Annual Report to Parliament 2019–20

Place du Centre
200 Promenade du Portage
4th Floor
Gatineau, Quebec
K1A 1K8

23 June 2020

The Honourable Dominic LeBlanc, P.C., M.P.
President of the Queen’s Privy Council for Canada
House of Commons
Ottawa, Ontario K1A 0A3

Dear Minister,

In accordance with subsection 13(3) of the Canadian Transportation Accident Investigation and Safety Board Act, the Board is pleased to submit, through you, its Annual Report to Parliament for the period 1 April 2019 to 31 March 2020.

Yours sincerely,

Original signed by
Kathleen Fox
Chair

Message from the Chair

The fiscal year just past was one of both continuity and change for the Transportation Safety Board of Canada (TSB).

Building on the successful 2018 introduction of the new Policy on Occurrence Classification, 2019–20 saw us working through a large caseload—with 84 investigations in progress at year-end. We also shared more information about transportation safety with the public than ever before through our limited-scope investigation reports and other communications vehicles.

Similarly, our extensive study on safety issues in the air-taxi sector shed light on risks in an important part of Canada’s aviation industry. Air taxi operators play a crucial role in moving people and goods—particularly in remote locations—but have a troubling and persistent accident history. In the final report of our study, which is the culmination of a five-year investigation, we recommended that both Transport Canada and industry associations step up to take concrete measures to raise the bar on air-taxi safety.

The January 2020 downing of Ukrainian International Airlines Flight 752 marked a tragic start to this new decade. The TSB appointed an Expert in accordance with the Convention on International Civil Aviation and deployed two investigators to Tehran to visit the accident site and meet with Iranian investigators. We will continue, to the greatest extent possible, to try to be involved in this investigation, which is being led by the Aircraft Accident Investigation Bureau of the Islamic Republic of Iran. We want to do our part to find out what happened and why—for the families and for all Canadians.

As we continued in these traditional roles in 2019–20, there was change among the Board and senior management. In particular, André Lapointe, a seasoned public service executive, became the TSB’s new Chief Operating Officer. Previously Assistant Deputy Minister, Corporate Services, and Chief Financial Officer at Transport Canada, André succeeds Jean Laporte, who retired in September 2019 after 35 years in the transportation safety field.

I look forward to tapping into the new ideas and fresh perspectives that have come with these and other changes in the TSB’s management team in recent months. Together, we will spend time in 2020–21 developing a new strategic plan to guide the organization for the next five years.

An important focus of that plan will be responding to the effects of the COVID-19 pandemic.

Canada’s response to this worldwide event accelerated our move to a digital workplace. Steps we had already taken, including introducing electronic, and portable, business tools—along with excellent work from our information management and technology teams—have allowed us to continue operating with little disruption throughout the ongoing pandemic period.

This solid foundation will serve us well as we continue to advance transportation safety during what promises to be a time of substantial change, not only in how and where we do our work but also in the transportation industry itself.

Kathleen Fox
Chair

The year in results

In 2019–20, staff from the Transportation Safety Board of Canada (TSB) assessed thousands of accidents and incidents that occurred across Canada in the aviation, marine, pipeline and rail sectors (see the definitions in the Policy on Occurrence Classification).

TSB personnel then deployed to the sites of some of these occurrences in person to collect data and carry out analysis in order to identify the causes and contributing factors, and highlight known and emerging safety concerns—all in an effort to improve transportation safety in Canada.

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The total number of occurrences reported to the TSB (as required under the Transportation Safety Board Regulations) in the 2019 calendar year (3881) was slightly more (0.9%) than the 2018 total of 3846.

The overall number of accidents reported has increased each year since 2016, with the 2019 total (1739) being almost 5% above the 2018 level (1660), and 7% higher than the 10-year average of 1626.

There were 36% more fatalities (159) across all transportation sectors in 2019 than there were in 2018 (117). The 2019 figure represents a 13% increase in fatalities over the 10-year average of 140.

The 2142 incidents reported to the TSB in 2019 is a slight decrease (2%) from the 2018 figure (2186), but 23% higher than the 10-year average (1746). This difference partly results from changes made in 2014 to TSB reporting requirements.

The TSB at work

Deployments

TSB investigators deployed 60 times during the 2019–20 fiscal year (down from 79 the previous year) in response to occurrences in all sectors. These deployments took staff from the TSB regional offices and Head Office to locations across the country.

In 2019–20, the TSB began 66 new investigations and completed 50 across all four transportation sectors (aviation sector reports; marine sector reports; pipeline sector reports; rail sector reports) and in all four classes (from in-depth and complex to limited scope).

Average completion times increased, both overall and for the various classes of investigations, although only by four days in the case of the limited-scope class 4 investigations (from 224 days in 2018–19 to 228 days in 2019–20). These investigations accounted for 52% of the total cases closed during the year. In them, the TSB quickly gathers, analyzes and reports the facts of straightforward occurrences, freeing up resources for more complex investigations that have greater potential for advancing transportation safety.

In support of TSB investigations, engineers, technicians and human factors specialists began 247 projects and completed 231 technical reports in 2019–20. They also began 23 projects and completed 16 technical reports for foreign investigation agencies.

While investigations are ongoing, the TSB issues safety advisories and safety information letters to notify regulatory and industry stakeholders of unsafe conditions. These communications may suggest remedial action to reduce safety risks or share observations to promote greater safety.

Safety concerns, which are usually communicated in final investigation reports, provide a marker to regulators and industry that the TSB’s five-member Board has identified a safety deficiency for which it does not yet have sufficient information to make a recommendation for corrective action.

The Board issued five recommendations in 2019–20, all of which were the result of aviation investigations. The Board makes recommendations when systemic deficiencies pose significant risks to the transportation system and, therefore, warrant the highest attention of regulators and industry.

Federal ministers must respond to the Board’s recommendations within 90 days, setting out specific actions their department plans to take. Board members then review and rate these responses.

Each year, the Board reassesses outstanding recommendations as part of ongoing efforts to urge stakeholders to take action on the safety issues TSB investigations have identified. In 2019–20, the Board reassessed 13 outstanding recommendations as Fully Satisfactory: 10 in aviation and 3 in rail.

Since 1990, the Board has made 609 recommendations. By the end of 2019–20, it had given 83% of the responses to these recommendations the highest rating of Fully Satisfactory (up from 81.5% at the end of 2018–19). This means that stakeholders, including Transport Canada, had taken action to substantially reduce the safety deficiencies the Board had identified.

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At 31 March 2020, there were 92 outstanding recommendations, slightly less than half of which date from 10 years ago or more. The Board is concerned about the slow progress on these older recommendations—an issue that has been on the TSB Watchlist of key safety issues since 2016.

Watchlist 2018

The TSB publishes its Watchlist every two years, so 2019–20 was the mid-cycle year for the 2018 version of this list of safety issues.

This period was a good opportunity to consult stakeholders to obtain their insights into the issues—including multi-modal issues such as fatigue management, and safety management and oversight—and learn about any actions they are taking to address them.

