Annual Report to Parliament 2005-2006
Occurrence Statistics and Investigations
A total of 1246 rail accidents were reported to the TSB in 2005, a 9% increase from the 2004 total of 1138 and an 18% increase from the 2000-2004 average of 1055. Rail activity is estimated to have increased by 3% over 2004 and by 6% over the five-year average. The accident rate increased to 13.0 accidents per million train-miles in 2005, compared to 12.3 in 2004 and the five-year rate of 11.7. Rail-related fatalities totalled 103 in 2005, compared to 101 in 2004 and the five-year average of 93.
Six main-track collisions occurred in 2005, compared to five in 2004 and the five-year average of seven. In 2005, there were 195 main-track derailments, a 28% increase from the 2004 total of 152 and a 47% increase from the five-year average of 133. Non-main-track derailments also showed a significant increase in 2005, totalling 538 compared to 450 in 2004 and the five-year average of 392.
In 2005, crossing accidents increased to 270 from the 2004 total of 237 and from the five-year average of 258. Crossing-related fatalities numbered 38, up from 25 in 2004 and the five-year average of 35. Trespasser accidents showed a 17% decrease from 2004, from 99 to 82, but a 4% increase over the five-year average of 79. With a total of 63 fatalities in 2005, trespasser accidents continue to account for the majority of rail fatalities.
In 2005, 215 rail accidents involved dangerous goods (this also includes crossing accidents in which the motor vehicle is carrying a dangerous good), up from 208 in 2004 but down from the five-year average of 222. Six of these accidents resulted in a release of product.
In 2005, rail incidents reported under the TSB mandatory reporting requirements reached a 23 year low of 244, down from 252 in 2004 and the five-year average of 300. Dangerous goods leakers not related to train accidents account for the largest proportion of total incidents each year. In 2005, dangerous goods leakers decreased to 124 from the 2004 total of 131 and from the five-year average of 166.
RAIL INVESTIGATIONS STARTED IN 2005-2006
Final determination of events is subject to the TSB's full investigation.
|2005.05.02||Maxville, Ont.||Ottawa Central Railway||Runaway and main-track train collision||R05H0011|
|2005.05.27||Bowden, Alta.||Canadian Pacific Railway||Main-track train derailment||R05C0082|
|2005.07.04||Prescott, Ont.||Canadian National||Main-track train derailment||R05H0013|
|2005.07.13||Calgary, Alta.||Canadian National||Non-main-track train derailment and collision||R05C0116|
|2005.07.31||Val-d'Or, Que.||Canadian National||Main-track train derailment||R05Q0033|
|2005.08.03||Wabamun, Alta.||Canadian National||Main-track train derailment||R05E0059|
|2005.08.05||Swift, B.C.||Canadian National||Main-track train derailment||R05V0141|
|2005.08.22||Monet, Que.||VIA Rail Canada Inc.||Crossing accident||R 05Q0040|
|2006.01.31||Buckskin, Ont.||Canadian Pacific Railway||Main-track train derailment||R06T0022|
RAIL REPORTS RELEASED IN 2005-2006
|2003.10.24||Near Cranbrook, B.C.||Canadian Pacific Railway||Main-track train derailment||R03C0101|
|2004.01.22||Bolton , Ont.||Canadian Pacific Railway||Main-track train derailment||R04T0013|
|2004.02.07||Montmagny, Que.||Canadian National||Main-track train derailment||R04Q0006|
|2004.03.04||Red Deer , Alta.||Canadian Pacific Railway||Main-track train derailment||R04E0027|
|2004.04.18||Linacy, N.S.||Cape Breton and Central Nova Scotia Railway||Main-track train derailment||R04M0032|
|2004.06.28||Munster, Ont.||VIA Rail Canada Inc.||Crossing collision||R04H0009|
|2004.08.08||Estevan , Sask.||Canadian Pacific Railway||Non-main-track train derailment||R04W0148|
|2004.10.24||Floods, B.C.||Canadian Pacific Railway||Main-track train derailment||R04V0173|
|2004.11.12||Lévis, Que.||Canadian National||Main-track train derailment||R04Q0047|
No rail recommendations were issued in 2005-2006.
ASSESSMENT OF RESPONSES TO RAIL RECOMMENDATIONS
The railway industry and the regulator provided updated information as to the response to TSB Rail Branch recommendations. The response to recommendations was reassessed for all 118 recommendations issued since 1991. The information provided prompted reassessment of active recommendations that were being monitored for industry response. The number of active recommendations was reduced from 54 to 26.
OTHER RAIL SAFETY ACTION TAKEN
In response to a Transport Canada (TC) Notice and Order issued by a TC Railway Safety Inspector, Canadian National (CN) took measures to ensure the accuracy of train journals. CN installed additional cameras to monitor cars during switching in rail yards and enhanced automatic car identification systems technology to facilitate prompt correction of any errors between train journals and clearing trains.
