TSB Quarterly Review — Second quarter 2021-22
ISSN 2369-7954
October 2021
Chair's message
Despite the fourth wave of the COVID-19 pandemic, the TSB has actively continued operations throughout the hot, (mostly) dry summer, striving to fulfill our mandate to advance transportation safety. In the second quarter of 2021, the TSB deployed investigators to 17 occurrence sites across the country and started 15 new investigations. The TSB released 10 investigation reports, notably marine investigation report M19A0025 – Captain Jim which illustrates how compromised stability can result from vessel modifications.
Based on information received from the RCMP and BC Wildfire Service, the TSB deployed an investigator to Lytton, B.C., on 9 July 2021 to gather information, examine and photograph the area, and assess the circumstances to determine if the rolling stock that passed through Lytton could have caused or sustained a fire that destroyed the town on 30 June 2021 (R21V0143). The TSB conducted significant investigative work to determine if there was a definitive connection between railway operations through Lytton, BC and the fire that destroyed the town. On 14 October, we informed the public that our investigation had not identified any such connection. The wildfire remains under investigation by BC Wildfire Service and the RCMP.
Over the last quarter, the TSB deployed to two derailments involving Ottawa’s Light Rail Transit (OLRT). A few weeks ago, the Director of Investigations, Rail/Pipeline, sent a Rail Safety Advisory 617-02/21 to the City of Ottawa detailing concerns over the roller bearing failure which led to the derailment that took place on August 8 (R21H0099). The rail/pipeline branch is also continuing its work on the more recent OLRT derailment (R21H0121) that took place on September 19.
This month, we begin our TSB Watchlist 2020 mid-cycle consultations. Making use of online tools and in-person consultations, we aim to better understand how air, marine, and rail industries are responding to the issues identified on the current Watchlist, and the challenges that they might be facing in trying to do so. The Board will consider the results of this consultation when preparing the next TSB Watchlist, which we expect to publish in the fall of 2022.
Stay healthy and safe!
Kathleen Fox
Completed investigations
Air
- February 2021 Loss of control and collision with terrain at Ottawa/Carp Airport, Ontario
- March 2021 Loss of control and collision with terrain at Lac Barron near Gore, Quebec
- January 2020 Limited visual cues and runway conditions contributed to runway excursion of passenger aircraft in Terrace, BC
- January 2021 Loss of control and inadvertent descent near Upper Kananaskis Lake, Alberta
Marine
- January 2019 Fatal sinking of the Captain Jim attributed to compromised stability following vessel modifications
- May 2020 Unmitigated mooring line hazards led to three people falling overboard from a workboat near Sombra, Ontario
- March 2019 Breakdowns in situational awareness and communications were key factors leading to a striking in Vancouver Harbour
Rail
- September 2019 Undetected internal rail defect led to CP freight train derailment near Blackfalds, Alberta
- February 2021 main track train derailment in Goderich, Ontario
- January 2019 Failure of a rail car coupler led to rail yard collision and derailment in Calgary, Alberta
New investigation pages
Air
- 24 September 2021 Collision with water in Ferme Neuve, Quebec
- 31 August 2021 Collision with terrain near Slave Lake, Alberta
- 16 August 2021 Collision with terrain at Thunder Bay Airport, Ontario
- 11 August 2021 Collision with terrain near Bathurst, New Brunswick
- 10 August 2021 Mid-air collision at Buttonville Airport, Ontario
- 26 July 2021 Loss of control on lift off and overturn in Tofino, British Columbia
- 25 July 2021 Collision with power lines in Brantford, Ontario
- 11 July 2021 Dual engine shutdown on touchdown at Copenhagen Airport, Denmark
- 5 July 2021 Collision with a lawn tractor during landing in Saint-Esprit, Quebec
Rail
- 20 September 2021 Light-rail train (O-train) derailment in Ottawa, Ontario
- 2 September 2021 Train collision in Prescott, Ontario
- 21 August 2021 Train derailment near Moncton, N.B.
- 9 August 2021 Light-rail train (O-train) derailment in Ottawa, Ontario
- 17 July 2021 Locomotive producing sparks in Calgary, Alberta
- 8 July 2021 Locomotive exhaust stack fire in Elko, British Columbia