In September 2019, the TSB sent questionnaires to a number of key stakeholders in all four transportation sectors to solicit their input. The survey responses informed subsequent panel presentations and other discussions the TSB held with industry members at meetings of the Air Transport Association of Canada, Helicopter Association of Canada and Canadian Marine Advisory Council in November 2019, and the Canadian Aviation Safety Collaboration Forum in January 2020. The TSB consulted the Railway Association of Canada, Canadian National Railway Company, VIA Rail Canada Inc. and Canadian Pacific Railway in February 2020.

This input is feeding into the work of the Board to prepare the next edition of the Watchlist, which will be published in the fall of 2020.

Securitas

The TSB operates the SECURITAS program to allow transportation employees and the Canadian public to report, in confidence, unsafe transportation acts and conditions they observe.

In 2019–20, the TSB received 274 new SECURITAS reports, a 59% increase from 2018–19, with each sector receiving more reports than it had the year before: 91% more in aviation; 42% more in marine and 34% more in rail. These increases may have been due to a variety of factors, including the ongoing impact of the shutdown of Transport Canada’s Civil Aviation Issues Reporting System in 2016–17, and the TSB’s growing social media presence and active industry outreach program. There were no pipeline-related reports to SECURITAS in 2019–20.

The trusted agents who handle SECURITAS reports on behalf of the TSB closed 261 reports over the course of 2019–20. Here are some notable examples of safety actions being taken in light of SECURITAS reports:

Unreported floatplane crash: A SECURITAS report informed the TSB that a floatplane crash had not been reported by the company. The TSB regional office contacted the company and learned that the owner was unaware the crash was a reportable occurrence. The TSB informed the owner that, due to the extent of the damage, it fell under the definition of an accident. It was classified as a Class 5 investigation and entered as such in the Aviation Safety Information System. 

Airport employee: A number of SECURITAS reports informed the TSB that an airport employee working on a ramp and fuelling aircraft was a known drug user and dealer. Transport Canada was informed, and the Royal Canadian Mountain Police took appropriate action.

Ferry maintenance: A SECURITAS report related to the maintenance of the machinery on board a ferry and contained concerns for the safety of the vessel and crew. Transport Canada subsequently carried out an inspection, identifying a number of deficiencies and action items. Transport Canada gave the inspection report to the ferry’s owners and the classification society.

Safety onboard a tug: Another SECURITAS report related to stability on board a tug, with concern for the safety of the vessel and crew. Transport Canada carried out an inspection upon receiving this information from the trusted agent.

Maintenance of railway crossing: A SECURITAS report noted that planks moved up and down when a crossing was traversed. The track supervisor directed an immediate inspection and found slight movement of the planks. They were fixed in place with lag bolts.

Safety defects: A SECURITAS report noted that a defective rail car had been released into service. In response, mechanical supervisors and carmen were coached to ensure they understood that all equipment placed into service must be free from safety defects, that they must enter information about defects into the railway’s system without any unnecessary delay, and that any defect can be escalated to ensure it is handled appropriately.

Active and regular communications and outreach are important aspects of the TSB’s efforts to advance transportation safety. Through its website, social media channels and in-person events, the TSB reaches industry and government stakeholders, and members of the public across Canada and around the world.

Outreach activities

The TSB had the rare opportunity in June 2019 to host the heads of 16 independent safety investigation authorities from member countries of the International Transportation Safety Association for three days of meetings in Quebec City. With the goal of sharing best practices and learning from the experiences of others, attendees covered topics such as safety deficiencies, studies and recommendations, investigation techniques, and training and recruiting strategies for investigators. The conference was also a platform for open and frank discussions among members on strategic issues and concerns.

In October 2019, the Air Branch held its annual TSB Air Safety Investigator Workshop in Cornwall, Ontario. The event was particularly successful, with presentations covering a wide array of contemporary air safety topics. This event had the largest attendance in its history, with approximately 80 participants, including TSB investigators, Board members, government representatives and industry stakeholders, such as airlines, manufacturers and aircrew labour unions. The workshop also welcomed air safety investigators from Denmark, Finland, Iceland, Norway, Sweden and the United States.

The TSB is a founding member of the Canadian Marine Industry Foundation, which was formally launched in November 2019. The non-profit foundation is a national forum to connect marine stakeholders to work together to increase the number of Canadians that choose marine careers in the public and private sector. In that regard, the Foundation will help the TSB recruit and develop individuals seeking to pursue a career in marine transportation safety.

The TSB released two videos in 2019–20, which are available on its YouTube channel:

• the Tug girding video, which has more than 88 000 views and has received wide international recognition, focuses on a common safety issue in the marine towing industry. The TSB created this video to illustrate the factors leading to girding and recovery methods (related investigation: M18P0230); and
• Sky’s the limit recognizes women’s contributions to the TSB and transportation safety in the air, marine, pipeline and rail sectors in Canada.

In conjunction with the release of the report of an in-depth TSB investigation into safety issues in Canada’s air-taxi sector, Board Chair Kathy Fox penned an article for Wings magazine about the need to raise the bar on air-taxi safety.

The Board Chair and TSB officials appeared before the House of Commons Standing Committee on Transport, Infrastructure and Communities twice in 2019–20.

The first appearance, on 2 April 2019, focused on bus safety. The Chair spoke about the TSB investigation (R13T0192) into the fatal 2013 collision between an Ottawa city bus and a VIA Rail passenger train. In its investigation, the TSB identified 15 causal and contributing factors and issued five recommendations. Three of them were directly related to the safety of buses.

In June 2019, the committee issued its report on bus safety, with nine recommendations, some of which mirrored those in the TSB investigation—in particular, that Transport Canada develop crashworthiness standards for passenger buses in excess of 11 793 kg as well as a standard for crashworthy event data recorders.

On 20 March 2020, the Chair and the Director of Investigations for the Air Branch appeared before the committee to answer questions about the aircraft certification process in Canada.

Over the course of 2019–20, the TSB developed and implemented a strategy to guide its interactions with Indigenous peoples during investigations. This strategy aligns the TSB with the government’s priority of reconciliation and renewed relationship with Indigenous peoples. It also contributes to meeting two of the TSB’s strategic priorities: engaging stakeholders and improving investigation policies, procedures and tools.

Under the strategy, the TSB held awareness training for investigators and media relations staff, reached out to national Indigenous associations and developed guidance for investigators. Looking ahead, the TSB plans to integrate training on interactions with Indigenous peoples into its comprehensive investigator-training program.

Aviation sector

The year in review

The Transportation Safety Board of Canada (TSB) recorded 226 aviation accidents during 2019. This is a 12% increase from 2018, but still lower than the 10-year average of 258. In general, aviation accidents in Canada have been declining over the past decade. Of 226 accidents, 217 involved Canadian-registered aircraft.

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In 2019, there were 26 fatal accidents involving Canadian-registered aircraft. However, none of these involved airliners or commuter aircraft. The majority of fatal accidents involved privately owned aircraft. Fatalities involving commercially operated flights were mainly in the air-taxi sector. The total number of resulting fatalities (70) was the highest since 2010 and included 11 deaths in foreign-registered aircraft operating in Canada.