Subsequent to a derailment caused by truck hunting at speeds over 50 mph by gondola wood chip cars (TSB Report R04Q0006), the Board expressed concern that these particular cars, which are not equipped with supplementary stabilization systems, are prone to truck hunting at speeds in excess of 50 mph and present a risk of derailment. "Truck hunting" is rapid oscillation of an empty car truck at high speeds, where the flanges tend to ride up on the head of the rail.
Subsequent to a derailment in Bolton, Ontario, at a location with a combination of adverse track conditions (TSB Report R04T0013), Canadian Pacific Railway (CPR) identified two additional track geometry defect types to be measured by the CPR track evaluation car. The new defect types take into consideration the effect of a combination of cross-level and alignment deficiencies and a combination of the train speed exceeding the design speed on a curve with unbalanced superelevation.
The TSB issued a Rail Safety Advisory subsequent to a crossing accident at Castleford, Ontario (TSB Report R04H0014). The advisory discusses the changing of the crossing warning signals from left-hand to right-hand orientation as viewed by an approaching motorist. This change was done to comply with a new standard that crossing signals be right-hand oriented. However, the curvature of the approaching roadway mandated that the signals be left-hand oriented to provide a better sightline of the signals when approaching. Left-hand oriented signals are in the process of being installed at that crossing.
After several derailments involving a breach of containment in tank cars loaded with anhydrous ammonia and subsequent exposure injury, including fatal injury, the classification of anhydrous ammonia is being changed from Class 2.2, non-flammable and non-toxic gases, to Class 2.3, toxic gases, with a sub-class 8, corrosive. The revisions to the Transportation of Dangerous Goods Regulations are to be mandatory after 15 August 2006.
Subsequent to a derailment in Estevan, Saskatchewan, CPR developed and distributed a "Tech Tip" poster across its system to illustrate what to look for when inspecting freight car centre plates and side bearings (TSB Report R04W0148). CPR instructed all certified car inspectors to review the poster. As well, CPR developed and implemented a system-wide risk assessment process that requires its Engineering and Field Operations departments to jointly perform a risk assessment on the track condition before any significant operational changes or when traffic is expected to increase substantially.
TC-approved Railway Locomotive Inspection and Safety Rules were revised, effective January 2006, with changes to the criteria and timeliness of safety inspections on locomotives.
TC developed a Canadian Road/Railway Grade Crossing Detailed Safety Assessment Field Guide (TP 14372E), dated April 2005, to promote enhanced pedestrian crossing protection as part of its compliance, awareness and research programs, and to guide persons performing grade crossing assessments.
Subsequent to the complete fracture and failure of a draft gear stop block in a dangerous commodities tank car (TSB Occurrence R04H0018), which was fortunately caught by inspection, the TSB Engineering Laboratory conducted a failure analysis of the fractured steel. It was determined that the stop block did not conform to the applicable Association of American Railroads (AAR) standard. A TSB Rail Safety Information Letter with this information was forwarded to the AAR for its perusal.
The AAR revised Standard S-580, Locomotive Crashworthiness Requirements, effective July 2005, to include requirements for car body-to-truck attachment and for emergency interior lighting on locomotives manufactured after 2008.
In response to a TSB Rail Safety Advisory and a Rail Safety Information Letter concerning improper loading of steel products on flat cars, CN set off all line shipments of such steel products to confirm that the loading was in compliance with the AAR rules. CN took measures to ensure that shippers of such steel products reviewed the proper loading requirements and provided copies of the required loading patterns. The AAR developed revisions to the Open Top Loading Rules to clarify the guidelines for such loads, and published the revisions in AAR Circular Letter C-10146.
In response to a TSB Rail Safety Advisory concerning shattered rim defects in Southern CH36 wheels manufactured in 1995 and the resultant derailments, the AAR declared that those wheels must be removed from the North American car fleet whenever the cars are in a repair shop and must not be put on another car. The Field Manual of the AAR Interchange Rules was revised accordingly. CN and CPR initiated programs that go beyond the requirements of the AAR. They are removing all Southern wheels from their equipment and have instructed their suppliers not to install Southern wheels on any cars owned or leased by them.
