, compared to 28 in 2003 and the five-year average of 37.

In 2004, 210 accidents involved railcars carrying or having recently carried dangerous goods, a 7% decrease from both the 2003 total and the five-year average of 225. Five of these accidents resulted in a release of product.

In 2004, rail incidents reported under TSB mandatory reporting requirements reached a 22-year low of 252, down from 295 in 2003 and from the five-year average of 317. Dangerous goods leakers not related to train accidents annually account for the largest proportion of total incidents. In 2004, dangerous goods leakers decreased to 132 from the 2003 total of 151 and from the five-year average of 173.

RAIL INVESTIGATIONS STARTED IN 2004-2005

The following information is preliminary. Final determination of events is subject to the TSB's full investigation.

DATE	LOCATION	COMPANY	EVENT	OCCURRENCE NO.
2004.04.18	Linacy, N.S.	Cape Breton and Central Nova Scotia Railway	Main-track train derailment	R04M0032
2004.06.28	Richmond, Ont.	VIA Rail Canada Inc.	Crossing accident	R04H0009
2004.07.08	Bend, B.C.	Canadian National	Movement exceeds limits of authority	R04V0100
2004.07.25	Burton, Ont.	Canadian National	Main-track train derailment	R04T0161
2004.08.08	Estevan, Sask.	Canadian Pacific Railway	Non-main-track train derailment	R04W0148
2004.08.17	Lévis, Que.	Canadian National	Main-track train derailment	R04Q0040
2004.10.06	Renfrew, Ont.	Ottawa Valley Railway	Crossing accident	R04H0014
2004.10.24	Eltham, Alta.	Canadian Pacific Railway	Crossing accident	R04C0110
2004.10.24	Floods, B.C.	Canadian Pacific Railway	Main-track train derailment	R04V0173
2004.11.12	Lévis, Que.	Canadian National	Main-track train derailment	R04Q0047
2005.01.31	Mackay, Alta.	VIA Rail Canada Inc.	Crossing accident	R05E0008
2005.02.09	Calgary, Alta.	Canadian Pacific Railway	Rolling stock damage	R05C0049
2005.02.17	Brockville, Ont.	Canadian National	Crossing accident	R05T0030
2005.02.23	Saint-Cyrille, Que.	Canadian National	Derailment	R05Q0010

RAIL REPORTS RELEASED IN 2004-2005

DATE	LOCATION	COMPANY	EVENT	REPORT NO.
2001.10.06	Drummond, N.B.	Canadian National	Crossing accident and derailment	R01M0061
2002.03.18	Éric, Que.	Quebec North Shore and Labrador Railway	Main-track train derailment	R02Q0021
2002.05.02	Firdale, Man.	Canadian National	Crossing accident and derailment	R02W0063
2002.07.03	L'Assomption, Que.	Canadian National	Main-track train derailment	R02D0069
2002.07.08	Camrose, Alta.	Canadian National	Main-track train derailment	R02C0050
2002.07.22	Lévis, Que.	Canadian National	Non-main-track train derailment	R02Q0041
2002.08.13	Milford, N.S.	Canadian National	Main-track train derailment	R02M0050
2002.10.24	Hibbard, Que.	Canadian National	Main-track train derailment	R02D0113
2002.12.04	Medicine Hat, Alta.	Canadian Pacific Railway	Main-track train derailment	R02E0114
2003.01.20	Saint-Charles, Que.	Canadian National	Collision involving a track unit	R03Q0003
2003.01.21	Agincourt, Ont.	Canadian Pacific Railway	Non-main-track train derailment	R03T0026
2003.01.22	Toronto, Ont.	Canadian National	Dangerous goods leaker	R03T0047
2003.02.05	Port Moody, B.C.	Canadian Pacific Railway	Non-main-track train derailment	R03V0019
2003.02.13	Nobel, Ont.	Canadian Pacific Railway	Main-track train derailment	R03T0064
2003.02.21	Melrose, Ont.	Canadian Pacific Railway	Main-track train derailment	R03T0080
2003.03.27	Sherbrooke, Que.	St. Lawrence & Atlantic Railroad	Main-track train derailment	R03D0042
2003.05.12	Manseau, Que.	Canadian National	Main-track train derailment	R03Q0022
2003.05.14	McBride, B.C.	Canadian National	Bridge collapse and train derailment	R03V0083
2003.05.21	Gamebridge, Ont.	Canadian National	Main-track train derailment	R03T0157
2003.05.21	Green Valley, Ont.	Canadian Pacific Railway	Main-track train derailment	R03T0158
2003.07.30	Villeroy, Que.	Canadian National	Main-track train derailment	R03Q0036
2003.10.19	Carlstadt, Ont.	Canadian Pacific Railway	Main-track train derailment	R03W0169
2004.01.08	New Hamburg, Ont.	VIA Rail Canada Inc.	Main-track train derailment	R04S0001
2004.02.17	Winnipeg, Man.	Canadian Pacific Railway	Non-main-track train derailment	R04W0035
2004.03.17	Linton, Que.	Canadian National	Main-track train derailment	R04Q0016