Eight accidents in 2019 involved a release of dangerous goods. While this is similar to 2018 (seven), it is higher than the average over the previous decade of about four per year.

In addition, 911 aviation incidents were reported to the TSB in 2019. This represents a rise from 860 in 2018, and remains above the yearly average of 777 observed between 2009 and 2018. This may be linked to an improved reporting culture in the industry and the widespread adoption of safety management systems among operators.

Over 90% of incidents (832) involved Canadian-registered aircraft, with 651 of these incidents occurring in Canada. The number of incidents that took place elsewhere (181) is high compared to the 10-year average of 85. The TSB continues to monitor this type of incident to determine whether there is a trend developing that warrants more detailed analysis.

The accident rate for Canadian-registered aircraft (excluding ultralights) per 100 000 hours flown has followed a downward trend since 2009. These aircraft flew an estimated 5.2 million hours in Canada and abroad in 2019. With 195 accidents over that period, the accident rate is 3.7 accidents per 100 000 hours flown, above the 2018 rate of 3.3, but below the 10-year average of 4.9.

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Investigations

TSB staff deployed to 36 aviation occurrences in 2019–20—two fewer than in 2018–19— began 39 investigations and completed 28.

*This was a comprehensive, five-year study of safety issues in the air-taxi sector.

In-depth report identifies risks in air-taxi sector

In 2015, the TSB began an in-depth safety issue investigation into the risks that persist in air-taxi operations across Canada (A15H0001). The investigation required significant resources and time in order to identify, document and analyze various safety topics, and included both human factors and macro analysis.

Air taxis are single- and multi-engine aircraft (other than turbo-jets) that have a maximum certificated take-off weight of 19 000 pounds and can seat nine or fewer passengers. These aircraft provide a wide variety of services throughout Canada, often in remote locations where there is less infrastructure available than at large airports and where access to basic weather information and the latest technology may be limited.

The Board published the report on the investigation, Raising the bar on safety: Reducing the risks associated with air-taxi operations in Canada, in November 2019. The investigation found that air-taxi accidents result from two main underlying factors: the acceptance of unsafe practices and the inadequate management of operational hazards.

To address these issues, the Board issued four recommendations aimed at improving safety in the air-taxi sector of Canadian aviation—a sector that continues to have more accidents, causing more fatalities, than all other sectors of commercial aviation in Canada combined:

• that Transport Canada collaborate with industry associations to develop strategies, education products and tools to help air-taxi operators and their clients eliminate the acceptance of unsafe practices (Recommendation A19-02);
• that industry associations such as the Air Transport Association of Canada, Helicopter Association of Canada, Association Québécoise du Transport Aérien, Floatplane Operators Association and Northern Air Transport Association promote proactive safety management processes and safety culture with air-taxi operators to address the safety deficiencies identified during the TSB investigation through training and sharing of best practices, tools and safety data specific to air-taxi operations (Recommendation A19-03);
• that Transport Canada review the gaps identified in the investigation regarding Subpart 703 of the Canadian Aviation Regulations and associated standards, and update the relevant regulations and standards (Recommendation A19-04); and
• that Transport Canada require all commercial operators to collect and report hours flown and movement data for their aircraft by Canadian Aviation Regulations subpart and aircraft type, and that Transport Canada publish those data (Recommendation A19-05).

The Board received responses to these recommendations in the first quarter of 2020 (see Appendix A for details) and completed its assessment of them in March 2020.

The TSB’s investigation (A17O0264) into the December 2017 collision with terrain of a Hydro One Networks Airbus Helicopters AS 350 B2 near Tweed, Ontario, revealed that a bag that was inadequately secured blew off an external platform, struck the tail rotor in flight and rendered the aircraft uncontrollable. The pilot and all three passengers, who were power line technicians, were fatally injured.

The TSB quickly issued Aviation Safety Advisory A17O0264-D1-A1, “Unsecured cargo and unrestrained passengers in helicopters,” on 21 December 2017. In it, the TSB alerted Transport Canada and industry stakeholders to the risks associated with unsecured cargo and unrestrained passengers in helicopters, and advocated for prompt action to address this safety issue.

The investigation report highlighted the ambiguity in the definition of “safety belt” in subsection 101.1(1) of the Canadian Aviation Regulations. The intent of this regulation is for passengers to always use shoulder harnesses when they are available. However, if regulations are not clear in requiring individuals to use all available components of a safety belt, they may not use shoulder harnesses as intended, increasing the risk of injury or death.

Consequently, the Board issued Recommendation A19-01 along with the final investigation report in October 2019. The recommendation calls on Transport Canada to amend the Canadian Aviation Regulations to remove any ambiguity associated with the definition of “safety belt.”

The Board received Transport Canada’s response to this recommendation in the first quarter of 2020 (see Appendix A for details).

On 30 July 2018, a privately operated Quad City Challenger II advanced ultralight aircraft crashed into trees en route from North Bay to Rockcliffe, Ontario, after the right wing separated from the aircraft. The single occupant was fatally injured.

As part of its investigation (A18O0106), the TSBissued Aviation Safety Advisory A18O0106-D1-A1, “Quad City Challenger II Advanced Ultralight – Bracket Failure,” to alert Transport Canada to the possible risks associated with the failure of the attachment brackets that secure the wing lift struts on the aircraft.

Quad City, the Canadian distributor of the Challenger II, is conducting a stress analysis on the addition of a fixture to reduce flexing and spread loads around the bolthole, where fatigue cracks appear to start.

In response to the safety advisory, Transport Canada issued Civil Aviation Safety Alert 2019-02 to inform owners of the possible failure of the brackets and the need for disassembly, inspection and part replacement.

The TSB’s investigation (A18W0129) into the August 2018 capsize during a water landing of a Cessna U2016G on Little Doctor Lake, Northwest Territories, highlighted the need for design improvements to the aircraft’s emergency exits. While the pilot and one passenger escaped the submerged fuselage, the remaining three passengers did not.

The investigation found that, although all doors were functional, the extended wing flaps used for landing had blocked the forward portion of the rear cargo doors. Based on this observation, the TSB issued Aviation Safety Advisory A18W0129-D1-A1 to highlight the significant safety issue involving Cessna 206 aircraft that are fitted with rear double cargo doors. Over the years, these doors have been identified as a risk to passengers in emergency situations. As a result, the TSB and other investigative agencies have been advocating for changes to the door design.

Transport Canada responded to the safety advisory by stating its intention to make a formal submission to the U.S. Federal Aviation Administration (FAA) requiring Cessna to develop, deploy and mandate improvements to the cargo door design to ensure successful egress in the event of an accident on water.

In April 2020, Transport Canada issued Airworthiness Directive CF-2020-10 in response to the safety advisory to impose new limits on how Cessna 206s can be configured and loaded. In addition, the directive noted that the FAA now requires 206s to include a door at the front on the right-hand side of the cabin. Transport Canada considers that this door offers a viable means of emergency egress for passengers in the front and centre-row seats in circumstances such as those in the 2018 occurrence.

