Annual Report to Parliament 2008-2009

Transportation Safety Board of Canada
Place du Centre
200 Promenade du Portage
4th Floor
Gatineau, Quebec K1A 1K8
819-994-3741
1 800 387-3557
communications@bst-tsb.gc.ca

© Minister of Public Works and Government Services Canada 2009
    Cat. No. TU1-2009
    ISBN 978-0-662-06770-2

ANNUAL REPORT TO PARLIAMENT 2008-2009

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

01 June 2009

The Honourable Josée Verner, P.C., M.P.
President of the Queen's Privy Council for Canada
House of Commons
Ottawa, Ontario K1A 0A6

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 01 April 2008 to 31 March 2009.

Yours sincerely,

Wendy A. Tadros
Chair

Table of Contents

The Chair's Message

Section 1: Overview

1.1 Members of the Board
1.2 Senior Management
1.3 Mission of the TSB
1.4 Independence

Section 2: Activities

2.1 Occurrences, Investigations and Safety Action
2.2 Communicating Transportation Safety to Canadians and the
Transportation Community
2.3 Marine Sector
2.3.1 Annual Statistics
2.3.2 Investigations
2.3.3 Safety Actions Taken
2.3.3.1 Marine Recommendations Issued in 2008-2009
2.3.3.2 Assessment of Responses to Marine Recommendations Issued in
2007-2008
2.3.3.3 Other Marine Safety Actions
2.4 Pipeline Sector
2.4.1 Annual Statistics
2.4.2 Investigations
2.4.3 Safety Actions Taken
2.5 Rail Sector
2.5.1 Annual Statistics
2.5.2 Investigations
2.5.3 Safety Actions Taken
2.5.3.1 Rail Recommendations Issued in 2008-2009
2.5.3.2 Assessment of Responses to Rail Recommendations Issued in
2007-2008
2.5.3.3 Other Rail Safety Actions
2.6 Air Sector
2.6.1 Annual Statistics
2.6.2 Investigations
2.6.3 Safety Actions Taken
2.6.3.1 Air Recommendations Issued in 2008-2009
2.6.3.2 Assessment of Responses to Air Recommendations Issued in
2007-2008
2.6.3.3 Other Air Safety Actions

Appendices

Appendix A - Reports Released by the TSB in 2008-2009 by Sector
Appendix B - Glossary
Appendix C - Assessment Categories and Ratings for Responses to Board
Recommendations
Appendix D - Deficiency File Status

Figures

Figure 1 - Occurrences Reported to the TSB
Figure 2 - Investigations Started, in Process, and Completed
Figure 3 - Ratings of Assessments of Responses, 1999-2008
Figure 4 - Marine Occurrences and Fatalities
Figure 5 - Canadian-Flag Shipping Accident Rates
Figure 6 - Pipeline Occurrences
Figure 7 - Pipeline Accident Rates
Figure 8 - Rail Occurrences and Fatalities
Figure 9 - Main-Track Accident Rates
Figure 10 - Air Occurrences and Fatalities
Figure 11 - Canadian-Registered Aircraft Accident Rates

Tables

Table 1 - Safety Outputs by the TSB
Table 2 - Board Assessments of Responses to Recomendations, 1999-2008
Table 3 - Marine Productivity
Table 4 - Pipeline Productivity
Table 5 - Rail Productivity
Table 6 - Air Productivity

The Chair's Message

The highly skilled and dedicated investigators of the Transportation Safety Board of Canada (TSB) are continuously called upon to conduct full and independent investigations into aviation, marine, railway and pipeline accidents. They painstakingly comb through wreckage, interview survivors, gather detailed, technical information from companies and manufacturers, and analyze the data to determine what happened, why it happened and what needs to be done to reduce the risk.

Important safety lessons come out of our investigations and we have communicated these lessons with a strong voice. This past year, the Board recommended the speedy removal from service of defective freight train wheel sets and improved component tracking in the railway industry. In the aviation sector, we brought attention to the need to reduce the risks of collision in crowded airspace. The Board also called for safety upgrades and improved towing procedures for small fishing vessels sailing in icy waters, and flagged the lack of effective communications when planning repair operations in the vicinity of pipelines.