RAIL RECOMMENDATIONS ISSUED IN 2004-2005

Napodogan Subdivision, New Brunswick - 6 October 2001 Crossing Accident - Canadian National		Report No. R01M0061
RECOMMENDATION	RESPONSE	BOARD ASSESSMENT OF RESPONSE	SAFETY ACTION TAKEN
R04-01
Transport Canada encourage the railway companies to implement technologies and/or methods of train control to assure that in-train forces generated during emergency braking are consistent with safe train operation.	TC accepted the Board's recommendation. TC encouraged the railways to implement new technologies that contribute to safer train operations.	Fully satisfactory	The railway industry is equipping fleets of locomotives and tail-end devices with the new technology.
Rivers Subdivision, Firdale, Manitoba - 2 May 2002  Crossing Accident and Derailment - Canadian National		Report No. R02W0063
RECOMMENDATION	RESPONSE	BOARD ASSESSMENT OF RESPONSE	SAFETY ACTION TAKEN
R04-02
The Department of Transport, in consultation with the provinces and the trucking industry, review and update, as necessary, educational and training material for drivers with respect to the risks associated with a heavy vehicle negotiating a public passive railway crossing.	TC agrees with the Board and raised the need to review this material with the Canadian Council of Motor Transport Administrators Standing Committee on Drivers and Vehicles. Reaction from the provinces has not yet come to fruition.	Satisfactory intent	TC, with the Railway Association of Canada, produced and distributed safety material, including videos, instructors' guides and safety quizzes, concerning safety at crossings for truck, bus and emergency drivers.
R04-03
The Department of Transport, in consultation with other federal, provincial and municipal agencies, implement consistent training requirements that ensure emergency first responders remain competent to respond to rail accidents involving dangerous goods.	TC shares the TSB's concern for the safety of emergency responders. TC sent a letter attaching the TSB report to provincial and territorial representatives requesting review and consideration.	Fully satisfactory	TC has made progress on the issue with the responsible change agents. TC has already started receiving positive feedback to the letter.

ASSESSMENT OF RESPONSES TO RAIL RECOMMENDATIONS ISSUED IN 2003-2004

Fraser Subdivision, near McBride, British Columbia - 14 May 2003 Timber Bridge Collapsed under a Train - Canadian National		Occurrence No. R03V0083
RECOMMENDATION	RESPONSE	BOARD ASSESSMENT OF RESPONSE	SAFETY ACTION TAKEN
R03-04
Canadian National verify the condition of its timber bridges and ensure their continued safety with effective inspection and maintenance programs.	CN did not completely accept the Board's recommendation.	Satisfactory in part	CN has verified the condition of its timber bridges and is developing a computerized inspection and maintenance tracking system for bridges.
R03-05
Transport Canada incorporate in its compliance reviews a comparison of railway working procedures and practices with railway inspection and maintenance records.	TC accepted the recommendation and indicated that the Safety Management System audit program is being aggressively developed.	Satisfactory intent	TC is developing an auditing practice to assess the efficacy of CN's Safety Management System for inspection and maintenance of bridges.

OTHER RAIL SAFETY ACTIONS TAKEN

On 1 March 2004, subsequent to the derailment of a passenger train due to a broken rail, the TSB issued Rail Safety Advisory 02/04 to the regulator and the industry. The Advisory raised a concern over the use of vintage open hearth rail on main track where passenger trains operate and dangerous goods are carried. Open hearth process has a known propensity to form transverse defects in rail because of impurity inclusions in the steel. On 24 August 2004, the Goderich-Exeter Railway Company (GEXR) advised TC that it had removed all open hearth rail from the jointed rail portion of the Guelph Subdivision.