The investigation also highlighted a number of risk factors. In particular, if the passenger safety briefing is incomplete, passengers may not know how to escape the aircraft in an emergency. In this occurrence, a pre-flight briefing was provided during which the operation of the rear cargo doors was demonstrated. However, no instructions were provided on what to do if the doors were blocked due to flap deployment.

Following the occurrence, the company stopped operating the Cessna 206 on floats. It also began providing underwater egress training for all floatplane flight crews, and increased training and experience requirements for new crew members.

The TSB investigated the March 2019 collision of a privately registered Piper J3C-65 aircraft on skis with the frozen surface of Snowshoe Lake in Ontario (A19C0026). Both the pilot and passenger sustained fatal injuries when the pilot lost control of the aircraft during the visual flight rules flight.

As part of the investigation, the TSB issued Aviation Safety Advisory A19C0026-D1-A1, “Federal Aviation Administration Airworthiness Directive 2015-08-04 Reliability of Main Spar Wing Lift Assembly Inspection – Punch Test Method.” The TSB wished to draw Transport Canada’s attention to the contrast between the results of two separate methods for determining the amount of corrosion within the strut assembly, stating that one of the methods—the punch test—can be inconclusive and therefore unreliable. The TSB further advised Transport Canada that it needs to review current inspection methods to ensure they are a reliable way to identify the unsafe condition. 

In its response, Transport Canada reported that it had obtained and shared with the FAA a copy of the TSB’s engineering report and entered into discussions with the FAA about having an alternative to the punch test that would provide more conclusive results. However, the FAA indicated that, after its investigation with the aircraft manufacturer, it is moving towards removing the punch test as an inspection method.

Not knowing when this will happen, Transport Canada reported that it is planning to take proactive action by issuing a unilateral airworthiness directive to remove the punch test as an inspection method for detecting lift strut corrosion.

Safety advisories and safety information letters

The TSB issued additional safety advisories and safety information letters in 2019–20 as part of investigations into occurrences during the year:

• January 2019 alternating current (AC) connector failures on a de Havilland DHC-8-402 aircraft, leading to diversion of flight to Calgary International Airport, Alberta (A19W0001):
  • Air Safety Advisory A19W0001-D1-A1 noted that the variable-frequency AC power feeder connectors in DHC-8-400 series aircraft, installed between the AC contactor box and the flight compartment’s variable-frequency AC circuit breaker panel, have a history of failure due to arcing. The TSB encouraged Transport Canada to address this safety issue and work with de Havilland to develop a more robust strategy for inspection and repair/replacement of the connectors.
• July 2019 collision with terrain of Robinson R44 helicopter near Lac Valtrie, Quebec, with fatal injury of two individuals (A19Q0109):
  • Air Safety Advisory A19Q0109-D1-A1 identified a safety issue involving the failure of the Kannad 406 AF-compact emergency locator transmitter switch locking system. The TSB also suggested that the periodic inspection procedures for these transmitters be revised so that such faults can be detected and corrected.
• October 2019 loss of braking and runway excursion of a de Havilland DHC-8-102 aircraft at Pickle Lake Airport, Ontario (A19C0136):
  • Aviation Safety Information Letter A19C0136-D1-L1 addressed the emergency procedure in the DHC-8-102’s Aircraft Flight Manual/Quick Reference Handbook for when the “WT ON WHEELS” caution light comes on. The TSB encouraged Transport Canada to work with the manufacturer to amend the procedure to include specific information about the possibility that the aircraft may not respond to anti-skid brakes and nose wheel steering input if two proximity sensors have failed.
• October 2019 in-flight breakup (right wing became detached from the fuselage) of a de Havilland DHC-3T aircraft near Little Grand Rapids, Manitoba, with fatal injury of the pilot and two passengers (A19C0138):
  • Air Safety Advisory A19C0138-D1-A1 identified an issue with the wing strut attachment inspection, finding that it may not be adequate for identifying cracks that form. The TSB encouraged Transport Canada to work with Viking Air Ltd., the aircraft type certificate holder, to amend the Supplementary Inspection and Corrosion Control Manual or to issue a new airworthiness directive to include inspection requirements outlined in Viking’s Alert Service Bulletin V3/0011.

Progress on outstanding recommendations

Of the 36 aviation recommendations the Board assessed and reassessed in 2019–20, 12 were closed. Among these, 10 were closed as Fully Satisfactory and 2 as Satisfactory in Part.

Among the recommendations closed as Fully Satisfactory were Recommendation A99-02 and Recommendation A99-03, which date from 1999 and which the Board had issued in the wake of the Swissair accident off the coast of Nova Scotia the previous year. Four other recommendations issued as part of that investigation (A98H0003) were also closed in 2019–20.

One of the shortcomings the TSB identified during its investigation was the limited recording capacity of the aircraft’s cockpit voice recorder (CVR). The CVR was able to record only 30 minutes, and therefore did not capture the timeframe when the fire that led to the accident started. In light of this, the Board recommended (Recommendation A99-02) to Transport Canada and the European Joint Aviation Authorities that, as of 1 January 2005, all aircraft that require both a flight data recorder and a CVR be required to be fitted with a CVR having a recording capacity of at least two hours.

Recommendation A99-03 focused on the Swissair aircraft’s lack of a dedicated independent power supply to power the CVR and the cockpit area microphone in the event that normal aircraft power sources to the CVR were interrupted. To address this, the Board recommended that as of 1 January 2005, for all aircraft equipped with CVRs having a recording capacity of at least two hours, a dedicated independent power supply be installed adjacent or integral to the CVR, to power the CVR and the cockpit area microphone for 10 minutes whenever normal aircraft power sources to the CVR are interrupted.

In May 2019, the amendments to the Canadian Aviation Regulations for flight data recorders and CVRs were published in the Canada Gazette, Part II. The Board is of the view that these amendments, which will come into effect in May 2023, will address the safety deficiencies associated with both recommendations.

The remaining 24 recommendations the Board assessed and reassessed in 2019–20 obtained the following ratings: Satisfactory Intent (7); Satisfactory in Part (7); Unable to Assess (7) and Unsatisfactory (3).

Marine sector

The year in review

There were 267 marine accidents reported to the Transportation Safety Board of Canada (TSB) in 2019, below the 2018 total of 289 and the 10-year average of 298. In 2019, 78% of marine accidents were shipping accidents, compared to 83% on average over the previous 10 years. The remaining 22% of marine accidents in 2019 were accidents aboard ship, above the 10-year annual average of 17%.

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In 2019, 17 marine fatalities were reported, below the 2018 total of 22, but slightly above the 10-year average of 15.2. Thirteen of the 17 fatalities occurred aboard ship, in contrast to 2018 when most fatalities (14 of 22) involved shipping accidents.

As in previous years, the majority of the marine fatalities (10 of the 17) were related to commercial fishing (Canadian-flag vessels in Canadian waters). Due to this continuing trend, commercial fishing safety is a Watchlist 2018 issue.