Once again this year, our challenge was to make sure that our messages are well understood by regulators, the industry and Canadians so that our recommendations will be more widely adopted. One way in which we do this is through our Board Outreach Program. This year, the main focus was the 10th anniversary of the Swissair accident. Our Board Members spoke at events in Canada, the United States, the United Kingdom and Russia to look back at what has been accomplished and to highlight what remains to be done. We also spoke at two Canadian railway safety events to highlight some outstanding safety deficiencies on Canada's railways. Our messages were well received, and we hope that they will encourage more action on our recommendations.

We will seek out ways to broaden our audience reach and work more closely with change agents to increase the uptake of our recommendations. The TSB website was updated to make our safety communications easier to find and to enhance the visibility of our recommendations and assessments of responses. This will ensure that Canadians know where we stand on action taken by regulators and industry.

We will continue to serve Canadians by conducting independent accident investigations and reporting to them on what happened and why. We will also continuously advocate for the changes needed to make transportation safer for all Canadians.

Wendy A. Tadros
Chair

Section 1: Overview

1.1 Members of the Board

Chair Wendy A. Tadros Transportation and legal experience includes Director of Legal Services for the National Transportation Agency of Canada; Inquiry Coordinator for "The Road to Accessibility: An Inquiry into Canadian Motor Coach Services"; and counsel to the Canadian Transport Commission before the Commission of Inquiry into the Hinton Train Collision.

Member Kathy Fox Transportation safety and air traffic services experience includes air traffic controller, commercial pilot, flight instructor, various management positions at Transport Canada, and Vice President of Operations at NAV CANADA. In 1999, received the Transport Canada Aviation Safety Award. In November 2004, was inducted into the Quebec Air and Space Hall of Fame.

Member Jonathan Seymour Transportation policy and marine management experience includes Executive Director of International Maritime Centre-Vancouver; chartering, commercial and general manager for several shipping companies; marine policy advisor to the British Columbia government; and policy and economic consultant.

Member James P. Walsh* Was the Member of the House of Assembly in Newfoundland and Labrador for the district of Conception Bay East-Bell Island from 1989 to 2003. Served as Minister of Works, Services and Transportation, and also served as Minister of Tourism and Culture, Parliamentary Secretary to the Minister of Finance and Treasury Board, and Parliamentary Secretary responsible for the Newfoundland and Labrador Housing Corporation. Also served as Caucus Chairman and Vice-Chair of the Public Accounts Committee. In 2003, received the distinction of Honorary Life Member of the Transportation Association of Canada. * Member Walsh is currently on administrative leave.

Member R. Henry Wright Management and consulting experience includes auditor for the Ontario Ministry of Community and Social Services; senior management administrator of several non-profit organizations; and consultant in government and public relations. * Member Wright's term ended on November 7, 2008.

1.2 Senior Management

Top of Page

1.3 Mission of the TSB

We conduct independent safety investigations and communicate risks in the transportation system.

1.4 Independence

To encourage public confidence in transportation accident investigation, the investigating agency must be, and be seen to be, objective, independent and free from any conflicts of interest. The key feature of the TSB is its independence. It reports to Parliament through the President of the Queen's Privy Council for Canada and is separate from other government agencies and departments. Its independence enables it to be objective in arriving at its conclusions and recommendations. The TSB's continuing independence and credibility rest on its competence, openness, integrity and the fairness of its processes.

Section 2: Activities

2.1 Occurrences, Investigations and Safety Action

In 2008, a total of 1865 accidents and 1459 incidents were reported in accordance with the TSB's regulations for mandatory reporting of occurrences.¹ The number of accidents in 2008 decreased by 12 per cent from the 2109 accidents reported in 2007 and by 16 per cent from the 2003-2007 annual average of 2211 accidents. The number of reported incidents increased to 1459 in 2008 from 1410 in 2007, and increased from the 2003-2007 average of 1398. There were also 742 voluntary incident reports. Fatalities totalled 161 in 2008, up 8 from the 2007 total, but down 12 from the 2003-2007 average.

Figure 1: Occurrences Reported to the TSB

[D]f1

All reported occurrences were assessed in accordance with the Board's Occurrence Classification Policy to identify those with the greatest potential for advancing transportation safety. Information was entered into the TSB database for historical record, trend analysis and safety deficiency validation purposes.

In fiscal year 2008-2009, investigations were undertaken for 61 of the occurrences reported to the TSB. In that same period, 88 investigations were completed, compared to 82 in the previous year.² The number of investigations in process decreased to 81 at the end of the fiscal year from 108 at the start. Average time to complete an investigation decreased to 534 days in fiscal year 2008-2009 from 630 days in the previous year.

