TSB Quarterly Review — First quarter 2021-22
ISSN 2369-7954
July 2021
Chair's message
Despite the ongoing challenges brought by the COVID-19 pandemic, the TSB continued to advance transportation safety in the first quarter of 2021, deploying to five occurrence sites across the country.
Since April 2021, we began six new investigations, including a Class 1 Safety Issue Investigation (SII) - R20H0082 into accidents at level rail crossings and released 12 investigation reports.
Additionally, on May 13, the TSB released its annual reassessment of responses to 62 outstanding safety recommendations in the air, marine and rail modes. The Board noted progress on some responses, with 12 recommendations now rated Fully Satisfactory: five in aviation, four in marine and three in rail.
However, other key issues showed minimal progress, indicating much work remains.
As mentioned above, last month we launched a new Class 1 SII aimed at understanding the factors leading to an increase in the rate of railway crossing accidents during winter months in Canada. Each year, approximately 23 people are killed and 28 more are seriously injured at rail crossings, making this type of accident among the deadliest of rail accidents. Each SII undertaken by the TSB involves a detailed study of a series of occurrences that have formed a pattern over time. Such investigations often involve a large team and significant resources in order to produce a lengthy and detailed report.
As we look ahead, we are preparing for the TSB Watchlist 2020 mid-cycle consultations. These sessions will allow us to understand how the air, marine and rail industries are progressing on the issues identified in the current Watchlist. We will use that information to start the process of preparing the next TSB Watchlist, due in the fall of 2022.
Stay healthy and safe!
Kathleen Fox
Completed investigations
Air
- November 2018 runway overrun highlights TSB Watchlist issues in Halifax, NS
- December 2020 fatal injury of a pilot during ground operations in Port Hardy, BC
- April 2020 continued approach below required aerodrome operating visibility led to runway excursion in Kugaaruk, NU
- January 2020 runway overrun highlights longstanding TSB Watchlist issue in Halifax, NS
- February 2020 TSB releases investigation report about a landing accident in Calgary, AB
- January 2020 unstable approach led to hard landing and rear fuselage strike in Schefferville, QC
- July 2019 offshore helicopter crew recovers from inadvertent descent to 13 feet above water near Sable Island, NS
- February 2020 interrupted checklist procedures contributed to runway excursion in Dryden, ON
Marine
- November 2020 grounding of a barge in the Fraser River in the Fraser River, BC
- August 2018 TSB calls for mandatory risk mitigation measures for passenger vessels operating in Canadian Arctic, NU
- February 2018 passenger ferry Deer Island Princess II made bottom contact near Letete, NB
Pipeline
New investigation pages
Air
- 28 June 2021 TSB deploys team to helicopter accident near Evansburg, AB
- 22 June 2021 TSB deploys team to helicopter accident near Nipigon, ON
- 11 May 2021 TSB deploys team to helicopter accident to Les Escoumins, QC
- 25 April 2021 TSB deploys team following a fatal helicopter accident near Resolute Bay, NU
Recommendations now classed as “Fully Satisfactory”
Air
- A16-01: 406 MHZ ELT requirement
- A16-02: Emergency locator transmitter system crash survivability standards – International Civil Aviation Organization
- A16-05: Emergency locator transmitter system crash survivability standards – Transport Canada
- A16-07: Emergency locator transmitter: Prohibiting the use of hook-and-loop fasteners
- A94-13: Knowledge of aircraft flight manuals
Marine
- M17-03: Automatic distress alerting
- M00-09: Emergency position indicating radio beacons
- M94-34: Passage planning
- M92-07: Anti-exposure worksuits
Rail
- R03-02: National standards for locomotive data recorders
- R13-02: In-cab locomotive video cameras
- R17-01: Factors affecting severity of derailments involving dangerous goods
Other developments
- Transportation Safety Board of Canada releases 2020 transportation occurrences statistics
- TSB launches safety issue investigation into higher rate of railway crossing accidents during winter in Canada
- Reassessments of outstanding safety recommendations highlight both progress and continued need for action