There were 230 vessels involved in the 207 shipping accidents that took place in 2019. In 2018, 267 vessels were involved in 233 shipping accidents. The highest decrease was observed in the Pacific region (to 90 from 119).

The number of marine incidents reported to the TSB increased to 947 in 2019, which is only a 2% increase from 2018, but a 65% increase from the 10-year average of 573. As in previous years, most reportable incidents (84%) were related to the total failure of machinery or technical systems. The increase in incidents of this type is due largely to changes made in 2014 to TSB reporting requirements.

According to Transport Canada, 2019 marine activity (commercial vessel-kilometres) for Canadian commercial non-fishing vessels over 15 gross tons (excluding passenger vessels and cruise ships) was 12% above the 2015 to 2018 average. The 2019 accident rate was 4.9 accidents per million commercial vessel-kilometres, lower than the 2015-to-2018 average of 6.3. (Transport Canada now provides a comprehensive distance-based metric of commercial marine activity in Canadian waters beginning from 2015. However, a five-year series is too short to test for meaningful trends, and vessel movements are no longer captured.)

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Investigations

TSB staff deployed to 8 marine occurrences in 2019–20—down by 7 from 2018–19—and began 7 investigations.

Of the 8 marine investigations the TSB completed in 2019–20, 5 were detailed class 3 investigations and 3 were limited-scope class 4s. The average time to complete the class 3 investigations was 548 days (up from 417 in 2018–19). The average duration of the class 4 investigations was 341 days, an increase from 294 days the previous year.

Internal resourcing issues, combined with a significant amount of workload from previous years, meant that the TSB focused its efforts on fewer marine occurrences in 2019–20.

Crew to be fully trained in life-saving equipment

During 2019–20, the TSB closed three investigations into three instances of passenger ferry lifeboats and rescue boats suddenly dropping into the water during drills.

In the first instance (M17A0391), the forward release hook on a lifeboat on the passenger ferry Northern Ranger suddenly released during scheduled operational testing in October 2017 in Nain, Newfoundland and Labrador. The four crew members on board were injured. The TSB found that the lifeboat fell because the release hook had been improperly reset, and its safety defence did not operate in compliance with the Life-Saving Appliance Code.

The TSB issued Marine Safety Advisory MSA 04/18 regarding the models of the release hooks involved in this occurrence. The ferry operator subsequently prohibited crew from being in lifeboats during retrieval.

Operational updates, including crew training, must accompany equipment changes

In the second investigation (M18P0087), the TSB found that incorrect securement had led to the 2018 uncontrolled fall during a drill of a rescue boat and its crew from the passenger ferry Queen of Cumberland in Swartz Bay, British Columbia.

The vessel had undergone a mid-life upgrade in 2016, during which the rescue boat davit, a device used to hoist and lower rescue boats and lifeboats, was changed. However, corresponding updates to operational and maintenance procedures were not made, and others went unidentified and unresolved.

Following the occurrence, the operator, BC Ferries, prohibited personnel from being on board rescue boats while they are being raised and lowered, except during emergencies. The operator also provided updated training on the operations and limitations of rescue boat davits, and updated its maintenance procedures.

In the third lifeboat-related investigation completed in 2019–20 (M18P0257), the TSB determined that a combination of inadequate risk assessment, informal practices and insufficient supervision led to two crew members’ falling from a rescue boat during a passenger ferry emergency drill. This occurrence, involving the Spirit of Vancouver Island, also took place at the Swartz Bay Ferry Terminal, a few months after the Queen of Cumberland occurrence.

The investigation determined that the rescue boats on board the Spirit of Vancouver Island had been replaced with another model that had different physical characteristics from the original, including having a greater overall height. However, the davits were not changed to match, and crew members had developed an informal practice to compensate. Further, in this occurrence, the chief officer’s high workload and simultaneous tasks at multiple locations meant he was not available to supervise the drill.

BC Ferries had voluntarily adopted a safety management system but did not identify hazards related to changing the rescue boat type. If key components of a safety management system, such as carrying out risk assessments when there are changes in equipment aboard ships, are not managed effectively and necessary updates to maintenance systems and schedules are not made, there is a risk that maintenance will be inadequate or overlooked. In addition, if changes to operational procedures and training are not made, the crew may not be proficient in the use of the equipment. Both of these factors increase the risk of equipment failures, accidents and injuries, and there is a risk that the safety of passengers and crew will be compromised. Safety management and oversight is a Watchlist 2018 issue.

Following the occurrences, BC Ferries made a number of changes to policies and procedures related to rescue boat operations.

The TSB investigated the December 2018 sinking of the lobster fishing vessel Charlene A in St. Margaret's Bay, Nova Scotia (M18A0425). The four crew members were wearing lifejackets and were rescued by another fishing vessel.

The vessel had been modified in the summer of 2018, when a stern extension and hinged tailgate-style bulwark (an extension of the vessel’s side above the level of the vessel’s exterior deck) was installed. However, the master did not determine whether the vessel had sufficient reserves of stability that would allow it to be safely modified. After the modifications were completed, no stability assessment was conducted, nor was a record of stability prepared, as is required by the Fishing Vessel Safety Regulations. Similarly, a fishing vessel modification history form was not completed.

Under the regulations, it is the responsibility of the master and the authorized representative of a fishing vessel to ensure the vessel complies with regulatory and safety requirements. When stability assessments are not conducted, these individuals and the crew may be unaware of adverse changes in vessel stability resulting from the modifications that may affect safety.

The TSB’s investigation (M18P0230) of the August 2018 girding and capsizing of the George H Ledcor in British Columbia highlighted risks associated with a lack of awareness of the factors leading to girding, informal work practices and insufficient guidance and training in the towing industry.

Girding occurs when a vessel is pulled broadside by a towline force and is unable to manoeuvre out of this position. From 2005 to 2018, the TSB received reports of 26 girding occurrences resulting in 21 capsizings. A video the TSB produced in 2019–20 explains factors that lead to girding and recovery methods.

The investigation into the 2018 occurrence highlighted a number of risk factors, notably a lack of initial and recurring training of tug masters and the towing industry’s continued reliance on tug masters to manage girding hazards through ship-handling skills and informal practices.

The vessel’s owner took a number of steps to reduce the likelihood of similar accidents. It supplemented its safety management system with procedures on how to recognize and avoid girding. It introduced voyage simulator and classroom training for its masters and mates. It also installed additional standard abort mechanisms in common locations on all company vessels.

Safety advisories

The TSB issued additional safety advisories in 2019–20 as part of investigations into marine occurrences:

• September 2018 capsizing of the fishing vessel Kyla Anne with three people on board, 1.3 nautical miles north of North Cape, Prince Edward Island (M18A0303):
  • Marine Safety Advisory MSA 03/19 referenced a lack of consultation between Fisheries and Oceans Canada and Transport Canada about the safety of lobster harvesters returning to their home port through the corridor in lobster fishing area 24.
• March 2019 striking of dock by roll-on/roll-off passenger ferry Apollo while berthing in Matane, Quebec (M19C0054):
  • Marine Safety Advisory MSA 01/19 addressed the state of seaworthiness of the Apollo.
• May 2019 sudden drop of the clump weight of the fishing vessel Newfoundland Victor during repairs, which pulled the net and a crew member into the water (M19A0211):
  • Marine Safety Advisory MSA 02/19 reviewed deficiencies regarding the winch brake system and the development of work procedures on board at the time of the occurrence.