In May 2004, Canadian Pacific Railway (CPR) modified its General Operating Instructions in an effort to improve situational awareness for locomotive engineers regarding hot box detectors (HBDs). Section 5, Item 21.2 requires the locomotive engineer to set the locomotive distance measuring device as soon as the train reaches the HBD location, and for the crew to verbally confirm any HBD announcements received with each other.

CPR, jointly with Canadian National (CN), has installed a trackside acoustic detector system on CN's Yale Subdivision (directional running zone). This device, the only one of its kind in Canada, is being tested to determine whether this technology can identify defective bearings on a predictive basis before they fail or overheat.

CPR has updated its computer system to provide the correct axle count information for Meyler cars in Expressway service.

CPR implemented a bearing temperature trending process on its coal loop in British Columbia. By connecting the HBDs to a central system, CPR performs trending analysis to proactively set out cars with suspect bearings. CPR is reviewing the option of extending this bearing trending process to other locations.

As a result of the potential failure to protect or repair improperly identified track geometry defects, TC issued a Notice pursuant to Section 31 of the Railway Safety Act. CN responded that the previously incorrectly identified defects had been protected or corrected, and that the company had initiated the following additional action:

• All defect settings on the test car were audited to ensure compliance with Railway Track Safety Rules standards.
• A daily procedure was developed and implemented that requires test car operators to review and validate defect parameter settings and track class before testing operations.
• Since the derailment, two additional test car runs were scheduled over the Bala Subdivision. All defects identified during these tests were properly protected and corrected.
• Two additional inspections using contracted track geometry vehicles with gauge restraint technology were scheduled on the Bala Subdivision.

A derailment occurred (TSB Report No. R03Q0022) when the car body on the E platform of loaded container car CN 677048 collapsed onto the main track due to fatigue at a high-stress location where a weld was missing and had gone undetected during inspection and repair practices. The TSB sent Rail Safety Advisory 03/03, Inspection of CN 677 series Doublestack Intermodal Rail Cars, to TC. CN issued instructions to all its field inspection forces to visually inspect all cars in the CN 677 series.

Subsequent to a derailment (TSB Report No. R03D0042) of a freight train proceeding at 26 mph in a 10 mph zone, the St. Lawrence & Atlantic Railroad reduced train speeds to 10 mph in all urban areas it serves. The frequency of ongoing inspections by the internal rail defect detection cars and of track geometry testing has been increased to twice annually. TC conducted an audit of methods and evaluated the track condition in the Sherbrooke Subdivision. TC also conducted train speed checks using radar in areas in which speed limits are in effect.

Subsequent to TSB Occurrence No. R03T0080, CPR modified the software on all wayside detectors such that, while passing the detector, the alarm tone is immediately followed by a radio announcement identifying the nature of the defect (e.g. dragging equipment, hot box or hot wheel). CPR's General Operating Instructions involving train inspections and HBDs have been revised.

CPR completed a tie replacement program on the Belleville Subdivision.

AIR

Occurrence Statistics and Investigations

ANNUAL STATISTICS

Canadian-registered aircraft, other than ultralights, were involved in 252 reported accidents in 2004, a 15% decrease from the 2003 figure of 295 and a 17% decrease from the 1999-2003 average of 305. The estimate of 2004 flying activity is 3,809,000 hours, yielding an accident rate of 6.6 accidents per 100,000 flying hours, down from the 2003 rate of 7.8 and the five-year rate of 7.9. Canadian-registered aircraft, other than ultralights, were involved in 24 fatal occurrences with 37 fatalities in 2004, fewer than the five-year average of 33 fatal occurrences with 60 fatalities. More than half of the fatal occurrences involved privately operated aircraft, and four of the remaining nine fatal occurrences involved helicopters.

The number of accidents involving ultralights decreased to 36 in 2004 from 46 in 2003, and the number of fatal accidents decreased slightly to six in 2004 from seven in 2003.

The number of foreign-registered aircraft involved in accidents in Canada decreased to 20 in 2004 from 30 in 2003. Fatal accidents also decreased to three with 10 fatalities in 2004 from six with eight fatalities in 2003.

In 2004, a total of 907 incidents were reported in accordance with TSB mandatory reporting requirements. This represents a 9% increase from the 2003 total of 834 and a 14% increase from the 1999-2003 average of 795.

AIR INVESTIGATIONS STARTED IN 2004-2005

The following information is preliminary. Final determination of events is subject to the TSB's full investigation.

