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TSB Quarterly Review — Fourth quarter 2018-19

ISSN 2369-7954

April 2019

Chair's message

The TSB has been fully engaged in deployments, investigations, reporting and outreach in all transportation modes under federal jurisdiction during the past three months. We held 2 news conferences, deployed investigators to 19 occurrence sites across Canada, published 18 new investigation pages, released 28 investigation reports and participated in 5 outreach events.    

At a January news conference in Toronto, we released our findings from a safety issues 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. To make these runways safer, the Board made four recommendations to NAV CANADA, Transport Canada, the US Federal Aviation Administration, and the Greater Toronto Airports Authority, regarding the phraseology used by air-traffic controllers, flight crew standard operating procedures and the design of the airport taxi layout itself.

In February, our investigators provided a first update on the fatal derailment that occurred near Field, British Columbia. Later that same month, our Marine and Communications staff attended the annual conference of the Standing Committee on Quebec Fishing Vessel Safety in Rimouski, Quebec, where the essential role of safety management in the fishing industry was discussed as well as how to address the risks associated with fatigue and substance abuse.

In March, I provided an update on our ongoing investigation into air taxi operations (A15H0001), among other topics, to the 2019 AQTA Conference in Saint-Hyacinthe, Quebec. On the same day, I also had the pleasure to deliver a guest lecture at the Aviation Safety and Security Management course at Montreal’s McGill University, Quebec.

Also in March, the TSB released its preliminary transportation occurrence statistics for 2018. These preliminary statistics will be further analyzed and supplemented as part of our annual Statistical Reports to be released in the next few months.

After a busy fourth quarter, I would like to personally acknowledge the dedication of our staff and partners, whose contributions help ensure that Canada’s transportation system remains safe for all Canadians and the millions of visitors who come to our country every year.   

Kathy Fox

Safety Issues Investigation A17O0038

On January 31, 2019, the TSB held a news conference to release its safety issues investigation report (A17O0038) on a series of runway incursions at Toronto/Lester B. Pearson International Airport, Ontario, between 2012 and 2017. Follow this rapid exit taxiway at the Toronto/Pearson South Complex. You will see some of the lights, signs, paint markings that guide crews along the way, and the hold-short lines where they are supposed to stop.

Panel discussion – Fishing while impaired: a risky mix

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

Completed investigations

New investigation pages