Figure 2: Investigations Started, in Process, and Completed

[D]f2

Overall, the TSB has been successful in identifying safety deficiencies and in reducing risks in the transportation system. TSB investigations result in reports identifying safety deficiencies and, where appropriate, containing recommendations to reduce risks. Over this past year, in all cases where the TSB undertook an investigation, safety deficiencies or contributing factors were identified and communicated. These results reflect careful application of the TSB's Occurrence Classification Policy in deciding whether to investigate, and a thorough implementation of the investigation methodology. This systematic approach ensures that TSB investigation resources are invested in areas with the greatest potential safety payoffs.

In 2008-2009, in addition to investigation reports, the TSB issued a total of 68 safety outputs: 5 recommendations, 31 safety advisories and 32 safety information letters (see Table 1 for a breakdown by sector).

Table 1: Safety Outputs by the TSB

Safety information is also provided informally to key stakeholders throughout the investigation process, permitting them to take immediate safety actions where appropriate. It is common practice for industry and government to take safety actions during the course of TSB investigations. Such safety actions range widely in scope and importance. Operators will often take immediate remedial action after discussion with TSB investigators (for example, to clear the sight-lines at a railway crossing by trimming bushes and vegetation). Regulators such as Transport Canada and the Federal Aviation Administration in the United States regularly issue mandatory directives requiring inspections and/or component replacement based on the TSB's preliminary findings. In such situations, rather than issuing recommendations, the TSB can then report on the corrective actions already taken by industry and government agencies.

In accordance with the Canadian Transportation Accident Investigation and Safety Board Act, a federal minister who is notified of a TSB recommendation must, within 90 days, advise the Board in writing of any action taken or proposed to be taken in response, or the reasons for not taking action. The Board considers each response, assessing the extent to which the related safety deficiency was addressed. When a recommendation generates responses from within and outside Canada, the Board's assessment is based primarily on the Canadian response. This year, the TSB continued to publish on its website its assessment of industry and government organization responses to its recommendations made after 01 January 2005.

As presented in Table 2, during the period between 01 January 1999 and 31 December 2008, a total of 155  recommendations were assessed by the Board in the fully satisfactory or active (satisfactory intent, satisfactory in part, and unsatisfactory) categories. In addition, 7 recommendations are awaiting Board assessment, bringing the total number to 162.

Table 2: Board Assessments of Responses to Recommendations, 1999-2008

In the 10-year period from 1999 to 2008, the greater majority of Board-assessed recommendations have effected positive change. As shown in Figure 3, in 79 per cent of cases (57 per cent fully satisfactory and 22 per cent satisfactory intent), change agents have taken action or plan to take action that will substantially reduce the deficiency noted in the recommendation. In 14 per cent of cases (satisfactory in part), change agents have taken or plan to take action that will only partially address the deficiency noted in the recommendation. In 7 per cent of cases (unsatisfactory), change agents have neither taken nor plan to take action that will address the deficiency noted in the recommendation.

Figure 3: Ratings of Assessments of Responses, 1999-2008

[D]f3

2.2 Communicating Transportation Safety to
Canadians and the Transportation Community

Telling Canadians what we learned during accident investigations is fundamental to advancing transportation safety. The TSB continuously strives to raise awareness of its investigative work, and to issue timely and accurate safety communications to Canadians which explain what happened, why it happened, and what needs to be done to make transportation safer and prevent future accidents.

To this end, the TSB communicates its findings to Canadians through routine updates to the TSB website, the production and dissemination of safety communications and final reports, and through organized media events held across the country.

This past fiscal year, we held 17 media events and responded to over 700 media inquiries through the Head Office central media line, not including those inquiries handled regionally or immediately at an accident site.

In 2008-2009, Board Members also pursued a number of key speaking engagements to connect with transportation industry stakeholders and help increase the uptake of TSB recommendations. They spoke to 11 audiences in the aviation, marine and railway industries to highlight outstanding safety deficiencies uncovered as part of TSB investigations.

Of particular note, Board Members marked the 10th anniversary of the crash of Swissair Flight 111 off the shores of Peggy's Cove, Nova Scotia, by speaking at five events in Canada, the United States, the United Kingdom and Russia. These addresses highlighted safety achievements made and outstanding safety deficiencies following our investigation of this tragic accident.

TSB investigation staff also continued to promote the TSB's work and share information about safety lessons learned by attending events and conferences in Canada and abroad. They also hosted visits from other international investigative bodies to exchange information and best practices in investigations.

