Marine

Marine investigation report M12L0147

Date 28 November 2012
Location Sainte-Anne-de-Sorel, Quebec
Vessel Tundra
Type Bulk carrier
Event Grounding
Safety action taken The vessel owner reminded officers of the entire fleet to regularly verify/monitor the vessel’s course when the vessel is under the conduct of a pilot. This issue was to be discussed at a safety meeting, and feedback then communicated to the company.

The Laurentian Pilotage Authority (LPA) and the Corporation des Pilotes du Saint-Laurent Central (CPSLC) will undertake a study on the risks related to fatigue. In addition, the LPA, in collaboration with the CPSLC and the Corporation of Lower St. Lawrence Pilots, published a brochure on the master-pilot exchange. This brochure is provided by the pilot to the master upon boarding and outlines the particulars of the exchange.

Marine investigation report M13N0001

Date 24 January 2013
Location Off Cape Race, Newfoundland and Labrador
Vessel Charlene Hunt
Lyubov Orlova
Type Tug
Passenger vessel
Event Loss of tow
Safety action taken No safety action was taken as a result of this investigation.

Marine investigation report M13L0055

Date 08 May 2013
Location Baie-Comeau, Quebec
Vessel Federal Yoshino
Type Bulk carrier
Event Accidental death
Safety action taken Fednav Limited immediately instructed Intership Navigation Company Limited to stop using provision cranes for lifting personnel.

Intership Navigation Company Limited had on-board safety training carried out on all vessels it manages.

Det Norske Veritas Germanischer Lloyd issued a casualty information newsletter intended for the maritime industry, focusing on the suitability of lifting equipment for the transport of personnel and addressing the importance of checking safety functions before lifting operations; e.g., by limiting switches for all lifting appliances.

The Marshall Islands (the vessel’s administrator and flag state) made recommendations to Intership Navigation Company Limited.

Marine investigation report M13N0014

Date 10 May 2013
Location 33 nm southwest of Burgeo, Newfoundland and Labrador
Vessel Western Tugger
Arctic Lift I
Type Tug
Barge
Event Capsizing of tow and accidental death
Safety action taken TC is currently consulting on the expansion of the Safety Management Regulations. Under the current proposal, the Western Tugger would be required to have a safety management system in accordance with the International Safety Management Code.

The vessel operator is repairing the vessel’s towing winch, which will not incorporate a second brake.

Marine investigation report M13L0067

Date 16 May 2013
Location Off Sainte-Pétronille, Île d’Orléans, Quebec
Vessel Louis Jolliet
Type Passenger vessel
Event Grounding
Safety action taken In response to a TSB Marine Safety Information Letter, Croisières AML responded that the vessel’s equipment and emergency procedures would be revised to address the stowage of items on the deck.

TC issued a FLAGSTATENET notice to all TC inspectors and others authorized to carry out inspections to remind them of the requirements under section 7 of the Fire and Boat Drill Regulations. TC also added new fields to the System Inspection Reporting System to remind inspectors to ensure that these requirements are met.

Croisières AML had tracks for the cruises traced onto the marine chart and began evaluating crew members’ understanding of safety matters on board the vessels. The company has issued a new procedure to the chief mates of the vessels, ensuring that crew members are aware of their respective positions according to the muster list, to avoid confusion in an emergency.

A summary of emergency procedures was developed, as well as a guidance document for the conduct of the various emergency procedures and drills, including a new pre-evacuation drill.

Employees have been provided with new equipment to wear during emergencies to identify them as crew members.

Marine investigation report M13M0102

Date 18 May 2013
Location Tabusintac Bay, New Brunswick
Vessel Marie J
Type Small fishing vessel
Event Grounding and subsequent sinking
Safety action taken The Canadian Coast Guard Aids to Navigation design and review specialists conducted a review and as a result, five green port-hand buoys were added to the channel.

Public Works and Government Services Canada, on behalf of Fisheries and Oceans Canada, commissioned a coastal study to assess alternative strategies for improving navigational safety to access McEachern’s Point harbour at Tabusintac Bay.

Marine investigation report M13L0123

Date 03 August 2013
Location Port of Montreal, Quebec
Vessel Heloise
Ocean Georgie Bain
Type Bulk carrier
Tug
Event Collision
Safety action taken No safety action was taken as a result of this investigation.