Progress on outstanding recommendations

The Board reassessed 20 marine recommendations in 2019–20, closing none of them.

Among these recommendations were four that progressed from various ratings to Satisfactory Intent. This included Recommendation M94-06, which had a rating of Unsatisfactory at the end of 2018–19, due to the Board’s concern about Transport Canada’s protracted delays in responding to it. In the recommendation, the Board had asked Transport Canada to require the installation of water-level detectors in all compartments below the waterline on large fishing vessels.

In January 2019, Transport Canada indicated that Phase 3 of the Fishing Vessel Safety Regulations would address this recommendation when the Large Fishing Vessel Regulations (LFVR) are repealed. In the interim, Transport Canada is now proposing to amend the existing LFVR to require the installation of water-level detectors on large fishing vessels in all compartments below the waterline. The amendment to the LFVR is expected to be published in the Canada Gazette, Part I in the fall of 2020. Once implemented, the amendment would mitigate the risk associated with this safety deficiency. The Board considers the response to the recommendation to show Satisfactory Intent.

The Board downgraded two recommendations to Unable to Assess from Satisfactory in Part and Unsatisfactory, respectively, since Transport Canada had not provided a response specific enough to satisfy the intent of these recommendations. Recommendation M17-02 recommended that Transport Canada take steps to ensure that small passenger enterprises have a safety management system. With Recommendation M18-02, the Board recommended that Transport Canada require vessel owners whose watchkeepers’ work and rest periods are regulated by the Marine Personnel Regulations to implement a comprehensive fatigue management plan tailored specifically for their operation, to reduce the risk of fatigue. Fatigue management is a Watchlist 2018 issue.

There were 21 active marine recommendations as of March 31, 2020. These recommendations have the following ratings: Satisfactory Intent (11), Satisfactory in Part (6), Unsatisfactory (1) and Unable to Assess (3).

Pipeline sector

The year in review

The Transportation Safety Board of Canada (TSB) received 48 reports of pipeline occurrences in 2019 (56% fewer than in 2018). All of them were incidents rather than accidents, compared to the one accident in 2018. The number of occurrences is well below the 10-year average of 132, including 6 accidents.

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Once again, there were no serious injuries or fatalities arising directly from the operation of any federally regulated pipeline, as has been the case since the TSB’s inception in 1990.

Of all 48 incidents in 2019, 20 involved a release of product:

• The proportion of incidents involving product release (42%) in 2019 is approximately equal to the proportion in 2018 (38%) and far below the 10-year average (73%).
• Most of the incidents involving product release resulted in the release of hydrocarbon gas (80%), as has been the case each year since 2015.
• Four other incidents involved the release of low vapour pressure hydrocarbons (as defined in Canadian Standards Association Standard Z662); as of July 2014, the minimum reporting threshold for releases of low vapour pressure hydrocarbons was established at 1.5 m3.

The TSB’s Statistical Summary of Pipeline Occurrences in 2019 contains more information on product releases during the year.

The 48 incidents in 2019 are considerably fewer than the average of 99 per year over the previous 10 years. The difference is mostly due to changes that were introduced in 2014 to the occurrence reporting criteria.

In 2019, only 13 incidents involved geotechnical, hydrotechnical or environmental activity—slope movements or river erosion, for example—down from 44 in 2018. This remains, however, above the average of 7 such events per year over the previous 10 years. The higher level of reported incidents since 2017 may be related to increased regulatory enforcement. Increased company inspections and reporting, as well as varied weather patterns and hydrotechnical activity over the last three years, are additional factors that may have contributed to this rise and decline.

Alberta accounted for the most occurrences in 2019 (19 out of 48), while British Columbia had 12 and Ontario 6. The remaining 12 occurrences were spread across Quebec, the Northwest Territories, Manitoba and Saskatchewan.

There were 70 860 km of federally regulated pipeline operating in Canada in 2019, according to the Canada Energy Regulator (formerly the National Energy Board). The 48 pipeline-related incidents reported to the TSB for the year result in an occurrence rate per 1000 km of operating pipeline of 0.7. This is down from the 2018 rate of 1.6 and continues the overall reduction since 2011. The 2019 rate is also below the average of 1.8 occurrences per 1000 km since 2011.

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Investigations

There were no pipeline-related occurrences to which TSB staff deployed in 2019–20, compared to one in 2018–19. Consequently, the TSB began no new investigations in 2019–20.

The TSB completed one pipeline investigation in 2019–20, a detailed class 3 investigation that took 513 days.

A TSB pipeline investigation (P18H0088) found that deficiencies in predicting the extent of stress corrosion cracking and a deferred inspection contributed to a pipeline rupture and fire near Prince George in 2018.

The model the pipeline operator used to predict stress corrosion cracking growth under its hazard management plan did not take into account all potential uncertainties, which resulted in cracks growing at higher rates than expected. Additionally, an inspection of this pipeline segment scheduled for 2017 was deferred until the fall of 2018. As a result, the existing cracks remained undetected.

Although emergency response activities mitigated the impacts of the occurrence, the investigation determined that not all nearby communities and operators of nearby pipelines had been included in emergency response exercises that had taken place in the four years prior to the occurrence. If pipeline emergency response exercises are not conducted periodically with all potentially affected stakeholders, gaps in emergency response plans may not be identified, thereby increasing the risk that all parties will not be sufficiently prepared to respond to a pipeline emergency.

Following the occurrence, the TSB issued Pipeline Safety Advisory 617-02/19 to Westcoast Energy Inc. suggesting that it might wish to review its stress corrosion cracking management practices, including inspection intervals, to mitigate the risks associated with the polyethylene tape-coated pipe involved in this occurrence. In response, Westcoast revised several aspects of its inspection practices and integrity management program for this pipeline.

The Canada Energy Regulator restricted operating pressures until it approved the engineering assessments submitted by the operator to ensure safe operation of the relevant segments of the pipeline. The Regulator also conducted field inspections to ensure regulatory requirements were met.

Progress on outstanding recommendations

The Board issued no pipeline safety recommendations in 2019–20 and had previously assessed all pipeline recommendations as Fully Satisfactory.

Rail sector

The year in review

Overall, 1246 railway accidents were reported to the Transportation Safety Board of Canada (TSB) in 2019, 7% more than in 2018 and a 17% increase from the 10-year average of 1064.

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There were 72 rail-related fatalities reported in 2019, 15 more than the previous year but comparable to the 10-year average of 73. Among the 2019 fatalities, 38 involved trespassers, compared to 34 in 2018 and the 10-year average of 43.