Occurrence Statistics and Investigations
Canadian-registered aircraft, other than ultralights, were involved in 258 reported accidents in 2005, a 2% increase from the 2004 total of 252 but a 10% decrease from the 2000-2004 average of 287. The estimate of flying activity for 2005 is 3 832 000 hours, yielding an accident rate of 6.7 accidents per 100 000 flying hours, up from the 2004 rate of 6.5 but down from the five-year rate of 7.3. Canadian registered aircraft, other than ultralights, were involved in 34 fatal occurrences with 51 fatalities in 2005, higher than the 24 fatal occurrences with 37 fatalities in 2004 but comparable to the five year average of 32 fatal occurrences with 54 fatalities. A total of 20 fatal occurrences involved privately operated aircraft (13 aeroplanes, 6 helicopters and 1 glider), and 12 of the remaining 14 fatal occurrences involved commercial operators (9 aeroplanes and 3 helicopters).
The number of accidents involving ultralights decreased to 30 in 2005 from 36 in 2004, and the number of fatal accidents decreased slightly to 5 in 2005 from 6 in 2004.
The number of foreign-registered aircraft accidents in Canada decreased to 18 in 2005 from 20 in 2004. Fatal accidents increased to 6 in 2005, from 3 in 2004.
In 2005, a total of 823 incidents were reported in accordance with the TSB mandatory reporting requirements. This represents a 9% decrease from the 2004 total of 909 and a 2% decrease from the 2000-2004 average of 837.
AIR INVESTIGATIONS STARTED IN 2005-2006
Final determination of events is subject to the TSB's full investigation.
|DATE||LOCATION||AIRCRAFT TYPE||OCCURRENCE NO.|
|2005.04.12||Vicinity of High Lake, Nun.||Lockheed L382G Hercules||A05W0059|
|2005.04.22||Comox, B.C.||Piper PA-31-350||A05P0080|
|2005.05.07||Bella Bella, B.C.||Messerschmitt-Bolkow-
Blohm BO 105 (helicopter)
|2005.05.27||St. John's , N.L.||de Havilland DHC-8-100||A05A0059|
|2005.06.02||Toronto/Lester B. Pearson International Airport, Ont.||Raytheon/Hawker 800 XP||A05O0112|
5 nm W
|2005.06.09||Hamilton, Ont.||Cess na TU206 G||A05O0120|
|2005.06.10||Richards Landing, Ont.||Bell 212 (helicopter)||A05O0115|
|2005.06.10||COUTS Intersection, Lethbridge, Alta.,
41 nm SE
15 nm N
|2005.06.18||Burntwood River Seaplane Base, Thompson, Man.||Stinson 108-1||A05C0109|
|2005.06.19||Abbotsford International Airport, B.C.||Piper PA-44-180 Seminole
Piper PA-44-180 Seminole
10 nm N
|Robinson R22 Beta (helicopter)||A05P0154|
|2005.06.24||Yellowknife , N.W.T.||de Havilland DHC-3T (Otter)||A05W0127|
|2005.06.25||Oshawa Airport , Ont.||Progressive Aerodyne Inc. SeaRey||A05O0125|
9 nm W
|2005.07.10||Moose Jaw , Sask.||Waco UPF-7 Wolf-Samson||A05C0123|
|2005.07.10||Sudbury , Ont.||Bell 204B (helicopter)||A05O0142|
|2005.07.16||Lac de la Solitude, Que.||Bell 205A-1 (helicopter)||A05Q0119|
|2005.07.18||Orillia Airport, Ont., 5 nm E||Cessna 185F (seaplane)||A05O0146|
|2005.07.18||Constance Lake, Ont.||Cessna A185F (seaplane)||A05O0147|
|2005.07.28||Shovelnose Creek, B.C.||Raytheon Beechcraft King Air 200||A05P0189|
|2005.08.02||Toronto/Lester B. Pearson International Airport, Ont.||Airbus 340-313||A05H0002|
35 nm NW
|MD Helicopters 500D (helicopter)||A05P0184|
|2005.08.09||Vicinity of 69° N 089° W, Nun.||Boeing 747-400
8 nm SE
|2005.08.22||Mount Burns , Alta.||Cessna 180||A05W0176|
|2005.09.01||Schefferville, Que., 20 nm NW||de Havilland DHC-2 Beaver||A05Q0157|
|2005.09.10||Loretto, Ont.||Pezetel SZD-50-3 Puchacz (glider)||A05O0204|
|2005.09.17||Duncan , B.C.,
1 nm S
|Enstrom 280C (helicopter)||A05P0227|
