TSB Quarterly Review — Third quarter 2017-18
ISSN 2369-7954
January 2018
Chair's message
As we embark on 2018, it is natural to look back and reflect on the work we accomplished in the previous year. During the last quarter of 2017, we deployed investigators to 18 accident sites across the country, started 14 new investigations and released 12 investigation reports.
One of those reports (A15P0081) includes a recommendation for Transport Canada and the industry to develop and implement requirements for a comprehensive substance abuse program to reduce the risk of impairment of persons while engaged in safety-sensitive functions. Also, as a marine accident report (M16A0327) demonstrates, concerns remain about unsafe operating practices and the use and availability of lifesaving appliances on board, such as emergency position-indicating radio beacons.
As part of our efforts to modernize our investigation processes and products, we have undertaken a pilot project and published a new short-form type of report for a few investigations. This pilot project will wrap-up in the next quarter and we expect to issue a new Occurrence Classification Policy along with some changes to our processes and products.
In the months ahead, we will continue through our investigations to dedicate time and effort to finding out what happened and why, to reduce the risk of it happening again. We will also take stock of the bigger picture and identify the key safety issues to be included in the next edition of our Watchlist, which will be published in late Fall.
Happy New Year!
Kathy Fox
Completed investigations
- Near-collision with terrain in Tofino, BC (Dec 2017)
- Crude oil leak at the Enbridge Terminal in Sherwood Park, AB (Dec 2017)
- Crossing collision in Sainte-Ursule, QC (Dec 2017)
- Train collision near Carvel, AB (Dec 2017)
- Sinking of fishing vessel off the coast of NL (Nov 2017)
- Floatplane accident near Manicouagan Reservoir, QC (Nov 2017)
- In-flight breakup north of Vancouver, BC (Nov 2017)
- Crossing collision near Saint-Norbert, QC (Oct 2017)
- Runaway, collision and derailment at CN MacMillan Yard, ON (Oct 2017)
- Helicopter accident near Flatlands, NB (Oct 2017)
- Helicopter crash near Whitecourt, AB (Oct 2017)
- Capsizing and sinking of tug in Montreal, QC (Oct 2017)
Developments
- Investigation update: Fond-du-Lac, SK
- Investigation update: Tweed, ON
- Statement from the Chair on fatigue management
Blog posts: The TSB Recorder
Investigations started
- Baldur, MB (Air)
- Tweed, ON (Air)
- Fond-du-Lac, SK (Air)
- Fraser River, BC (Marine)
- Billy Bishop Toronto City Airport (Air)
- Saint-Luc Yard, Montreal, QC (Rail)
- Thompson Airport, MB (Air)
- Springbank Airport, AB (Air)
- Lac-aux-Sables, QC (Rail)
- Jean Lesage International Airport, QC (Air)
- Mountain Subdivision, BC (Rail)
- Belledune, NB (Marine)
- Antelope, SK (Rail)
- Campbell River, BC (Air)
This is not a comprehensive list.