DATE	LOCATION	AIRCRAFT TYPE	OCCURRENCE NO.
2004.04.07	CYXU London, Ont.	Cessna 172M Boeing 737-200	A04O0092
2004.04.08	Mount O'Leary, B.C.	Cirrus Design SR20	A04P0110
2004.04.19	CYMT Chibougamau/Chapais, Que.	Beechcraft A100	A04Q0049
2004.04.22	CYTS Timmins, Ont.	Raytheon B300	A04O0103
2004.04.28	Tasu Creek (Queen Charlotte Islands), B.C.	Bell 206L	A04P0142
2004.05.05	CYVR Vancouver Intl, B.C.	de Havilland DHC-8-100 de Havilland DHC-2	A04P0153
2004.05.08	Thetis Island, B.C.	Cessna 305A	A04P0158
2004.05.15	Tabusintac, N.B., 2 nm E	Eurocopter AS350-B3	A04A0050
2004.05.18	Fawcett Lake, Ont.	de Havilland DHC-2 Mark I Beaver	A04C0098
2004.05.28	CYMQ Moncton/Greater Moncton Intl, N.B.	Boeing 727-225	A04A0057
2004.06.07	Taltson River (Ferguson's Cabin), N.W.T.	Cessna A185F	A04W0114
2004.06.11	Bob Quinn Airstrip, B.C.	MD Helicopter 369D	A04P0206
2004.06.13	CYQB Québec/Jean Lesage Intl, Que.	Airbus A320 Cessna 172S	A04Q0089
2004.06.14	Gatineau, Que., 2 nm SE	de Havilland DHC-2 Mark 1	A04H0002
2004.06.25	Flourmill Volcano, B.C., 5 nm W	Eurocopter AS350 B2	A04P0240
2004.07.14	CYOW Ottawa/Macdonald-Cartier Intl, Ont.	Embraer EMB-145	A04O0188
2004.07.18	Stanley, N.S.	Schreder HP 18 (amateur-built glider)	A04A0079
2004.08.05	Québec (YQB VOR), Que.	Cessna 208B Cessna 172R	A04Q0124
2004.08.13	McIvor Lake, B.C.	Robinson R22 Beta	A04P0314
2004.08.19	CYSJ Saint John, N.B.	Piper PA-31-350	A04A0099
2004.08.26	CJE7 Ashern, Man., 15 nm SW	Piper PA-28-235	A04C0162
2004.08.31	CYQM Moncton/Greater Moncton Intl, N.B.	Boeing 727-200	A04A0110
2004.08.31	Nain, N.L., 45 nm NW	Eurocopter AS 350 D	A04A0111
2004.09.02	Kingston, Ont.	de Havilland DHC8-102	A04O0237
2004.09.10	CYXD Edmonton City Centre (Blatchford), Alta.	Beech C90A	A04W0200
2004.09.21	CYVC La Ronge Airport, Sask.	Fairchild SA-227-AC Metro III	A04C0174
2004.10.14	CYHZ Halifax Intl, N.S.	Boeing 747-200	A04H0004
2004.10.30	Shepherd Bay, Nun.	Bell 212	A04C0190
2004.12.01	CYGS St-Georges, Que.	Beech B300	A04Q0188
2004.12.05	CYYT St. John's Intl, N.L.,10 nm SW	Piper PA-28	A04A0148
2004.12.16	CYOO Oshawa, Ont.	Shorts SD3-60	A04O0336
2004.12.19	CYPG Gaspé, Que.	Piper PA-31-350	A04Q0196
2004.12.24	CYVP Kuujjuaq, Que.	Beech A100	A04Q0199
2004.12.28	Invermere, B.C., 16 nm S	Robinson R44	A04P0422
2005.01.01	SCEM, Santiago, Chile	Boeing 767-300	A05F0001
2005.01.19	Kelowna, B.C., 80 nm NE	Beechcraft King Air 200	A05P0018
2005.01.20	CYYC Calgary Intl, Alta.	McDonnell Douglas DC-9-83	A05W0010
2005.01.24	La Grande-4, Que., 60 nm SE	Eurocopter AS-350 B	A05Q0008
2005.02.11	Spearhead Glacier, B.C.	Bell 212	A05P0032
2005.02.21	CZBM Bromont, Que.	Hawker Siddeley HS 125	A05Q0024
2005.02.24	Blue River, B.C.	Bell 212	A05P0038
2005.03.06	Varadero, Cuba	Airbus A310-300	A05F0047