|2005.09.28||Tumbler Ridge, B.C., 21 nm SE||Bell 205A-1 (helicopter)||A05W0205|
|2005.09.29||Lac Ouimet, Que.||Cessna 185 (seaplane)||A05Q0178|
|2005.09.30||Kashechewan, Ont.||Piper PA-31 Navajo||A05O0225|
|2005.10.06||Winnipeg , Man.||Cessna 208B Caravan||A05C0187|
|2005.10.26||Devils Lake, B.C.||Bell 206B (helicopter)||A05P0262|
|2005.10.30||Calgary International Airport, Alta.||Boeing 737-900||A05W0222|
|2005.11.03||Bella Coola, B.C.,
20 nm SE
|Boeing Vertol BV-107 II||A05P0269|
|2005.11.06||Thetford Mines, Que., 10 nm NE||Cessna 172M||A05Q0208|
|2005.11.15||Hamilton Airport, Ont.||Gulfstream 100||A05O0257|
|2005.11.20||Brantford , Ont.||Ryan Aeronautical Navion B||A05O0258|
3 nm SE
Blohm BO 105 (helicopter)
|2005.12.19||Edmonton International Airport, Alta., 70 nm N||Canadair CL-600-2B19 (RJ) Boeing 737-700||A05W0248|
|2005.12.20||Terrace, B.C.||Mitsubishi MU-2B-36||A05P0298|
|2005.12.25||Halifax International Airport, N.S.||Boeing 737-700||A05A0161|
|2005.12.26||Winnipeg International Airport, Man.||Airbus A319-100||A05C0222|
|2006.01.05||Norman Wells, N.W.T.||Douglas C-54G||A06W0002|
|2006.01.21||Port Alberni, B.C.,
11 nm SSE
|2006.01.30||Las Vegas , Nevada, United States||Airbus A319-100||A06F0014|
|2006.03.08||Powell River , B.C.||Piper PA-31-350||A06P0036|
|2006.03.21||Zama Lake , Alta.,
25 nm NW
|McDonnell Douglas 600N (helicopter)||A06W0041|
AIR REPORTS RELEASED IN 2005-2006
|DATE||LOCATION||AIRCRAFT TYPE||EVENT||REPORT NO.|
International Airport, Ont.
|Airbus A321-211||Roll oscillations
|2003.03.11||Kelowna Airport , B.C.||Boeing 737-200||In-flight engine failure||A03P0054|
|2003.04.07||Lake Temagami, Ont.||Found Brothers FBA?2C1||Stall/spin and collision with terrain||A03O0088|
|2003.05.22||Active Pass , B.C.||de Havilland DHC-3 (Otter) Sikorsky S-76A (helicopter)||Risk of collision||A03P0113|
3 nm SE
|Beech 58TC Baron||Controlled flight into terrain||A03O0171|
|2003.07.26||Québec, Que.||Cessna 172M||Fuel exhaustion and forced landing||A03Q0109|
|2003.08.17||Bonaparte Lake , B.C.||Bell 204B (helicopter)||Loss of engine power - collision with terrain||A03P0247|
|2003.11.04||Ottawa/Macdonald-Cartier International Airport, Ont.||de Havilland DHC-8-102||Elevator control restriction at take-off||A03O0302|
|2004.01.26||Toronto/Lester B. Pearson International Airport, Ont.||Boeing 767-233||Aircraft pitch-up/stall warning on departure||A04O0020|
|2004.02.25||Edmonton International Airport, Alta.||Boeing 737-210C||Landing beside
|2004.03.03||Vancouver International Airport , B.C.||Boeing 737-200 Cessna 182||Risk of collision
on the runway
|2004.03.31||Québec/ Jean-Lesage International Airport, Que.||de Havilland DHC-8-300||Control difficulty||A04Q0041|
Airport, Ont., 5 nm N
|Cessna 172 Boeing 737-200||Risk of collision||A04O0092|
|2004.04.19||Chibougamau/ Chapais Airport, Que.||Beechcraft A100 Beechcraft B100||Runway excursion||A04Q0049|
|2004.04.22||Timmins, Ont.||Raytheon B300 (Super King Air)||Aircraft stall
during instrument approach
|2004.04.28||Tasu Creek, B.C.||Bell 206L (helicopter)||In-flight power loss||A04P0142|
|2004.05.05||Vancouver International Airport, B.C., 4 nm S||de Havilland DHC-8-100 de Havilland DHC-2 Mk 1 Beaver||Air proximity - safety not assured||A04P0153|
|2004.05.18||Fawcett Lake, Ont.||de Havilland DHC-2 Mk 1 Beaver||Loss of control
and collision with terrain
|2004.05.28||Moncton, N.B.||Boeing 727-225||Wing scrape during a rejected landing||A04A0057|
|2004.06.07||Taltson River ( Ferguson's Cabin), N.W.T.||Cessna A185F (seaplane)||Upset on water landing||A04W0114|
