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TSB Quarterly Review — Third quarter 2018-19

ISSN 2369-7954

January 2019

Chair's message

At the TSB, 2018 ended with a significant workload and list of accomplishments as we ramped up our efforts to launch and promote Watchlist 2018. From October to December, we held 2 news conferences, 2 field updates (A18O0150 and A18A0085) and 16 outreach activities. We deployed investigators to 9 occurrence sites, released 15 investigation reports, and started 9 new investigations. We also posted 21 status updates on current ongoing investigations.

The launch of Watchlist 2018 on 29 October highlighted key safety issues, including: runway incursions and runway overruns; the lack of additional defences to ensure railway signals are consistently followed; and the disturbing safety record of the commercial fishing industry. Other issues affect all three transportation modes: fatigue, inadequate safety management and oversight, and slow progress on addressing Board recommendations.

On 14 December, the TSB issued two recommendations aimed at preventing flight crews operating in remote areas from taking off with ice, snow and frost on the aircraft. The recommendations stem from the TSB's ongoing investigation into the December 2017 collision with terrain of the West Wind Aviation ATR-42 in Fond-du-Lac, Saskatchewan (A17C0146).

In 2019 we will continue through investigations, recommendations and outreach to call for action and monitor progress.

Happy New Year!

Kathy Fox

Completed investigations

Other news releases

Investigations started

This may not be a comprehensive list.

Launch of Watchlist 2018

On 29 October, Board members Paul Dittmann, Kathy Fox and Faye Ackermans called on the regulator and stakeholders to take action on seven systemic safety issues across the Canadian transportation system.
Watchlist 2018 news conference

Recommendations on de-icing

On December 14, Investigator-in-charge David Ross, Chair Kathy Fox and Winnipeg Regional Manager Eric Vermette discussed  two recommendations issued as part of the ongoing investigation into the December 2017 Fond-du-Lac accident (A17C0146).
Air investigation report A17C0146 - News Conference

Field update: Mid-air collision over Carp, Ontario

On 6 November, Investigator-in-charge Beverly Harvey and Senior Investigator Nora Vallée explained the challenges specific to investigating mid-air collisions (A18O0150).

News briefing: Runway overrun at Halifax Stanfield Airport, Nova Scotia

On 8 November, Investigator-in-charge Austin Adams and Senior Investigator Isabelle Langevin reported on the initial field phase of the investigation and the next steps (A18A0085).