The number of crossing accident fatalities increased in 2019 (28) compared to 2018 (19) and was higher than the 10-year average of 22. To better understand these data, the TSB is examining the underlying factors for crossing accidents, including why these have increased by roughly six each month from December to February over the past 13 years. The analysis so far indicates weather-related factors are responsible, rather than reduced daylight in winter.

Among all railway accidents reported to the TSB in 2019, 169 involved dangerous goods. This is up from 125 in 2017 and from the 10-year average of 127. Eight accidents in 2019 resulted in dangerous goods being released.

There were 236 railway incidents reported to the TSB in 2019, a 17% decrease from 2018 (286), and a 12% decrease from the 10-year average (269). Incidents involving movements that exceeded limits of authority accounted for 57% (137) of all railway incidents in 2019—four fewer than in 2018 but above the 10-year average of 121.

According to Transport Canada data, 2019 main-track (non-yard) rail activity increased by 1% from 2018. The main-track accident rate in 2019 was 3.3 accidents per million main-track train-miles, up from 2.6 in 2018 and above the 10-year average of 2.3.

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Investigations

TSB staff deployed to 16 rail occurrences in 2019–20, one fewer than in 2018–19, and began 20 investigations.

Of the 13 rail investigations the TSB completed in 2019–20, 8 were detailed class 3 investigations and 5 were limited-scope class 4s. The average time to complete the class 3 investigations was 520 days (up from 447 in 2018–19). The duration of the class 4 investigations was 219 days, a slight increase from the previous year.

Assessing risks of operational changes essential

The TSB’s investigation into the 2017 fatal injury of a yard helper during overnight switching operations in a Canadian Pacific Railway yard in Montréal (R17D0123) found the lack of a risk assessment following a significant change in operations to be a contributing factor to the occurrence, along with fatigue and task interruption.

The St-Luc Yard changed its switching operations in 2012 but did not conduct a risk assessment at that time, since the company’s safety management system did not require one. Consequently, Canadian Pacific Railway missed the opportunity to identify and mitigate any new hazards the changes created.

The short break the yard helper took from his post shifted his focus away from his duties. This led him to incorrectly align the locomotives carrying out the switching activities away from the destination track. It is likely that the yard helper’s fatigue also contributed to the incorrect alignment of the crossover switch.

Both safety management and oversight and fatigue management are Watchlist 2018 issues, and the TSB investigation (R16C0065) into a September 2016 collision and derailment of Canadian Pacific Railway trains in Calgary also focused on the importance of risk assessments.

For its part, Canadian Pacific Railway conducted employee awareness campaigns focusing on the hazards present when working on or near tracks and the associated risk mitigation processes.

With the completion of two investigations in the last three years into the fatal injury of a person in a wheelchair at a railway crossing, the TSB continues to shine the spotlight on the need to improve safety at crossings designated for persons using assistive devices.

A May 2018 accident (R18V0127) saw an individual’s motorized wheelchair become immobilized in a crossing in Chilliwack and then struck by a freight train. The investigation determined that, as the person in the wheelchair was crossing the tracks, both of the chair’s rear caster wheels likely rotated and fell into the 103 mm gap between the sidewalk and the rail (known as a flangeway).

The investigation also found that impending changes to Transport Canada’s Grade Crossings Standards, which will reduce the maximum flangeway width to 75 mm at designated crossings, would not have prevented the 50 mm caster wheels of the chair involved in this accident from becoming lodged in the flangeway.

Following the accident, Transport Canada issued a letter of non-compliance and concern to Canadian National Railway Company that identified a number of safety concerns with the crossing. Transport Canada also issued a notice to the City of Chilliwack outlining concerns with the sidewalks and road approaches. The municipal authorities subsequently arranged for an engineering assessment of the crossing and for improvement work, which was completed in April 2020.

In response to Recommendation R18-01, which the Board made after an investigation into an occurrence in Moncton in 2016 (R16M0026), Transport Canada said it had taken steps to identify and assess engineering options that would help improve crossing safety for persons using assistive devices. The Board has assessed this response as showing Satisfactory Intent. The TSB is continuing to monitor Transport Canada’s progress on its planned activities and will monitor other related safety actions taken by the industry and road authorities. 

A collision between a train and a track machine in October 2018 near Crysler, Ontario, resulted from a gap in track-clearing procedures that prevented the timely sharing of safety-critical information among railway engineering employees who were engaged in track work, the TSB investigation (R18H0105) found.

At the time of the occurrence, a trainee was operating the track machine (a Unimat tamper) under the supervision of a trainer. However, the trainer was not aware that a train was approaching or that the tamping tools had been lifted and extended toward the adjacent track. In addition, since the tamper was not on the list of equipment for which work heads must be pulled in and work stopped when trains operate on adjacent tracks, engineering staff did not mention when it was time to clear the track.

The TSB issued Rail Safety Advisory 617-09/18 on 16 November 2018. It stated that, given the potential risks when trains operate through work sites, Transport Canada might wish to review the application of Rule 42 of the Canadian Rail Operating Rules. This Rule allows ongoing work activities when a train is passing on the adjacent track.

Canadian National Railway Company added the Unimat tamper to its clearing procedures for track services, and shared these procedures with engineering staff in the Eastern Region. The company also posted labels inside the cab of machines that are restricted from working while trains are passing on an adjacent track.

A TSB investigation (R18D0069) found that cargo that had been inadequately secured and fell from an A-frame flat car led to the derailment of 22 cars of a Canadian Pacific Railway train near Saint-Polycarpe, Quebec, in July 2018.

The TSB issued Rail Safety Advisory 617-07/18 to Transport Canada on 9 October 2018. The Safety Advisory focused on Canadian Pacific Railway’s loading practices for cars with open tops. This was because the lateral movement of a top-heavy load that had not been properly secured had led to a boxcar striking a section of stock rail that had fallen from the A-frame flat car that preceded it and derailing. The investigation also determined that there had been no inspection to Railway Association of Canada standards of the car before it was released for travel.

This occurrence confirms the TSB’s view that when railways do not develop and implement procedures for the safe loading and securement of rail cars, and do not train personnel to assess top loading, cargo may not be properly loaded and/or secured. This increases the risk that material could fall off a rail car during train operations.

In its response to the safety advisory, Transport Canada told the TSB that it had followed up with the railway and confirmed that it had adequately addressed the problem that had led to the occurrence. For its part, Canadian Pacific Railway issued a written procedure on loading and inspection of A-frame flat cars and trained its employees on it.

Safety advisories

The TSB issued additional safety advisories in 2019–20 as part of investigations into derailments and releases of dangerous goods.