|2004.06.11||Bob Quinn Airstrip, B.C.||MD Helicopters (Hughes) 369D (helicopter)||Engine power loss||A04P0206|
|2004.06.14||Ottawa River, Gatineau, Que.||de Havilland DHC-2 Mk 1 Beaver (seaplane)||Collision with water||A04H0002|
|2004.06.25||Flourmill Volcano, B.C.,
5 nm W
|Eurocopter AS350 B2 (helicopter)||Blade strike and rollover||A04P0240|
|2004.07.14||Ottawa/Macdonald-Cartier International Airport, Ont.||Embraer EMB-145LR||Runway overrun||A04O0188|
|2004.08.05||Québec/Jean-Lesage International Airport, Que., 12 nm SW||Cessna 208 Caravan Cessna 172||Risk of collision||A04Q0124|
|2004.08.13||McIvor Lake , B.C.||Robinson R22 Beta (helicopter)||Collision with water||A04P0314|
|2004.08.26||Ashern , Man. ,
15 nm SW
|Piper PA-28-235||Flight into adverse weather - collision with terrain||A04C0162|
|2004.08.31||Nain, N.L., 45 nm NW||Aerospatiale AS350D||Loss of control - collision with terrain||A04A0111|
|2004.09.02||Kingston, Ont.||de Havilland DHC-8-102||Flight control difficulties||A04O0237|
|2004.09.10||Edmonton, Alta.||Beech King Air C90A||Navigation deviation||A04W0200|
|2004.09.21||La Ronge, Sask.||Fairchild SA-227-AC Metro III||Landing gear collapse and runway excursion||A04C0174|
|2004.10.30||Shepherd Bay , Nun.||Bell 212 (helicopter)||Collision with terrain||A04C0190|
|2004.12.05||St. John's , N.L.,
10 nm SW
|Piper PA-28-140||Collision with terrain||A04A0148|
|Short Brothers SD3?60||Rejected landing - collision with terrain||A04O0336|
|2004.12.24||Kuujjuaq, Que.||Beech King Air A100||Runway excursion||A04Q0199|
|2004.12.28||Fairmont Hot Springs, B.C., 15 nm SW||Robinson R44 Raven II (helicopter)||Drive-belt failure and collision with terrain||A04P0422|
180 nm N
|Boeing 767-375||Engine failure - fuel starvation||A05F0001|
80 nm NE
|Beechcraft King Air 200||Control difficulty due to airframe icing||A05P0018|
|McDonnell Douglas DC-9-83||Failure to remain on the runway (rejected landing)||A05W0010|
|2005.02.11||Spearhead Glacier, B.C.||Bell 212 (helicopter)||Settling with power - rollover||A05P0032|
|2005.02.24||Blue River , B.C.||Bell 212 (helicopter)||Dual engine power loss and hard landing||A05P0038|
|2005.04.12||Vicinity of High Lake, Nun.||Lockheed L382G Hercules||Component failure - wing-to-fuselage attach angle||A05W0059|
|2005.04.22||Comox, B.C.||Piper PA-31-350||In-flight fire||A05P0080|
|2005.05.07||Bella Bella, B.C.||Messerschmitt-
Bolkow-Blohm BO 105 (helicopter)
|Tail-rotor strike (external load) - loss of control||A05P0103|
|2005.05.27||St. John's , N.L.||de Havilland DHC-8-100||Stall and loss of control during climb||A05A0059|
|2005.06.24||Courtenay, B.C., 10 nm N||Robinson R22 Beta (helicopter)||Power loss||A05P0154|
|2005.06.24||Yellowknife , N.W.T.||de Havilland DHC-3T (Otter) (seaplane)||Incorrect loading/ centre of gravity||A05W0127|
|2005.07.06||Andrew, Alta., 9 nm W||Piper PA-18||Collision with terrain||A05W0137|
|2005.07.10||Moose Jaw , Sask.||Waco UPF-7 Wolf-Samson||In-flight collision||A05C0123|
|2005.07.28||Shovelnose Creek, B.C.||Raytheon Beechcraft King Air 200||Collision with terrain||A05P0189|
|2005.08.09||Sundre, Alta., 8 nm SE||Lancair IV-P||Loss of control||A05W0160|
|2005.09.10||Loretto, Ont.||Pezetel SZD-50-3 Puchacz (glider)||Aircraft loss of control - collision with terrain||A05O0204|
|2005.10.26||Devils Lake , B.C.||Bell 206B (helicopter)||Helicopter rollover - glassy water||A05P0262|
AIR RECOMMENDATIONS ISSUED IN 2005-2006
|Winnipeg, Manitoba - 6 October 2005
Cessna 208 Operation into Icing Conditions - Morningstar Air Express Inc.