AIR REPORTS RELEASED IN 2004-2005

DATE	LOCATION	AIRCRAFT TYPE	EVENT	REPORT NO.
2001.10.08	Mollet Lake, Que.	de Havilland DHC-2 MK I	Collision with water	A01Q0166
2002.01.20	Patapédia River Valley, N.B.	Piper PA28-161	Collision with terrain	A02Q0005
2002.02.22	Val d'Or Airport, Que.	Eurocopter AS 350 BA	In-flight engagement of collective lever lock	A02Q0021
2002.05.09	Des Passes Lake, Que.	Cessna 180F	Nose down and over on take-off	A02Q0054
2002.05.13	Toronto/Lester B. Pearson Intl Airport, Ont.	Boeing 767-300	Cargo bay fire	A02O0123
2002.05.18	North Bay Airport, Ont.	Beechcraft King Air A100	Nose landing gear actuation failure	A02O0131
2002.05.20	Three Valley Gap, B.C.	Bell 206L-4	Loss of control and collision with terrain	A02P0096
2002.07.11	Chitek Lake, Sask.	Bell 205	Drive shaft failure and collision with terrain	A02C0161
2002.07.14	Saint-Stanislas de Kostka, Que.	Gilles Léger Super Chipmunk	In-flight separation of right wing	A02Q0098
2002.08.07	Smithers, B.C., 10 nm S	Bell 214B-1	Engine power loss	A02P0168
2002.08.15	McBride, B.C., 20 nm S	Eurocopter SA315B Lama Helicopter	Engine power loss - component failure	A02P0179
2002.08.25	Toronto Airport Control Tower, Toronto/Lester B. Pearson Intl Airport, Ont.	Cessna 206 McDonnell Douglas DC-9-51	Risk of collision	A02O0272
2002.09.02	Québec/ Jean Lesage Intl Airport, Que.	Mooney M20E	Engine failure and loss of control	A02Q0119
2002.09.07	Lake St. John, Orillia, Ont.	Cessna 172P	Loss of control and collision with terrain	A02O0287
2002.09.10	Gander Intl Airport, N.L.	DC-8-63F	Runway overrun	A02A0107
2002.09.11	Halifax Intl Airport, N.S.	Navajo Chieftain PA-31-350	Wheels-up landing	A02A0108
2002.09.11	Pink Mountain, B.C. 20 nm W	Bell 212	Tail rotor drill shaft coupling failure	A02W0178
2002.09.17	London, Ont.	Sikorsky S-76A	Hard landing	A02O0301
2002.10.17	Churchill, Man., 290 nm NE	Boeing 777-228ER	Cockpit fire - precautionary landing	A02C0227
2002.10.20	Timmins, Ont., 40 nm W	Airbus A340-300	Engine power loss in flight	A02P0261
2002.10.24	Toronto/Lester B. Pearson Intl Airport, Ont.	de Havilland DHC8-311	Aircraft difficult to control	A02O0349
2002.12.16	Lake Errock, B.C.	Sikorsky S-61N	Loss of engine power	A02P0320
2003.01.21	Mekatina, Ont.	Eurocopter AS 350 B2	Loss of control - collision with terrain	A03O0012
2003.02.14	Goose Bay, N.L., 5 nm E	Cessna 210 N	Loss of control - collision with terrain	A03A0022
2003.03.05	Gander, N.L.	McDonnell Douglas MD-11 Boeing 757-224	Communications failure - loss of separation	A03H0001
2003.03.13	Dauphin, Man., 25 nm SW	Beechcraft King Air C90A	Flight control malfunction	A03C0068
2003.03.25	Langley Airport, B.C., 6 nm NE	Piper PA-28-140	Spiral dive - collision with terrain	A03P0068
2003.04.09	Peace River, Alta.,10 nm SE	Robinson R44	Loss of control - inadequate rotor RPM	A03W0074
2003.04.23	Prince Albert, Sask., 6 nm SW	Beech 99A	Loss of pitch control - collision with object	A03C0094
2003.05.31	Chilliwack Airport, B.C., 7.5 nm E	Cessna 182	Controlled flight into terrain	A03P0133
2003.06.05	Lake Wicksteed, Ont.	de Havilland DHC-6-300	Loss of control on water	A03O0135
2003.06.06	Ward Creek, B.C.	Bell 206B	Engine power loss - hard landing and rollover	A03P0136
2003.06.18	Gisborne, New Zealand, 300 nm ESE	Convair 580	Navigational and rollover error - fuel shortage	A03F0114