• February 2019 derailment of 99 freight cars and 2 locomotives near Field, British Columbia, and fatal injury of the three crew members (R19C0015):
  • Rail Safety Advisory 617-04/19 advised Transport Canada to ensure that effective safety procedures are applied to all trains stopped due to an emergency on both “heavy grades” and “mountain grades.”
  • Rail Safety Advisory 617-05/19 advised Transport Canada to review the efficacy of air brake system inspection and maintenance procedures for grain hopper cars used in unit train operations, and ensure that these cars can be operated safely at all times.
• April 2019 derailment of two coaches of a VIA Rail passenger train near Moncton (R19M0018):
  • Rail Safety Advisory 617-06/19 encouraged Transport Canada to review how rail condition monitoring is performed at railway crossings and provide guidance (as necessary) to ensure these inspections are conducted in an effective and consistent manner.
• June 2019 derailment of 44 freight cars and the mid-train remote locomotive on the Canadian side of the Canadian National Railway Company tunnel between Sarnia and Port Huron, Michigan, and release of sulphuric acid (R19T0107):
  • Rail Safety Advisory 617-08/19 suggested that, for the safety of operating crew members, Transport Canada ensure that railways have specific instructions or guidance in their emergency procedures for conducting train inspections following a derailment in a tunnel when dangerous goods are involved.
  • Rail Safety Advisory 617-09/19 suggested that, given the potentially significant consequences of a freight car sustaining structural failure during train operations, Transport Canada and the Federal Railroad Administration may wish to ensure that railways and car owners have procedures in place to identify, inspect and repair (as required) bathtub gondola cars that are equipped with stub sills, particularly those that are being used in scrap iron and steel service, which were constructed in the late 1970s and early 1980s.
• February 2020 derailment of 32 tank cars near Guernsey, Saskatchewan, with resulting release of product and a pool fire (R20W0025):
  • Rail Safety Advisory 617-02/20 suggested that Transport Canada further review and modify key train speeds, as appropriate, based on various train risk profiles, while also considering other factors that influence the severity of a derailment.
  • Rail Safety Advisory 617-03/20 advised Transport Canada that the current Rules Respecting Track Safety do not address the increased risks associated with the operation of key trains and that it should, therefore, consider revising these rules to include enhanced track standards for key routes.

Progress on outstanding recommendations

Of the 15 rail recommendations the Board reassessed in 2019–20, 3 were closed as Fully Satisfactory.

Among those closed was Recommendation R07-04, which the Board had issued in the wake of the derailment of 18 tank cars and the release of approximately 200 000 L of gasoline and diesel fuel in the marshy area of the Grande Plée Bleue, near Saint-Henri-de-Lévis, Quebec, in 2004.

The damage sustained by the Class 111A tank cars involved in this occurrence and the risks posed by the subsequent product release were typical of that identified in previous TSB investigations. The Class 111A tank cars’ weaknesses have been acknowledged by the regulator and industry, resulting in measures, including standards, to mitigate risk in the event of a derailment. However, the safety enhancements included in the standards did not apply to Class 111A tank cars with a maximum gross weight of 263 000 pounds or less, or to other non-pressurized tank cars. Consequently, a large number of the existing tank cars carrying dangerous goods were vulnerable to puncture, even during derailments at moderate operating speeds. The Board recommended that Transport Canada extend the safety provisions of the construction standards applicable to 286 000 pound cars to all new non-pressurized tank cars carrying dangerous goods.

This recommendation is related to Recommendation R14-01, in which the Board recommended that all Class 111 tank cars used to transport flammable liquids meet enhanced protection standards that significantly reduce the risk of product loss when these cars are involved in accidents. Recommendation R07-04 is for new tank cars only and includes consideration for non-flammable dangerous goods transported in these cars.

In January 2018, Transport Canada published a new edition of tank car standard TP14877, which consolidated the requirements for the Class 117 tank car for flammable liquids, and re-affirmed the requirements for enhanced Class 111 cars for the remaining non-pressure liquid dangerous goods. This new edition of the standard was published in the Canada Gazette, Part II, and took effect in the Transportation of Dangerous Goods Regulations in July 2019. Given that initiatives have been implemented to mitigate the ongoing residual risks, the Board considered the response to Recommendation R07-04 to be Fully Satisfactory and closed this recommendation.

The remaining 12 recommendations the Board reassessed in 2019–20 obtained the following ratings: Satisfactory Intent (9) and Satisfactory in Part (3).

Who we are and what we do

The Transportation Safety Board of Canada (TSB) advances transportation safety in the aviation, marine, pipeline and rail transportation sectors in Canada:

• It conducts independent investigations into selected occurrences and makes findings about their causes and any contributing factors.
• It identifies safety deficiencies arising in transportation occurrences and makes recommendations to eliminate or reduce them.
• It reports publicly about its investigations and findings.

As part of its investigations, the TSB reviews developments in transportation safety and identifies safety risks that governments and the transportation industry must address in order to reduce the risk of injury and loss.

Role of the Board

The Board, which comprises up to five members, including the Chair, approves all investigation reports, makes findings and issues recommendations.

The Board

Kathleen Fox
Chair

Joseph Hincke
Board member

Faye Ackermans
Board member

Paul Dittmann
Board member

Kenneth Potter
Board member

The TSB website contains biographies of each Board member.

In making findings, the Board does not assign fault or determine civil or criminal liability for an occurrence. Rather, it seeks to find out what happened and why in an objective manner, independent from government, and all other departments and agencies involved in transportation, and free from any conflict of interest. It also draws impartial conclusions and makes recommendations to those best placed to take action.

About the TSB

A staff of 220, led by the Chief Operating Officer and senior management, supports the Board. The work of the organization is guided by a five-year strategic plan and five core values:

• Respect: We are committed to treating all individuals and organizations with consideration, courtesy, discretion and fairness.
• Openness: We actively share and exchange information to advance transportation safety.
• Safety: We maintain and promote a positive and proactive safety culture.
• Integrity: We are guided by honesty, impartiality, propriety and accountability for our actions and decisions.
• Excellence: We maintain a highly skilled and knowledgeable team of professionals through leadership, innovation and commitment to continuous improvement in the delivery of our products and services.

TSB investigators are professionals with years of experience in the various transportation modes the TSB covers. They work in collaboration with engineering and technical specialists, human factors investigators and industry analysts, all of whom are supported by small teams of communications specialists, corporate services professionals and administrative officers.

The TSB’s headquarters is in Gatineau, Quebec. The TSB also has a laboratory in Ottawa, and regional offices in Vancouver, Edmonton, Calgary, Winnipeg, Toronto, Montréal, Quebec City and Dartmouth.

The investigation process

There are three main phases of the investigation process. During the field phase, investigators collect data and assess the occurrence. This generally involves travelling to the scene of the occurrence, securing the site and documenting it, conducting interviews and selecting wreckage for further examination. Unless the investigation is limited to data collection, an investigation page is created and posted to the website, and is updated periodically as the investigation progresses.

During the examination and analysis phase, investigators review the data to determine the sequence of events leading to the occurrence and the underlying causes and contributing factors.

In the report phase, investigators draft a report on the investigation, which then goes through a review and approval process, prior to public release.

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Appendices

Appendix A: Investigation reports released in 2019–20 and related safety actions

The following is a list of the investigation reports the Transportation Safety Board of Canada (TSB) released during 2019–20. Each entry includes details of any safety actions taken during the investigation and after the report was published, and a link to the main page for the investigation. The list is organized by transportation sector and in the order in which the occurrences took place.

Aviation sector