|Occurrence No. A05C0187|
|RECOMMENDATION||RESPONSE||BOARD ASSESSMENT OF RESPONSE||SAFETY ACTION TAKEN|
|The Department of Transport take action to restrict the dispatch of Canadian Cessna 208, 208A, and 208B aircraft into forecast icing meteorological conditions exceeding "light," and prohibit the continued operation in these conditions, until the airworthiness of the aircraft to operate in such conditions is demonstrated.||Awaiting response||Pending||To be reported next fiscal year|
|The Department of Transport require that Canadian Cessna 208 operators maintain a minimum operating airspeed of 120 knots during icing conditions and exit icing conditions as soon as performance degradations prevent the aircraft from maintaining 120 knots.||Awaiting response||Pending||To be reported next fiscal year|
|The Federal Aviation Administration take action to revise the certification of Cessna 208, 208A, and 208B aircraft to prohibit flight into forecast or in actual icing meteorological conditions exceeding "light," until the airworthiness of the aircraft to operate in such conditions is demonstrated.||Awaiting response||Pending||To be reported next fiscal year|
|The Federal Aviation Administration require that Cessna 208 operators maintain a minimum operating airspeed of 120 knots during icing conditions and exit icing conditions as soon as performance degradations prevent the aircraft from maintaining 120 knots.||Awaiting response||Pending||To be reported next fiscal year|
|Varadero, Cuba - 6 March 2005
Rudder Separation in Flight - Air Transat Airbus 310-308
|Occurrence No. A05F0047|
|RECOMMENDATION||RESPONSE||BOARD ASSESSMENT OF RESPONSE||SAFETY ACTION TAKEN|
|The Department of Transport, in coordination with other involved regulatory authorities and industry, urgently develop and implement an inspection program that will allow early and consistent detection of damage to the rudder assembly of aircraft equipped with part number A55471500 series rudders.||Awaiting response||Pending||To be reported next fiscal year|
|The European Aviation Safety Agency, in coordination with other involved regulatory authorities and industry, urgently develop and implement an inspection program that will allow early and consistent detection of damage to the rudder assembly of aircraft equipped with part number A55471500 series rudders.||Awaiting response||Pending||To be reported next fiscal year|
ASSESSMENT OF RESPONSES TO AIR RECOMMENDATIONS ISSUED IN 2004-2005
|Timmins, Ontario, 40 nm W - 20 October 2002
Engine Power Loss in Flight - Cathay Pacific Airways Airbus A340-300
|Report No. A02P0261|
|RECOMMENDATION||RESPONSE||BOARD ASSESSMENT OF RESPONSE||SAFETY ACTION TAKEN|
|The Direction Générale de l'Aviation Civile and the Federal Aviation Administration issue airworthiness directives to require the implementation of all CFM56-5 series jet engine service bulletins whose purpose is to incorporate software updates designed to ensure that, in the event of a permanent magnet alternator failure, the electronic control unit will revert to aircraft power.||On 29 August 2005, the TSB received a letter dated 25 May 2005 in which the Federal Aviation Administration (FAA) responded to recommendation A04-03. The response stated that the C.3.J version software has been incorporated by over 90 per cent of the affected worldwide operators; the remaining CFM56-5C operators are complying voluntarily. The software has been provided to all operators. All other engine models with the same alternator design have similar software logic in place.
The FAA also reported that there has not been an alternator failure due to the identified cause (bearing failure) in over 20 months. In total, there have been 29 alternator failures due to this cause. CFM International is currently pursuing root cause and corrective action for this failure, and intends to report its progress to the FAA.
The FAA determined that an Airworthiness Directive is not necessary due to the absence of an unsafe condition.
|Satisfactory in Part||The C.3.J version software has been incorporated by over 90 per cent of the affected worldwide operators; the remaining CFM56-5C operators are complying voluntarily.
CFM International is currently pursuing root cause and corrective action for this failure.
|The Department of Transport ensure the continued airworthiness of Canadian-registered aircraft fitted with the CFM56-5 series engine by developing an appropriate safety assurance strategy to make certain that, in the event of a permanent magnet alternator failure, the electronic control unit will revert to aircraft power.||On 11 March 2005, Transport Canada (TC) responded to recommendation A04 04. TC stated that it confirmed, through communication with the Canadian aviation industry, "that all Canadian aircraft presently affected by CFM Service Bulletin 73 0126 will have their ECU [electronic control unit] software upgraded to version C.3.J by March 2005." The response indicated that TC was not planning to take any further action.
On 7 October 2005, a second response was received. This response amplified TC's course of action, which includes the monitoring of Canadian operators until all the applicable CFM56-5 series service bulletins have been incorporated, and the publication, on 3 August 2005, of a Service Difficulty Alert to both Canadian operators and foreign civil aviation authorities to highlight the applicable service bulletins.
|Fully Satisfactory||TC is committed to the monitoring of Canadian operators until all the applicable CFM56-5 series service bulletins have been incorporated; and published, on 3 August 2005, a Service Difficulty Alert sent to both Canadian operators and foreign civil aviation authorities to highlight the applicable service bulletins.|
In June 2005, the Air Branch reassessment package approved by the Board in May 2005 was provided to Transport Canada, Director General, Civil Aviation. The 2005 annual review of assessments of responses to TSB air recommendations was conducted on 57 "active" recommendations. Consequently, the Board approved the review, which assigned 22 recommendations to "inactive" status. In summary, following the Board's 2005 reassessment, there were 32 "active" recommendations. In addition to these 32, this year's reassessment includes 3 "active" recommendations from 2004, for a total of 35 due for reassessment.