2003.06.24	Wasaga Beach, Ont., 5 nm WSW	Mooney M20 E	Engine failure and forced landing on water	A03O0156
2003.06.26	Buchans, N.L., 25 nm SE	Dromader PZL-M-18	Loss of control - collision with terrain	A03A0076
2003.07.04	Boucher Lake, Que.	Bell 206B Jet Ranger	Collision with water	A03Q0092
2003.07.13	Manning, Alta., 75 nm NE	Bell 204B	Loss of power - mechanical malfunction	A03W0148
2003.07.16	Cranbrook, B.C., 2.5 nm S	Lockheed L-188 Electra	Collision with terrain	A03P0194
2003.07.18	Harrison Hot Springs, B.C., 24 nm NNW	Cessna 172M	Collision with terrain	A03P0199
2003.08.05	Toronto, Ont.	Boeing 767 Fokker 100	Loss of separation	A03O0213
2003.08.10	Princeton, B.C.	Cessna 210A	Collision with terrain	A03P0239
2003.08.11	Port Hardy, B.C., 26 nm W	Boeing 747-400 Boeing 757-200	Risk of collision	A03P0244
2003.08.23	Vernon, B.C.	Airbus A319-114	Navigational error - premature descent	A03P0259
2003.08.29	Penticton, B.C., 11 nm NE	de Havilland DHC-2 Mark I	Collision with terrain	A03P0265
2003.09.03	Vancouver Harbour, B.C.	de Havilland DHC-6-100 (Twin Otter)	Collision with dock	A03P0268
2003.09.11	Summer Beaver, Ont.	Cessna 208B	Caravan Collision with terrain	A03H0002
2003.09.16	Mayo, Y.T., 80 nm N	Bell 206B	Power loss and dynamic rollover	A03W0194
2003.09.23	Calgary, Alta., 49 nm SW	Cessna 414A	Controlled flight into terrain	A03W0202
2003.09.26	Toronto/Lester B. Pearson Intl Airport, Ont.	Gulfstream Aerospace LP Astra SPX	Runway excursion	A03O0273
2003.09.27	Gaspé, Que.	PA-31-310	Controlled flight into terrain	A03Q0151
2003.10.04	Linda Lake, B.C.	Piper PA-18-150	Loss of control/stall	A03W0210
2003.10.09	Toronto/Buttonville Municipal Airport, Ont. 2 nm SSE	Cessna 172N	Engine power loss and forced landing	A03O0285
2003.11.06	Vancouver Intl Airport, B.C.	Airbus A330-300	Maintenance error - in-flight fuel leak	A03P0332
2003.12.16	Jellicoe, Ont.	de Havilland DHC-3 (Otter)	Loss of control after take-off	A03O0341
2004.01.13	La Grande, Que., 160 nm SSW	Boeing 767 Boeing 777	Loss of separation	A04Q0003
2004.01.15	Dryden Regional Airport, Ont.	Fairchild SA-277-AC	Loss of directional control and runway excursion	A04C0016
2004.01.19	Toronto/Lester B. Pearson Intl Airport, Ont.	Airbus A321-211	Nosewheel axle failure	A04O0016
2004.02.20	Kumealon Inlet, B.C.	Robinson R22	In-flight breakup	A04P0033
2004.02.29	Fraser River near Lake Ruskin, B.C.	LA-4-200 Buccaneer	Collision with water	A04P0041
2004.03.04	Swift Current, Sask., 4 nm SW	Bell 206B Jet Ranger	Loss of visual reference - collision with terrain	A04C0051
2004.03.08	Saint-Hubert, Que.	Schweizer 269C-1	Separation of main rotor on runup	A04Q0026
2004.03.12	Nanaimo, B.C., 20 nm N	Cessna 185 Cessna 185	In-flight collision	A04P0057
2004.03.20	Ralph, Sask.	Baby Belle amateur-built helicopter	In-flight breakup - collision with terrain	A04C0064
2004.04.08	Mount O'Leary, B.C.	Cirrus Design SR20	Loss of control - parachute system descent	A04P0110
2004.05.08	Thetis Island, B.C.	Cessna 305A	Loss of control	A04P0158
2004.05.15	Tabusintac, N.B., 2 nm E	Eurocopter AS350-B3	Main rotor overspeed - difficult to control	A04A0050
2004.07.18	Stanley Airport, N.S.	Schreder HP18 (amateur-built glider)	Aerodynamic stall - loss of control	A04A0079