Marine investigation report M13C0071

Date 06 November 2013
Location Iroquois, Ontario
Vessel Claude A. Desgagnés
Type General cargo vessel
Event Striking and subsequent grounding
Safety action taken Transport Desgagnés Inc. revised and updated the Bridge Manual Instructions included in its Quality, Safety, Security and Environmental Management System. This revision includes the bridge resource management procedures required while the vessel is under the conduct of a pilot and, in particular, the responsibilities of the master and officer of the watch, supervision of the pilot, safe conduct of the vessel, and access to the vessel’s bridge and equipment.

Marine investigation report M13M0287

Date 07 November 2013
Location Digby, Nova Scotia
Vessel Princess of Acadia
Type Roll-on/roll-off passenger vessel
Event Grounding
Safety action taken Lloyd’s Register changed the frequency of testing for the generator breakers on the Princess of Acadia to yearly, citing the age and usage of the breakers.

Bay Ferries Ltd. has required the bow thruster to be on and tested at Checkpoint 1 Delta when the Princess of Acadia arrives in Digby. In addition, the engine room assistant is now required to stay in the engine room until the vessel secures to the dock in Digby. An uninterrupted power supply has been installed to provide battery back-up to the gyro compass. A simplified voyage data recorder has also been installed, which will record 12 hours of bridge audio and data from the radars, the automatic identification system and other available sensors.

Marine investigation report M13L0185

Date 15 December 2013
Location Gros-Morne, Quebec
Vessel Andre H.
I.V. NO. 8
I.V. NO. 9
I.V. NO. 10
Type Tug
Barge
2 service vessels
Event Loss of tow and subsequent grounding
Safety action taken No safety action was taken as a result of this investigation.

Marine investigation report M14P0014

Date 25 January 2014
Location Fraser River, British Columbia
Vessel Cap Blanche
Type Container vessel
Event Grounding
Safety action taken The TSB issued a marine safety advisory letter to the Pacific Pilotage Authority (PPA) on 08 May 2014, providing information about the discrepancy between input from a vessel’s automatic identification system and input from the pilots’ wide area augmentation system based differential global positioning system antennas.

The PPA distributed the safety advisory letter to all pilots in a notice to pilots.

Marine investigation report M14P0023

Date 11 February 2014
Location South Arm Fraser River, British Columbia
Vessel Jose Navarez
TCT 8000
Type Tug
Barge
Event Loss of propulsion
Safety action taken Lafarge Canada established weekly meetings within the Lafarge Marine Division to review safety procedures, drills, and preventive maintenance at the beginning of a shift. The company also replaced the tug’s main engine and cooling system, including an upgrade to the monitoring system and alarm panel.

Pipeline

Pipeline investigation report P13H0013

Date 02 August 2013
Location Near Wrigley, Northwest Territories
Company Enbridge Pipelines Inc.
Event Crude oil pipeline leak
Safety action taken The National Energy Board issued a Board order requiring Enbridge to complete and submit assessments and to submit a plan outlining how and when Enbridge will implement selected technology.

Enbridge complied with all of the conditions of the Board order and submitted a plan outlining how and when it would implement leak-detection technologies on Line 21 into its engineering assessments.

Rail

Rail investigation report R12E0182

Date 26 December 2012
Location Clover Bar, Alberta
Company Canadian National
Event Contractor employee injury
Safety action taken TC approved the updated Canadian Rail Operating Rules that were formulated and submitted by the Railway Association of Canada to include rules on safety watch and lone worker protection.

Rail investigation report R13C0008

Date 19 January 2013
Location Tilley, Alberta
Company Canadian Pacific
Event Crossing collision
Safety action taken TC asked the Transportation Development Centre to undertake a research project pertaining to the audibility of train horns.

Rail investigation report R13E0015

Date 24 January 2013
Location Paynton, Saskatchewan
Company Canadian National
Event Crossing collision
Safety action taken TC indicated that it had asked the Transportation Development Centre to undertake a research project on the audibility of horns to analyze a horn’s effectiveness when long hood leading. TC acknowledged the importance of this to railway safety in Canada, and indicated that the research project would be assigned high priority in the next fiscal year.

Rail investigation report R13W0083

Date 26 March 2013
Location Carlyle, Saskatchewan
Company Canadian National
Event Crossing accident
Safety action taken The Province of Saskatchewan amended the School Bus Operating Regulations to require drivers, when approaching a railroad crossing that does not have an automatic signal indicating the approach of a train, to stop the bus, open the front door of the bus, and look in both directions.