This past fiscal year, the TSB published 88 investigation reports and work was undertaken to make the recommendations contained in the reports easier to locate, in both the hard copy and electronic formats. During that period, 329 new subscribers joined the TSB electronic notification system for a total of 2579 subscribers. The TSB Macro-Analysis Division published annual and monthly statistical reports and responded to 196 requests for complex transportation occurrence database information.

The TSB website was updated in 2008-2009 to make information, particularly Board recommendations and safety concerns, easier to find through the TSB homepage. The website continues to be an important resource for providing information on accident investigations and transportation safety in general. We received an average of 82 503 daily hits and 28 214 daily visits. While most of the visits were from the United States, our website was viewed by people around the world.

In summary, 2008-2009 was a very active year in reaching out to Canadians and to stakeholders in the transportation community.

2.3 Marine Sector

2.3.1 Annual Statistics

In all, 418 marine accidents were reported to the TSB in 2008, an 8 per cent decrease from the 2007 total of 456 and 15 per cent decrease from the 2003-2007 average of 491. Marine fatalities totalled 24 in 2008, up from the 2007 total of 14 and the 2003-2007 average of 19.

Shipping accidents, which comprised 86 per cent of marine accidents, reached a 34-year low of 359 in 2008, down from 396 in 2007 and from the five-year average of 437. Nearly half of all vessels involved in shipping accidents were fishing vessels. Accidents to persons aboard ship, which include falls, electrocution, and other types of injuries requiring hospitalization, totalled 59 in 2008, a 2 per cent decrease from the 2007 total of 60 and a 9 per cent increase from the five-year average of 54.

Marine activity for Canadian commercial non-fishing vessels over 15 gross tons (excluding passenger vessels and cruise ships) increased by 3 per cent from the 2003-2007 average. This yields an accident rate of 3.4 accidents per 1000 movements, unchanged from the five-year average. Marine activity for foreign commercial non-fishing vessels decreased by 1.7 per cent from the 2003-2007 average while the accident rate decreased by 31 per cent to 1.1 accidents per 1000 movements, down from the five-year average of 1.6.

In 2008, shipping accidents resulted in 13 fatalities, up from 3 in 2007 and the five-year average of 12. Accidents aboard ship resulted in 11 fatalities, the same as the 2007 total and up 4 from the five-year average.

Thirty-three vessels were reported lost in 2008, up from the 2007 total of 31 and the five-year average of 30.

In 2008, 247 marine incidents were reported to the TSB in accordance with the mandatory reporting requirements. This represents an 8 per cent increase from the 2007 total of 228 and the five-year average of 229.

Figure 4: Marine Occurrences and Fatalities

[D]f4

One indicator of marine safety in Canada is the Canadian-flag shipping accident rate. The 2008 accident rate increased to 3.4 accidents per 1000 movements from the 2007 rate of 3.3.

Figure 5: Canadian-Flag Shipping Accident Rates

[D]f5

2.3.2 Investigations

In 2008-2009, 6 marine investigations were started and 18 investigations were completed. The number of investigations completed is comparable to last year. The average duration of completed investigations decreased to 796 days compared to 936  ays the year before.

Table 3: Marine Productivity

2.3.3 Safety Actions Taken

Two marine safety recommendations were issued in 2008-2009.

The Marine Branch reassessed responses to 35 active recommendations issued since 1992. With Board approval, 9 recommendations went from active to inactive status. Of the 26 active recommendations, three (M03-05, M03-06 and M05-04) continue to be assessed as Fully Satisfactory but warrant further monitoring action.

2.3.3.1 Marine Recommendations Issued in 2008-2009

2.3.3.2 Assessment of Responses to Marine Recommendations
Issued in 2007-2008

2.3.3.3 Other Marine Safety Actions

The Department of Fisheries and Oceans issued Fleet Circular 07-2008, Suspension of the Towing of Small Vessels with Persons Onboard While in Ice. This document instructs masters that, until further notice, all Canadian Coast Guard vessels are directed not to take into tow, while in ice, any small vessels that have persons aboard (TSB investigation report M08M0010).

The Department of Fisheries and Oceans distributed to each pool captain a copy of TSB's Marine Safety Information 11/08, Stability of Vessels Engaged in Multiple Fishing Operations, with their herring replacement licence packages. Marine Safety Information 11/08 was sent to Transport Canada, with a copy to the Department of Fisheries and Oceans, informing them of the facts concerning an occurrence involving a vessel engaged in multiple fisheries and reiterating the importance of vessel stability assessments (TSB occurrence M08W0189).