OTHER AIR SAFETY ACTION TAKEN
Following an internal investigation into the occurrence involving control difficulties due to airframe icing, Northern Thunderbird Air Inc., as an interim safety action, distributed a memorandum to advise flight crews to review all available weather data before flights. The company has since developed a syllabus, examination and emergency checklist regarding severe icing and has implemented them as part of its training program to provide flight crews with more in-depth knowledge of severe icing conditions and exit strategies.
As a result of a tail-rotor strike by an external load and subsequent loss of control by a Transport Canada (TC) helicopter, the TC Aircraft Services Directorate issued a safety notice restricting operations with empty or light external sling loads. On 25 May 2005, the TC Aircraft Services Directorate produced draft standard operating procedures (SOPs) for helicopter external load operations. These SOPs restrict the use of bonnets and caution pilots about light and unstable loads.
Following an in-flight engine failure on a WestJet Airlines Boeing 737-200 aircraft, TC issued Service Difficulty Advisory 2004-05. This advisory strongly advises maintainers, operators and other responsible persons that compressor surging should be given the same attention as compressor stalls. Surges should be considered to be minor stalls, and the damage that can occur should not be underestimated. The advisory also stated that compressor surges and stalls can induce latent fatigue fractures culminating in engine failures.
As a result of a risk of collision occurrence, NAV CANADA initiated an airspace study entitled Airspace Review of the Vancouver, Lower Mainland and Victoria Areas on 26 November 2003. The purpose of the study was to determine the optimum airspace configuration, routes and procedures required for the area. Both operators involved in the occurrence are active participants in this study. Both operators and NAV CANADA are involved in frequent dialogue regarding traffic conflicts and the safety of their operations. Both operators believe that the number of conflicts has been reduced as a result.
As a result of an occurrence involving an elevator restriction at take-off, Bombardier issued a revised procedure for control checks following application of de-icing or anti-icing fluids. The operator took steps to ensure that, when two trucks are used to de-ice an aircraft, they operate symmetrically. The operator also incorporated lessons from this occurrence into flight crew briefings on winter operations and specifically highlighted the manufacturer's recommendation as to flight control checks. The operator amended the SOPs for the Dash-8 to include a new requirement for a control check to be performed after application of de-icing and anti-icing fluids.
Following an occurrence involving aircraft pitch-up/stall warning on departure, Air Canada implemented several initiatives aimed at enhancing flight crew safety awareness.
- Manuals were updated to reflect new information on speed protection annunciation and information received from Boeing that addresses autopilot operations in a degraded mode of operation.
- The Flight Crew Training Manual was updated with a description of the incident, along with a reminder that, when the aircraft is on autopilot and operating in a degraded mode, speed protection will not be available and crew intervention will be required.
- The 2004 Winter Instrument Procedures Flight had, as part of the pre-briefing, a PowerPoint presentation and instructor/candidate interactive dialogue that included what happened during this event.
- Flight crews now view a pictorial display of flight deck indications that demonstrate when crew intervention would be required.
- Flight technical personnel, in conjunction with Air Canada Tech Ops, are determining if all aircraft need to be configured to flight control computer Customer Option 6 or one of the other available options.
- An Aircraft Technical Bulletin has been created to make crews aware of speed protection annunciation and autopilot flight director system failures. This bulletin will remain active until all the relevant information is made available in the aircraft operating manual.
- Boeing 767 SOPs, Initial Climb, have been amended to include an automatic flight speed protection warning: "WARNING - The auto flight system design lacks airspeed protection in ALT CAP mode. Excessive rate of climb when transitioning to ALT CAP mode can create an insufficient energy condition resulting in rapid airspeed decay."
As a result of a risk of collision occurrence, NAV CANADA developed and implemented procedures detailing helicopter operations at the London International Airport, Ontario. Local helicopter operators were briefed on the procedures. As well, NAV CANADA staffed the position of Unit Operations Specialist at the London control tower.