AIR RECOMMENDATIONS ISSUED IN 2004-2005

Pelee Island, Ontario - 17 January 2004 Collision with terrain, Georgian Express		Occurrence No. A04H0001
RECOMMENDATION	RESPONSE	BOARD ASSESSMENT OF RESPONSE	SAFETY ACTION TAKEN
A04-01
The Department of Transport require that actual passenger weights be used for aircraft involved in commercial or air taxi operations with a capacity of nine passengers or fewer.	TC's response stated that current regulations make it clear that air operators are to ensure that their aircraft are flown within the limits of the weight and balance envelope and that the standards provide options that may be used but do not override the regulatory requirement to remain within the weight limits of the aircraft. TC continues to review the standards. One option that is under consideration is the use of actual weights for all operations conducted under subpart 3 (Air Taxi Operations) of Part VII (Commercial Air Services) in the Canadian Air Regulations. Once our review, including a risk assessment, is complete, a Notice of Proposed Amendments (if required) will be developed and submitted to the Canadian Aviation Regulation Advisory Council for consultation.	Satisfactory intent	None
A04-02
The Department of Transport re-evaluate the standard weights for passengers and carry-on baggage and adjust them for all aircraft to reflect the current realities.	TC re-evaluated the standard weights for passengers and carry-on baggage and adjusted them for all aircraft to reflect the current realities. A Commercial & Business Aviation Advisory Circular (CBAAC 0235) and Policy Letter were issued in October 2004 and the Aeronautical Information Publication (AIP) published weights will be amended on 20 January 2005. Operators whose approved weight and balance control program is based on the AIP weights will need to amend their programs to reflect these new weights.	Fully satisfactory	A Commercial & Business Aviation Advisory Circular (CBAAC 0235) and Policy Letter were issued in October, and the AIP Canada published weights were amended on 20 January 2005.
Timmins, Ontario 40 nm W - 20 October 2002 Engine Power Loss in Flight - Cathay Pacific Airways Airbus A340-300		Report No. A02P0261
RECOMMENDATION	RESPONSE	BOARD ASSESSMENT OF RESPONSE	SAFETY ACTION TAKEN
A04-03
The Direction Générale de l'Aviation Civile and the Federal Aviation Administration issue airworthiness directives to require the implementation of all CFM56-5 series jet engine service bulletins whose purpose is to incorporate software updates designed to ensure that, in the event of a permanent magnet alternator failure, the electronic control unit will revert to aircraft power.	In a letter received on 2 March 2005, the FAA aknowledged receipt of the recommendation and advised that it had been forwarded to the appropriate office for staffing. The letter advised that the TSB would be informed of the resolution of the TSB recommendation. DGAC has not yet responded.	Pending
A04-04
The Department of Transport ensure the continued airworthiness of Canadian-registered aircraft fitted with the CFM56-5 series engine by developing an appropriate safety assurance strategy to make certain that, in the event of a permanent magnet alternator failure, the electronic control unit will revert to aircraft power.	TC's response stated that it confirmed, through communication with the Canadian aviation industry, that all Canadian aircraft presently affected by CFM SB 73-0126 will have their ECU software upgraded to version C.3.J by March 2005. Therefore, TC is not planning on taking any further action.	Pending