A Canadian ship management company developed and implemented an "Hours of Work Log" form for all shipboard personnel, including vessel masters and chief engineers. The management company also sent a fleet directive to its managed vessels trading into Ontario Trap Rock facility/Bruce Mines, re-emphasizing the navigational risk associated with Bruce Mines and its approach channel and reinforcing the available mitigating actions to be taken to ensure safe navigation (TSB investigation report M08C0024).

The Flag State of a sail training vessel with its operating base in Canada carried out an audit of the systems and procedures of the vessel. The audit indicated the changes that the operators had made to the vessel and its program as a consequence of the loss of a deckhand. All crew and volunteers are now required to have, as a minimum, basic safety training (TSB investigation report M06F0024).

On fishing vessel safety issues, Transport Canada, in conjunction with WorkSafeBC, held a two-day inter-provincial fishing safety and awareness meeting with provincial and territorial government workplace safety agencies, the Department of Fisheries and Oceans, fishing industry associations, and educational institutions to promote the awareness of educational programs and best practices to improve fishing vessel safety (TSB investigation reports M01L0112 and M02W0147).

2.4 Pipeline Sector

2.4.1 Annual Statistics

In 2008, 6 pipeline accidents were reported to the TSB, down from the 2007 total of 7 and down from the 2003-2007 average of 10. Estimated pipeline activity decreased 5 per cent from the previous year. The last fatal pipeline accident in the portion of the industry under federal jurisdiction occurred in 1988, and the last accident involving serious injury occurred in 2006.

In 2008, 83 pipeline incidents were reported to the TSB in accordance with the mandatory reporting requirements, up from 64 in 2007 and the five-year average of 64. In all, 78 per  cent of those incidents involved uncontained or uncontrolled release of small quantities of gas, oil and high-vapour-pressure products.

Figure 6: Pipeline Occurrences

[D]f6

One indicator of pipeline transportation safety in Canada is the pipeline accident rate.⁴ The 2008 rate was 0.5 pipeline accidents per exajoule, unchanged from 2007 and down from the 2003-2007 average of 0.8.

Figure 7: Pipeline Accident Rates

[D]f7

2.4.2 Investigations

In 2008-2009, 1 pipeline investigation was started and 2 investigations were completed. The average duration of completed investigations has increased to 542 days, compared to 489 days in 2007-2008.

Table 4: Pipeline Productivity

2.4.3 Safety Actions Taken

A safety information letter was issued in 2008-2009 related to excessive corrosion occurring in cleaning tool sending traps caused by the movement of sour gas streams through the pipeline system.

2.5 Rail Sector

2.5.1 Annual Statistics

A total of 1148 rail accidents were reported to the TSB in 2008, a 13 per cent decrease from the 2007 total of 1323 and a 17 per cent decrease from the 2003-2007 average of 1387. Estimated rail activity decreased by 2 per cent from 2007 and by 2 per cent from the five-year average. The accident rate decreased to 12.6 accidents per million train-miles in 2008 from 14.2 in 2007 and the five-year rate of 14.9. Rail-related fatalities totalled 74 in 2008, down from the 2007 total of 84 and the five-year average of 92.

Six main-track collisions occurred in 2008, compared to eight in 2007 and the five-year average of five. In 2008, there were 129 main-track derailments, a decrease of 19 per cent from the 2007 total of 159 and of 20 per cent from the five-year average of 162. Non-main-track derailments decreased to 550 in 2008 from 631 in 2007 and from the five-year average of 700.

In 2008, crossing accidents decreased to 214 from the 2007 total of 221 and from the five-year average of 245. Crossing-related fatalities numbered 26, the same as in 2007 and down from the five-year average of 29. Trespasser accidents decreased by 28 per cent to 73 in 2008 from 101 in 2007, and decreased by 17 per cent over the five-year average of 88. With a total of 47 fatalities in 2008, trespasser accidents continued to account for the majority of rail fatalities.

In 2008, 147 rail accidents involved dangerous goods (this also includes crossing accidents in which the motor vehicle is carrying a dangerous good), down from 190 in 2007 and from the five-year average of 204. Two of these accidents resulted in a release of product.