As a result of a wing scrape occurrence during the performance of a rejected approach in poor weather, TC is proposing changes to the Canadian Aviation Regulations that will define the use of pilot-monitored approaches as part of the new approach-ban regulations. In response to this occurrence, TC regional staff conducted an inspection of the weather observation service at Moncton, New Brunswick, on 5 October 2005. As a result of the findings, the floodlights near the ceiling projector were adjusted to reduce interference with weather observations, and NAV CANADA implemented new procedures to improve the communication of information related to changing weather conditions between the weather office and the tower personnel.
Following a fatal floatplane upset occurrence, TC published an article in Issue 1/2005 of the Aviation Safety Letter, and plans to prepare new or revised safety promotional material to address the topic of underwater egress. It also intends to develop an emergency procedures training program for its inspectors and to review information on seaplane operations to determine the best method to reach private operators with information on conducting thorough pre-flight briefings, including underwater egress and situational awareness.
TC published an article in Issue 2/2005 of the Aviation Safety Letter that summarized an occurrence in which a pilot had advised a friend of his proposed flight itinerary, but the friend was unaware of his responsibilities concerning search and rescue notification requirements. The Aviation Safety Letter is sent to all Canadian licensed pilots. The article emphasized the need for pilots to ensure that persons responsible for the flight itinerary fully understand the search and rescue notification requirements.
Following an occurrence in which a landing gear collapsed as a result of the installation of an incorrect part during maintenance and failure to properly check the installation, Northern Dene Airways Ltd. commissioned an independent safety audit of its complete operation. All maintenance staff of the authorized organization responsible for maintaining Northern Dene Airways Ltd.'s aircraft met to review the company's maintenance procedures outlined in its Maintenance Policy Manual. The following policy was reinforced: "No one is to install any parts on any aircraft without first referring to the appropriate parts and service manuals to ensure correct part number and also that the integrity of the affected aircraft system is still in place."
A Canadian Helicopters Limited helicopter departed into environmental conditions conducive to whiteout and collided with terrain with one fatality. Following the occurrence, the company, as part of its safety management system, completed an internal investigation to draw lessons from the accident. Canadian Helicopters Limited increased its use of full-motion flight simulator training to help replicate departures under whiteout conditions and to monitor flight crew interaction. Following a review of its existing SOPs, simulator training will also emphasize compliance. The company instituted a policy requiring a minimum of 50 hours on type before pilots perform departures under whiteout conditions. It is assessing the use of low-profile reflective markers at Northern Warning System helipads to provide additional visual cues along departure and approach paths.
As a result of a component failure on a Lockheed L382 Hercules, Lockheed Martin issued Revision 3 of Service Bulletin 382-53-61/82-752, dated 4 August 2005. Revision 3 of the Service Bulletin specifically identified the need for a visual inspection of the wing-to-fuselage attach angles on applicable aircraft, to be accomplished within 30 days after receipt of the Service Bulletin to determine if repairs have been installed, and further recommended replacement of any previously repaired attach angle within 365 days.
Following an engine fire and crash of a Piper PA-31-350, TC confirmed, after consultation with the U.S. Federal Aviation Administration, that the intent of Airworthiness Directive (AD) 2002 12-07 was to include "ALL rebuild or overhauled engines." Effectively, the intent was to broaden the "Applicability" section of the AD to ensure that all affected (old-style) gaskets identified by part number LW 13388 be removed from service, purged from the system, and replaced with new gaskets identified by part number 06B23072, in accordance with Part II or Part III of Textron Lycoming Supplement 1 to Mandatory Service Bulletin (MSB) 543A. TC sent a Service Difficulty Alert (AL-2005-08), dated 17 October 2005, to all owners, operators and overhaul facilities to ensure that owners/operators and overhaul facilities of engines affected by AD 2002-12-07 had complied with all the requirements stated within the AD, incorporated Lycoming MSB 543 latest issue, and ensured that inventories of spare parts had been purged of any converter plate gaskets identified by part number LW.
|Accident||in general, a transportation occurrence that involves serious personal injury or death, or significant damage to property, in particular to the extent that safe operations are affected (for a more precise definition, see the Transportation Safety Board Regulations)|
|Incident||in general, a transportation occurrence whose consequences are less serious than those of an accident, or that could potentially have resulted in an accident (for a more precise definition, see the Transportation of Safety Board Regulations)|
|Occurrence||a transportation accident or incident|
|Recommendation||a formal way to draw attention to systemic safety issues, normally warranting ministerial attention|
|Safety Advisory||a less formal means for communicating lesser safety deficiencies to officials within and outside the government|
|Safety Information Letter||a letter that communicates safety-related information, often concerning local safety hazards, to government and corporate officials|
1. While the Board's operations are for the 2005-2006 fiscal year, occurrence statistics are for the 2005 calendar year. Comparisons are generally to the last 5 or 10 years. For definitions of terms such as accident, incident and occurrence, see Appendix A.
2. Investigations are considered complete after the final report has been issued.
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