Rail investigation report R13T0060

Date 03 April 2013
Location White River, Ontario
Company Canadian Pacific
Event Main-track train derailment
Safety action taken The Association of American Railroads (AAR) Tank Car Committee undertook a study on the general performance of tank car bottom outlet valves in transport, and on the possible retrofit of existing valve actuating devices built according to an old standard. The committee is proposing upgrades to the protection of bottom outlet valves.

TC’s Transportation of Dangerous Goods Directorate participates on an AAR task force set up to investigate the behaviour of bottom outlet valves in derailments and to propose possible solutions.

Rail investigation report R13W0124

Date 28 April 2013
Location Togo, Saskatchewan
Company VIA Rail Canada Inc.
Event Subgrade collapse and derailment
Safety action taken TC approved the Railway Locomotive Inspection and Safety Rules formulated and submitted by the Railway Association of Canada, which prescribe that fuel tanks on new and remanufactured locomotives are to be of a high impact resistant design that meets or exceeds current recommended practices.

Canadian National (CN) produced a video on spring readiness inspections, and two supporting documents were produced and provided to all track inspectors and supervisors as a refresher.

Rail investigation report R13Q0012

Date 02 May 2013
Location Québec, Quebec
Company VIA Rail Canada Inc.
Event Collision at a level crossing
Safety action taken TC met with representatives of the City of Québec, the White Birch Paper mill, and CN to review the operation of the systems at this level crossing and to examine solutions.

VIA Rail Canada Inc. amended its procedures so that trains no longer stop upon exiting the Gare du Palais.

Rail investigation report R13C0049

Date 18 May 2013
Location Dunmore, Alberta
Company Canadian Pacific
Event Main-track train collision
Safety action taken TC’s Advisory Council on Railway Safety Working Group will provide TC with a written report on options and recommendations concerning physical fail-safe train control by the fall of 2015.

Rail investigation report R13T0122

Date 02 June 2013
Location Wanup, Ontario
Company Canadian Pacific
Event Main-track derailment
Safety action taken No safety action was taken as a result of this investigation.

Rail investigation report R13C0069

Date 27 June 2013
Location Bonnybrook Bridge Calgary, Alberta
Company Canadian Pacific
Event Bridge failure and derailment
Safety action taken TC is updating its Guideline for Bridge Safety Management and Guideline for Culvert Safety Management. Scour, erosion, and stream stability hazards, including those associated with spread foundations, will be addressed.

Rail investigation report R13D0054

Date 06 July 2013
Location Lac Mégantic, Quebec
Company Montreal, Maine & Atlantic Railway
Event Runaway and main-track derailment
Safety action taken See Lac-Mégantic investigation section in this report.

Rail investigation report R13C0087

Date 11 September 2013
Location Inglewood, Alberta
Company Canadian Pacific
Event Main-track derailment
Safety action taken CP removed the crossover switches at Mile 0.30 to prevent any risk of a subsequent incident.

Rail investigation report R13E0142

Date 19 October 2013
Location Gainford, Alberta
Company Canadian National
Event Non main-track derailment
Safety action taken CN has commenced a program for rail grinding on high-speed sidings such as Gainford.

Rail investigation report R13D0077

Date 06 November 2013
Location Taschereau Yard Montreal, Quebec
Company Canadian National
Event Derailment
Safety action taken TC issued a circular with specific instructions for when a train is occupying the 15-degree curve.

Rail investigation report R13W0257

Date 10 November 2013
Location Nickel Lake, Ontario
Company Canadian National
Event Main-track derailment
Safety action taken CN has reviewed the track geometry and train speed in this area.

Rail investigation report R13W0260

Date 19 November 2013
Location Tisdale, Saskatchewan
Company Canadian National
Event Employee fatality
Safety action taken TC identified the issue of trainee supervision in its risk-based business plan for the upcoming program year, and is developing risk-control actions to address it.

CN issued an Operating Bulletin to remind employees who are assigned a trainee that they must be in a position that allows for continuous monitoring of the trainee, and for immediate intervention and corrective action of any non-compliant or unsafe activity.

Aviation

Aviation investigation report A12P0008

Date 17 January 2012
Location Cultus Lake, British Columbia
Aircraft Eurocopter AS 350 B3 (helicopter)
Event Engine power loss and hard landing
Safety action taken Royal Canadian Mounted Police chief pilots are now providing all pilots with “Cold Weather and Warm Weather Operations” briefings at the beginning of each season, reviewing critical aspects in relation to the operational environment and aircraft flown.