In 2008, rail incidents reported to the TSB in accordance with the mandatory reporting requirements totalled 215, down from 223 in 2007 and from the five-year average of 248. Movements exceeding limits of authority incidents (111) comprised the largest proportion of the 215 reportable incidents. The second largest proportion was dangerous goods leaker incidents (64).

Figure 8: Rail Occurrences and Fatalities

[D]f8

One indicator of rail transportation safety in Canada is the main-track accident rate. This rate decreased from 3.1 accidents per million main-track train-miles in 2007 to 2.6 in 2008.⁵

Figure 9: Main-Track Accident Rates

[D]f9

2.5.2 Investigations

A total of 11 rail investigations were started in 2008-2009 and 22 investigations were completed. The average duration of completed investigations decreased to 539 days from 697 days in 2007-2008.

Table 5: Rail Productivity

2.5.3 Safety Actions Taken

Two rail safety recommendations were issued in 2008-2009.

The Rail Branch reassessed responses to 126 recommendations issued since 1991. With Board approval, 4 recommendations went from active to inactive status and 23 recommendations remained active. The Board's reassessments were communicated to the appropriate change agent(s) for information and action.

2.5.3.1 Rail Recommendations Issued in 2008-2009

2.5.3.2 Assessment of Responses to Rail Recommendations Issued in
2007-2008

2.5.3.3 Other Rail Safety Actions

The United States Federal Railroad Administration and the North American railway industry's "Next Generation Tank Car" project has resulted in the issuance of a final rule improving the safety of rail tank cars that carry poisonous by inhalation materials such as chlorine and anhydrous ammonia. The improvements increase rail hazardous material car crashworthiness over existing design standards (TSB investigation report R04Q0040).

Transport Canada initiated a new Community and Partnership Outreach Program with the objective of promoting safety at railway crossings and addressing the problem of trespassing incidents and crossing collisions within communities. Emphasis has been put on pedestrian crossings near industries and schools, particularly elementary schools (TSB Rail Safety Advisory 06/08).

Transport Canada conducted a crossing accident site follow-up with the Renfrew County Road Authority and the Ottawa Valley Railway concerning the installation of the advanced warning sign WA-18L, advanced pavement markings, and LED lights on the automatic warning devices (TSB occurrence R08H0030 and Rail Safety Information 08/08).

Canadian Pacific Railway enhanced its location-specific General Operating Instructions relating to the locking of locomotive cab after completing 1398 locomotive inspections to ensure that the locking and latching mechanisms of cab doors and windows were operable (TSB Rail Safety Advisory 06/07).

The Association of American Railroads revised Section G, Part II (Wheel and Axle Manual) of the Manual of Standards and Recommended Practices and Section 1.1.8 of Standard S-659 (Axles - General Practices) to include the requirement for wet particle testing of the journal fillet area before the mounting of the roller bearings on those axles that do not require the removal of the wheels (TSB investigation report R07T0240 and Rail Safety Advisory 01/08).

Transport Canada issued an emergency directive pursuant to section 33 of the Railway Safety Act to Canadian National to identify and remove certain suspect defective wheel sets manufactured by Canadian National's wheel shops from Canadian service (TSB investigation report R06T0022).

The Association of American Railroads revised the Manual of Standards and Recommended Practices, Section G, Part II (Wheel and Axle Manual), RP-631, Part 2.3.3 (Wheel Mounting Record Retention), mandating that records of the marking of wheels and axles and the pressures of wheel mountings be kept on file for a minimum of 10 years (TSB investigation report R06T0022).

Transport Canada conducted a review of Canadian National's rail failures at exothermic connections and thermite welds, including a comparison of track defects over the past three years involving thermite welds, and reviewed Canadian National's field procedures for thermite welding and installation of exothermic track connections (TSB Rail Safety Advisory 02/08).

Transport Canada conducted an audit of inspection procedures on the Chemin de fer de la Matapédia et du Golfe inc. and conducted an inspection on part of the Mont-Joli Subdivision. Transport Canada found some deficiencies related to the Safety Management System. It issued a Notice on 18 July 2008 pursuant to subsection 31(1) of the Railway Safety Act and followed up on its findings on site (TSB occurrence R08M0015 and Rail Safety Advisory 04/08).

Further to the December 2007 Ministerial Order, which ordered that specified federally regulated railway companies formulate a rule requiring minimum qualification standards for specified railway industry employees, Transport Canada extended the date for filing said rules by four months, which allowed specified federally regulated railway companies to file said rule with the Minister on or before 21 February 2009 (TSB Rail Safety Advisory 12/07).