OTHER AIR SAFETY ACTIONS TAKEN

• Calgary Airport Authority has responded to Safety Information Letter A040061-1 by requesting that NAV CANADA file a NOTAM (Notice to Airmen) outlining revised Landing Distances Available for Land and Hold Short Operations. The Canada Flight Supplement and the Canada Air Pilot documents will follow at the next amendment cycle.
• TC published an article in their Aviation Safety Letter, Issue 1/2005, highlighting the details of an occurrence reported to them concerning the throttle arrangement of Beech 90s.
• TC included an article in the Aviation Safety Maintainer on the topic of scheduled lubrication intervals after being advised by the TSB of an occurrence involving a Beech 1900D.
• TC took action to advise the Type Certificate Holder for the Piper PA-18-150 that certain weight and balance information available to Piper PA-18 owners and operators in Canada may be in error.
• TC issued a Notice of Proposed Amendment to the Canadian Aviation Regulation Advisory Council to strengthen and streamline the aerodrome data verification process as a result of advice from the TSB in Safety Advisory A040059 concerning information discovered during the investigation into the MK 747 accident in Halifax.
• Air Canada initiated an internal awareness campaign concerning visual approach guidance and published a description of the TSB investigation into an approach to the wrong airport. Enhancements were made to the Flight Operations Manual with respect to visual approach guidance.
• The RCMP Air Services made arrangements for all pilots who did not have a current proficiency check ride to have one done. The operations manual has been amended to reflect a requirement for their helicopter pilots to have a proficiency check ride every two years and a route check on alternate years.
• The Transport Canada Civil Aviation Medicine Branch has initiated a project with the TSB to re-examine the accidents with known or suspected cardiac incapacitation during the past 10 years. Following this review, more frequent or extensive testing may be proposed.
• On 27 May 2004, Robinson Helicopter Company issued an updated service bulletin (SB-78A) that included background information regarding a recent accident and the risk of excessive teetering of the main rotor, should the brackets fail. That service bulletin requested that owners, operators and service centres determine if SB-78A was complied with and, if not, to proceed with the instructions for SB-78A. The U.S. Federal Aviation Administration plans to issue a Notice of Proposed Rulemaking Airworthiness Directive to mandate the installation of the manufacturer's higher strength teeter stop brackets.
• NAV CANADA increased the ability of Calgary Tower and Edmonton Flight Information Centre personnel to search computer records for positive information on aircraft arrival and departure, with options for search by registration or time frame. In addition, the Edmonton Area Control Centre (ACC) shift managers and the Edmonton air traffic operations specialist, located in the Edmonton ACC, now have access to the same computer records for search capabilities. A similar system is being beta-tested in two centres and will be considered for national deployment.
• As a result of a loss of separation occurrence, NAV CANADA has added one controller on the day shift to avoid the situation in which one controller works more than one data board. Toronto ACC and Cleveland ARTCC (Air Route Traffic Control Center) held discussions that resulted in the staffing of additional full-time day and evening data controllers in both units to manually pass hand-off data.
• As a result of a water bombing occurrence, and commencing with its 2004 annual pilot training course, Air Spray Ltd. has placed additional emphasis on human factors and emergency manoeuvring in mountainous areas. Particular attention has been given to the deceptive nature of mountainous terrain at high sun angles, and the deceptive illusionary nature of mountain flying continues to be stressed in its training programs.
• Following a low fuel situation over the Pacific Ocean, Kelowna Flightcraft Air Charter Ltd. has purchased up-to-date North American data cards from Garmin for all Apollo 820 GPSs installed in its Convair 580 aircraft.
• Following a collision with terrain occurrence, TC produced a Service Difficulty Alert (AL-2003-07, dated 2003-07-17) indicating that the installation procedures of the horizontal stabilizer actuator in the King Air maintenance manual are being reassessed.
• As a result of an in-flight fire and precautionary landing, Boeing has undertaken a program to redesign the window terminal block to eliminate the screw connection. All Boeing 747, 757, 767 and 777 windows delivered thereafter, either on new airplanes or as spares, will have the new terminals installed. The intent is to eliminate concerns with arcing at the window power terminals.

APPENDIX A - GLOSSARY

Accident	in general, a transportation occurrence that involves serious personal injury or death, or significant damage to property, in particular to the extent that safe operations are affected (for a more precise definition, see the Transportation Safety Board Regulations)
Incident	in general, a transportation occurrence whose consequences are less serious than those of an accident, or that could potentially have resulted in an accident (for a more precise definition, see the Transportation Safety Board Regulations)
Occurrence	a transportation accident or incident
Recommendation	a formal way to draw attention to systemic safety issues, normally warranting ministerial attention
Safety Advisory	a less formal means for communicating lesser safety deficiencies to officials within and outside of government
Safety Information Letter	a letter that communicates safety-related information, often concerning local safety hazards, to government and corporate officials

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1.   While the Board's operations are for the 2004-2005 fiscal year, occurrence statistics are for the 2004 calendar year. Comparisons are generally to the last 5 or 10 years. For definitions of terms such as accident, incident and occurrence, see Appendix A.

2.   Investigations are considered complete after the final report has been issued.

3.   For definitions of terms such as recommendation, safety advisory and safety information letter, see Appendix A.

4.   Also includes responses to recommendations issued in the previous fiscal year.