A complete safety risk profile involving all stakeholders was completed on the human external transportation system program. All stakeholders were educated on the flight envelope and aircraft limitations within which these operations take place.

TC has initiated a review of the engine inlet design in accordance with the Airworthiness Manual. This review is a National Aircraft Certification project requiring international coordination.

TC has published a civil aviation safety alert regarding the AS 350, to raise operator awareness of the problem with moisture collection in the plenum chambers of this aircraft.

Eurocopter issued a safety information notice regarding ice and rain protection.

Aviation investigation report A12Q0029

Date 21 February 2012
Location Montréal/Saint-Hubert Airport, Quebec
Aircraft Beechcraft B100
Event Smoke in the cabin
Safety action taken Pascan Aviation Inc. reminded its maintenance personnel to closely inspect the hot air ducts and under-floor bleed air line installation. In addition, flight crews have been reminded to report any problems relating to the bleed air and heating system.

Aviation investigation report A12Q0161

Date 10 September 2012
Location Gaspé Airport, Quebec
Aircraft de Havilland DHC-8-301
Event Hard landing and aft fuselage strike
Safety action taken Jazz Aviation LP has issued a pilot memo on duck-under (glideslope adherence) events and made amendments to the aircraft operating manual. It added the “Dash-8 Q400 Pitch Awareness” video to DH8 100/300 training and issued an all-pilots memo regarding stabilized approach and landing.

Aviation investigation report A12Q0182

Date 15 October 2012
Location Victoriaville, Quebec
Aircraft Piper PA-34-200
Event In-flight engine fire leading to a forced landing
Safety action taken No safety action was taken as a result of this investigation.

Aviation investigation report A12C0154

Date 18 November 2012
Location Snow Lake, Manitoba
Aircraft Cessna 208B
Event Loss of control and collision with terrain
Safety action taken No safety action was taken as a result of this investigation.

Aviation investigation report A13F0011

Date 23 January 2013
Location Mount Elizabeth, Antarctica
Aircraft de Havilland DHC 6 300
Event Controlled flight into terrain
Safety action taken Kenn Borek Air Ltd. has taken over flight-following in the Antarctic from a third-party flightfollowing organization, amended its GPS standard operating procedures to prevent incorrect data input, improved the accuracy of aviation navigational charts in the Antarctic, and developed company visual flight rules routes for flights exceeding 400 nautical miles. It also implemented a terrain awareness and warning system limitation awareness program for flights above the 70th parallel north and below the 70th parallel south; and improved administrative oversight of daily aircraft inspections.

Aviation investigation report A13W0009

Date 27 January 2013
Location Fox Creek, Alberta
Aircraft Robinson R44 Raven II (Helicopter)
Event Loss of control and in-flight breakup
Safety action taken Gemini Helicopters Inc. amended its operations manual and its flight following procedures. It has also developed and implemented a daily flight risk-assessment document that is used by the operations and dispatch departments.

ACR Electronics has modified emergency locator transmitter mounting.

Aviation investigation report A13O0045

Date 11 March 2013
Location Toronto Lester B. Pearson International Airport, Ontario
Aircraft Embraer EMB190
Event Runway incursion and risk of collision
Safety action taken Greater Toronto Airports Authority (GTAA) issued an operational directive to secure vehicles airside. GTAA aviation safety officers undertook spot checks and airside traffic stops of any vehicle that appeared to have a weak or inoperative roof beacon, and directed drivers to have vehicle beacons repaired or replaced. It also issued an advisory to inform the Toronto Pearson aviation community of minimum luminosity expectations for vehicle beacons.

Sunwing Airlines reported to TC Civil Aviation that it had inspected all of its airside vehicles’ rotating beacon bulbs, and replaced bulbs found not to meet specifications.

Aviation investigation report A13O0049

Date 19 March 2013
Location Hamilton Airport, Ontario
Aircraft Boeing 727-281
Event Risk of collision
Safety action taken Kelowna Flightcraft Air Charter Ltd. issued a memo to all flight crews discussing air traffic control-initiated rejected takeoffs and standard terminology, and it included these takeoffs in recurrent training exercises.