VIA Rail Canada Inc. issued Notice HQ09-02 to all its locomotive engineers containing revised instructions to clarify and provide a guideline on performance of brake tests using stabilization and leakage test methods (TSB Rail Safety Advisory 02/09).

Transport Canada issued a Notice and a Notice and Order to OmniTRAX with reference to train handling instructions and practices on the Kettle Falls International Railway in British Columbia (TSB occurrence R08V0270).

Transport Canada followed up with VIA Rail Canada Inc. on new procedures for and inspections of all brake pipe cut-out cocks on passenger coaches. Transport Canada asked VIA to equip all its passenger trains with end-of-train technology similar to that which freight trains are required to have (TSB occurrence R08T0142 and Rail Safety Advisory 05/08).

Canadian Pacific Railway amended its wording of Canadian Rail Operating Rules Rule 303.1(c) and (e) to enhance the applicable protocols related to communications and recording in writing. Speed restrictions were introduced so that the closing-up train must not enter the limits of the other train at more than 15 mph and be prepared to stop short of the preceding train or transfer (TSB investigation report R08W0058).

Transport Canada Rail Safety inspectors reviewed brake testing procedures and training records of car inspectors after a report of safety deficiencies in the brake systems of cars interchanged into the United States. Canadian National issued a bulletin to car inspectors as a reminder to ensure proper inspection of brake rigging during air brake tests (TSB Rail Safety Information 04/08).

2.6 Air Sector

2.6.1 Annual Statistics

Canadian-registered aircraft, other than ultralights, were involved in 251 reported accidents in 2008, a 12 per cent decrease from the 2007 total of 284 and a 7 per cent decrease from the 2003-2007 average of 270. The estimate of flying activity for 2008 is 4 432 000 hours, yielding an accident rate of 5.5 accidents per 100 000 flying hours, down from the 2007 rate of 6.6 and from the five-year rate of 6.7. Canadian-registered aircraft, other than ultralights, were involved in 25 fatal occurrences with 50 fatalities in 2008, comparable to the 33 fatal occurrences with 49 fatalities in 2007 and the five-year average of 31 fatal occurrences with 50 fatalities. A total of 9 fatal occurrences involved commercial aircraft (3 aeroplanes and 6 helicopters), and 10 of the remaining 16 fatal occurrences involved privately operated aeroplanes.

The number of accidents involving ultralights decreased to 29 in 2008 from 30 in 2007, but the number of fatal accidents increased to 12 in 2008 from 5 in 2007.

The number of foreign-registered aircraft accidents in Canada increased to 15 in 2008 from 10 in 2007. There were no fatal accidents in 2008 or in 2007.

In 2008, a total of 914 incidents were reported to the TSB in accordance with the mandatory reporting requirements. This represents a 2 per cent increase from the 2007 total of 895 and a 7 per cent increase from the 2003-2007 average of 857.

Figure 10: Air Occurrences and Fatalities

[D]f10

One indicator of air transportation safety in Canada is the accident rate for Canadian-registered aircraft. In 2008, this rate decreased to 5.5 accidents per 100 000 hours from the 2007 rate of 6.6, and was below the five-year average of 6.7. The trend line shows a significant downward trend over the past 10 years.

Figure 11: Canadian-Registered Aircraft Accident Rates

[D]f11

2.6.2 Investigations

A total of 43 air investigations were started in 2008-2009 and 46 investigations were completed. This represents a decrease in the number of investigations completed compared to the previous year (47). The average duration of completed investigations has decreased to 430 days, compared to 493 days the year before.

Table 6: Air Productivity

2.6.3 Safety Actions Taken

One air safety recommendation was issued in 2008-2009. The response has been received and it is being assessed.

The Air Branch reassessed responses to 28 recommendations issued in previous years. With Board approval, 5 recommendations went from active to inactive status. At the end of fiscal year 2008-2009, there were 38 active recommendations. The Board's reassessments were communicated to the appropriate change agent(s) for information and action.

2.6.3.1 Air Recommendations Issued in 2007-2008

2.6.3.2 Assessment of Responses to Air Recommendations Issued in
2007-2008

2.6.3.3 Other Air Safety Actions

During a Class 5 occurrence (A08O0337), a discrepancy on the Jeppesen Taxiing Chart for Toronto/Lester B. Pearson International Airport (CYYZ Chart 10-9) was noted showing that Taxiway Delta is depicted on the chart as being the same width on the southeast side of the button of Runway 06L as it is entering Runway 06L on the northwest. In fact, Taxiway Delta is much narrower on the opposite side of Runway 06L because the holding bay width is not continued. Jeppesen immediately modified the chart when notified by an e-mail.

