TSB Quarterly Review — First quarter 2020-21
The past few months have seen a dramatic shift in the way that the TSB conducts its work, as employees respond to the challenges caused by the global pandemic.
Since mid-March, TSB employees shifted into full telework mode, quickly adapting to new workflows for day-to-day operations and safety protocols for deployments. This was in no small part thanks to our IM/IT teams, who worked (and are still working!) tirelessly to ensure that our networks stay up and running with the increased demand.
Throughout this time, our work has continued. Over the past three months, we have deployed investigators to five occurrence sites, started 12 investigations and released 16 investigation reports.
Here’s a recap of just a few noteworthy events:
- In April, we released investigation report M17C0179 completing our investigation into the August 2017 bottom contact of the passenger vessel Island Queen III near Kingston, Ontario. As part of the report, the Board issued three safety concerns relating to carriage of lifejackets for children and infants, Transport Canada’s (TC) validation and approval process of passenger vessel evacuation procedures, and specialized training for crew members who are responsible to manage passengers during an emergency.
- In May, we released investigation report A18Q0030 regarding a February 2018 runway overrun that occurred in Havre-Saint-Pierre, Quebec, along with a video detailing what happened. As part of the report, the Board issued two recommendations regarding approaches and landings at Canadian aerodromes during periods of low visibility.
- In June, we released investigation report R17W0267 regarding a 2017 employee fatality following the uncontrolled movement of rail cars at CN’s Melville Yard in Saskatchewan. This report included a recommendation that TC, along with railway companies and their labour representatives, work together to reduce the number of uncontrolled movements in rail yards, specifically those caused by rail cars being moved without using air brakes – a routine task known as “switching without air”. It also contained a Board safety concern about the pairing of inexperienced yard workers performing remote control locomotive operations. This release was also accompanied by a video explaining the occurrence as well as the findings, recommendation and concern.
Finally, the TSB has participated in the download of the flight recorders for Ukrainian International Airlines Flight 752 in Paris. We had sent a team of investigators including a specialist in aircraft recorder download and analysis. Our team followed both the TSB and Government of Canada’s health measures to ensure safe travel for our investigators.
Air report release
February 2018 runway overrun in Havre-Saint-Pierre, QC
On 21 May 2020, the Transportation Safety Board of Canada (TSB) released its investigation report (A18Q0030) into the February 2018 runway overrun in Havre-Saint-Pierre, Quebec, which contains two safety recommendations and one Board safety concern.
Rail report release
2017 uncontrolled movement and employee fatality at Melville Yard in Saskatchewan
On 10 June 2020, the Transportation Safety Board of Canada (TSB) released its investigation report (R17W0267) into a 2017 employee fatality following the uncontrolled movement of a rail car at Melville Yard in Saskatchewan, which contains a safety recommendation.
- December 2019 collision with terrain near Stewardson Inlet, British Columbia
- November 2019 main-track train derailment in Bolton-Ouest, Quebec
- May 2018 capsizing of a fishing vessel in Port Medway, Nova Scotia
- December 2017 employee fatality at Melville Yard in Saskatchewan
- May 2019 engine power loss and forced landing accident near Smithers, British Columbia
- January 2019 main-track train derailment near Saskatoon, Saskatchewan
- April 2019 striking of a shore crane by a container vessel at the Fraser Surrey Docks, British Columbia
- October 2019 girding and sinking of a tug in Williamsons Landing, British Columbia
- February 2018 runway overrun in Havre-Saint-Pierre, Quebec
- January 2019 runway incursion at Toronto/Lester B. Pearson International Airport, Ontario
- August 2017 bottom contact of a passenger vessel near Kingston, Ontario
- January 2019 loss of control and collision with ground near Whatì Airport, Northwest Territories
- September 2018 fatal main-track derailment near Ponton, Manitoba
- February 2019 collision of a passenger train and track maintenance material near Brighton, Ontario
- January 2019 loss of separation near Kelowna, British Columbia
- August 2019 fatal wheels-down water landing in Upper Raft Lake, Ontario
- Download of the Ukraine International Airlines flight PS752 recorders
- TSB reassesses outstanding safety recommendations to assess progress and promote accountability
New investigation pages
- 28 April 2020 runway excursion in Kugaaruk, Nunavut
- 13 mai 2020 collision with terrain near Gibbons, Alberta
- 06 June 2020 collision with terrain near Maple Ridge, British Columbia
- 14 June 2020 mid-air collision in Constance Bay, Ontario
- 14 June 2020 collision with terrain in Saint-Fulgence, Quebec
- 12 may 2020 bulk carrier capsizing near Sombra, Ontario
- 25 May 2020 fishing vessel accident in Placentia Bay, Newfoundland and Labrador
- 10 June 2020 bulk carrier collision with dock while berthing in Québec, Quebec
- 25 May 2020 main-track derailment near Ignace, Ontario
- 1 June 2020 employee fatality at the Thornton Yard in Surrey, British Columbia