Aviation investigation report A13A0033

Date 27 March 2013
Location St. Anthony, Newfoundland and Labrador
Aircraft de Havilland DHC-6-300
Event Nosewheel failure on landing
Safety action taken Air Labrador Limited amended the Twin Otter standard operating procedures, including to restrict all landings to crosswinds of 30 knots at 90°.

Aviation investigation report A13O0098

Date 26 May 2013
Location Sault Ste. Marie Airport, Ontario
Aircraft Bombardier DHC-8-402
Event Hard landing and tail strike
Safety action taken Porter Airlines Inc. initiated a safety management system investigation. Part of the immediate corrective action involved a revision of the Pitch Awareness Training document to highlight previous occurrences and the need to arrest high descent rates with power and not pitch.

Aviation investigation report A13P0127

Date 29 June 2013
Location Pemberton, British Columbia
Aircraft Cessna 150F and STEMME S10-VT
Event Mid-air collision
Safety action taken No safety action was taken as a result of this investigation.

Aviation investigation report A13C0073

Date 01 July 2013
Location Gull Lake, Manitoba
Aircraft Bell 206B (Helicopter)
Event Collision with water
Safety action taken Custom Helicopters Ltd. incorporated the Pilot Competencies for Helicopter Wildfire Operations guide into its spring training program. The purpose of the guide is to promote effective helicopter operations in wildfire operations, and the competencies it outlines are standards that pilots must meet before being dispatched to work in wildfire operations.

Aviation investigation report A13A0075

Date 03 July 2013
Location Moosehead Lake, Newfoundland and Labrador
Aircraft CL-415
Event Loss of control – collision with water
Safety action taken The Government of Newfoundland and Labrador Air Services Division has made aircraft-related changes such as ensuring life vests are secured in the cockpit and cabin, the life raft is installed in a manner that provides ease of removal, and storage cases and cargo straps are used to secure cargo and loose items. It has also equipped each aircraft with a portable satellite telephone, and made improvements to the training programs and to its procedures.

Aviation investigation report A13O0125

Date 04 July 2013
Location Griffith Island, Ontario
Aircraft Cessna 182
Event Loss of control – collision with water
Safety action taken No safety action was taken as a result of this investigation.

Aviation investigation report A13P0163

Date 04 August 2013
Location Bella Coola, British Columbia
Aircraft Kamov Ka-32
Event Engine power loss, emergency landing, and rollover
Safety action taken The Russian aviation regulator issued a revised airworthiness directive that increased maintenance requirements for engines installed in Kamov Ka-32 helicopters used for external load operations.

VIH Helicopters Ltd. has increased “load release” training and added it to the yearly recurrent training requirements, and is field testing an improved electrical release guard.

Aviation investigation report A13P0165

Date 06 August 2013
Location Kamloops, British Columbia
Aircraft Cessna 172L
Event Loss of control – collision with terrain
Safety action taken No safety action was taken as a result of this investigation.

Aviation investigation report A13P0166

Date 16 August 2013
Location Hesquiat Lake, British Columbia
Aircraft de Havilland DHC-2 Beaver
Event Controlled flight into terrain
Safety action taken No safety action was taken as a result of this investigation.

Aviation investigation report A13C0105

Date 22 August 2013
Location Ivanhoe Lake, Northwest Territories
Aircraft de Havilland DHC-3 Otter
Event Loss of control – collision with water
Safety action taken Transwest Air issued and circulated a safety directive to all employees that expands on its expectation of compliance with section 605.06 of the Canadian Aviation Regulations.

Aviation investigation report A13P0278

Date 24 October 2013
Location West Cracroft Island, British Columbia
Aircraft Cessna C-185E
Event Aerodynamic stall – collision with terrain
Safety action taken Air Cab has begun emphasizing an awareness of aircraft modifications and their effect on aircraft handling during pilot initial and recurrent training. The company is also implementing a back-up to the aircraft’s emergency locator transmitter, and the installation of a disconnect G switch on its aircraft batteries to reduce the risk of fire.

Aviation investigation report A13Q0186

Date 04 November 2013
Location Montreal, Quebec
Aircraft Boeing 767-36N/ER
Event Belt loader fire leading to cabin smoke and evacuation of passengers
Safety action taken No safety action was taken as a result of this investigation.

Aviation investigation report A14Q0011

Date 23 January 2014
Location Alma, Quebec
Aircraft Piper PA-46-350P
Event Runway excursion
Safety action taken No safety action was taken as a result of this investigation.