As part of another Class 5 occurrence (A08C0004), a fracture was identified in an aircraft nose landing gear drag brace. Without the TSB having to conduct a formal investigation, the TSB supplied the aircraft manufacturer with the safety deficiency and the manufacturer advised that it:

• believed that the problem was fatigue related, driven by retraction cycle hydraulic loads and rigging tolerances;
  
  
• had a new, redesigned part in manufacture, both for new aircraft and in-service parts; and
  
  
• had a new aircraft maintenance manual procedure written to conduct ongoing ultrasound inspections of the part, and to replace it if cracked.

Following a runway overrun accident investigation (A07A0029) at Gander International Airport, Newfoundland and Labrador, Volga-Dnepr Airlines developed an in-house dedicated safety assurance program for the company's intensive flight operations via Gander Airport for the 2007-2008 season.

As a result of a TSB investigation (A07W0072) into a loss of separation in Alberta airspace, the NAV CANADA Edmonton Area Control Centre began a project to vertically split the airspace over Alberta and Northern British Columbia. The airspace change resulted in reduced workload, frequency congestion, and complexity.

Following a mid-air collision (A06O0206) near Brampton, Ontario, NAV CANADA independently initiated an Airspace and Services Review in the Montréal-Toronto-Windsor corridor.

A helicopter accident investigation (A08P0244) found that a cover (doghouse cover), over the engine intake and around the main rotor control system was not removed before flight. The helicopter crashed, and there were four fatalities. The cover did not have any straps or physical barriers that fall at or below human eye level. Once the pilot got into the helicopter, there were no visual cues of the cover's installation.

Following the accident, Prism Helicopters required that blade tie-downs be installed whenever the doghouse cover is installed. Also, the covers were modified with tape/straps that hang down and are to be placed in the front doors. The manufacturer of the doghouse cover (Aerospace Filtration Systems Inc.) took safety action in modifying the cover to make it more visible to crew inside the helicopter.

Following a Northwestern Air Lease Limited Jetstream 3212 runway overrun investigation (A08W0001), the company instituted an enhanced pilot training program emphasizing crew resource management, conducting stabilized approaches, decision making regarding go-arounds, and airspeed control on approaches. In addition, quick reference charts featuring required landing distance were placed in company Jetstream cockpits, and required landing distance was to be included in pre-landing briefings.

Appendix A - Reports Released by the TSB in
2007-2008 by Sector

Marine Reports Released in 2008-2009

Pipeline Reports Released in 2008-2009

Rail Reports Released in 2008-2009

Air Reports Released in 2008-2009

Appendix B - Glossary

Appendix C - Assessment Categories and Ratings
for Responses to Board Recommendations

Responses to recommendations are assessed based on the extent to which the underlying safety deficiency has been or is being addressed. The acceptance or understanding of a deficiency is not a criterion for the assessment rating. The assessment criterion is the potential or actual effectiveness of action planned or taken to reduce or eliminate the deficiency.

Four categories are used to assess responses: fully satisfactory, satisfactory intent, satisfactory in part and unsatisfactory.

Appendix D - Deficiency File Status

Deficiency files can be assigned one of three status designations as follows:

1. While the Board's operations are for the 2008-2009 fiscal year, occurrence statistics are for the 2008 calendar year unless otherwise indicated. Please note that, in a live database, the occurrence data are constantly being updated. Consequently, the statistics can change slightly over time. Comparisons are generally to the last 5 or 10 years. For definitions of terms such as accident, incident and occurrence, see Appendix B.↑

2. Investigations are considered complete after the final report has been issued. See Appendix A for a list of reports released by the TSB in 2008-2009 by sector.↑

3. For definitions of terms such as recommendation, safety advisory and safety information letter, see Appendix B.↑

4. Pipeline accident rates after 2003 reflect the impact of clarifications to the pipeline industry of the TSB's accident and incident reporting requirements, and of internal adjustments to the data in TSB's Pipeline Occurrence Database.↑

5. Because accident statistics (derailments since 2001) have been adjusted in light of clarifications to industry of TSB's reporting requirements, historical rail accident rates after 2001 have been updated accordingly.↑