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Departmental Performance Report

2.7 Marine Sector

2.7.1 Annual Statistics

In all, 467 marine accidents were reported to the TSB in 2006, a 4 per cent decrease from the 2005 total of 489 and an 8 per cent decrease from the 2001-2005 average of 506. Marine fatalities totalled 18 in 2006, down from both the 2005 total of 20 and the 2001-2005 average of 25.

Shipping accidents, which comprised 90 per cent of marine accidents, reached a 30-year low of 419 in 2006, down from 444 in 2005 and from the five-year average of 455. 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 48 in 2006, a 7 per cent increase from the 2005 total of 45 but a 6 per cent decrease from the five-year average of 51.

Marine activity for Canadian commercial non-fishing vessels (excluding passenger vessels and cruise ships) increased by 1 per cent from the 2001-2005 average, resulting in a 7 per cent decrease in the accident rate from 3.6 to 3.3 accidents per 1,000 movements. Although marine activity for foreign commercial non-fishing vessels remained relatively unchanged compared to the 2001-2005 average, accidents increased, yielding an 11 per cent increase in the accident rate from 1.6 to 1.8 accidents per 1,000 movements.

In 2006, shipping accidents resulted in 12 fatalities, down from 13 in 2005 and the five year average of 16. Accidents aboard ship resulted in 6 fatalities, down 1 from the 2005 total and down 3 from the five-year average.

Thirty-one vessels were reported lost in 2006, up from the 2005 total of 26 but down from the five-year average of 34.

In 2006, 212 marine incidents were reported to the TSB in accordance with the mandatory reporting requirements. This represents a 7 per cent decrease from the 2005 total of 227 and a 5 per cent decrease from the five-year average of 222.

Figure 4. Marine Occurrences and Fatalities[D]f4

One indicator of marine safety in Canada is the Canadian-flag shipping accident rate. This accident rate has decreased from 3.7 accidents per 1,000 movements in 2005 to 3.3 in 2006, but no significant statistical trend was found.

Figure 5. Canadian-Flag Shipping Accident Rates[D]f5

2.7.2 Investigations

In 2006-2007, 8 marine investigations were started and 8 investigations were completed. This represents a decrease (from 12 to 8) of the number of investigations completed compared to 2005-2006. The decrease is still linked to the delay to staff vacant positions. The average duration of completed investigations increased to 801 days, compared to 651 days the year before and an average of 797 days between 2002-2003 and 2005-2006. This is attributable to concentrated efforts to complete older investigations. A complete list of all marine reports released in 2006-2007 can be found in Appendix A.

Table 7: Marine Productivity

2.7.3 Link to Resources Utilized

Table 8 shows the net costs of marine investigations for Canadians. Net costs increased over the previous fiscal year. The average net cost per completed investigation increased by 62.5 per cent due to various factors, including the costs of the operations undertaken during the large-scale investigation of the sinking of the Queen of the North ferry off the coast of Prince Rupert, British Columbia, as well as overtime worked to compensate for a lack of investigators. The average duration of completed investigations also increased, and the number of investigations undertaken and completed by investigator decreased over 2005-2006 by 53 per cent and 34 per cent respectively. This is also attributable to the ongoing complex investigation and a decision to limit the number of new investigations in this sector until the backlog has been dealt with.

Table 8: Marine Resources

2.7.4 Safety Actions Taken

No marine safety recommendations were issued in 2006-2007.

The Marine Branch assessed responses to 3 recommendations issued in 2005-2006 (details can be found in Appendix B) and reassessed responses to 42 published recommendations issued in previous years. With Board approval, 9 recommendations went from active to inactive status and 33 recommendations remained active. The Board's reassessments were communicated to the appropriate change agent(s) for information and action.

2.7.4.1 Other Marine Safety Actions

BC Ferries implemented additional procedures to ensure that bridge officers and quartermasters are familiarized with new bridge equipment. TSB Marine Safety Advisory 07/06 on the adequacy of crew familiarization with equipment was sent to BC Ferries following the sinking of the ferry Queen of the North (TSB Occurrence M06W0052).

BC Ferries implemented a new procedure for establishing passenger manifests to ensure that the passengers on board its vessels on northern routes are accurately reflected in the passenger manifests maintained ashore. TSB Marine Safety Advisory 09/06 on the adequacy of current guidelines for creating ferry passenger manifests was sent to Transport Canada (TC) and copied to BC Ferries following the sinking of the ferry Queen of the North (TSB Occurrence M06W0052).

TC met with industry and government representatives to discuss updating current port procedures for the handling of dangerous cargo at the Port of Saguenay, Quebec. A small explosion had occurred on board a vessel unloading a cargo of explosives (TSB Occurrence M06L0045). TC decided to deploy an inspector to the site when notified of a shipment of dangerous cargo at the port. Also, TC informed the Swedish and German port authorities involved (where the vessel was loaded) of the incident and of the handling and loading of the cargo at the port of loading. TSB Marine Safety Advisory 08/06 on the inadequate explosive cargo handling practices was sent to TC and the Port of Saguenay.

2.8 Pipeline Sector

2.8.1 Annual Statistics

In 2006, 8 pipeline accidents were reported to the TSB, up from the 2005 total of 5 but down from the 2001-2005 average of 15. Pipeline activity is estimated to have increased by 2 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 2000.

In 2006, 63 pipeline incidents were reported to the TSB in accordance with the mandatory reporting requirements, down from 79 in 2005 but up from the five-year average of 52. In all, 88 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. This rate increased to 0.6 pipeline accidents per exajoule in 2006, up from 0.4 in 2005 but down from the 2001-2005 average of 1.2. The trend line also indicates a clear downward direction.

Figure 7. Pipeline Accident Rates[D]f7

2.8.2 Investigations

In 2006-2007, one pipeline investigation was started and one investigation was completed. The completed investigation required 407 days, a significant decrease from the 922 days required in 2005-2006 (the latter was a very complex investigation that required a high degree of effort to gather and analyze the data). Details regarding the pipeline report released in 2006-2007 can be found in Appendix A.

Table 9: Pipeline Productivity

Note: Results can fluctuate significantly from year to year due to a number of factors such as staff turnover, the complexity of investigations and the investigation of major occurrences.

2.8.3 Link to Resources Utilized

Table 10 provides a picture of the net cost to Canadians of pipeline investigations. The net cost of pipeline investigations increased slightly compared to 2005-2006. One investigation was started and one was completed during the year.

Table 10: Pipeline Resources

2.8.4 Safety Actions Taken

No pipeline safety recommendations were issued in 2006-2007.

2.8.4.1 Other Pipeline Safety Actions

In response to the Pipeline Safety Information letter, the National Energy Board issued a Safety Advisory to all companies under its jurisdiction, as well as to the Canadian Energy Pipeline Association, the Canadian Association of Petroleum Producers and provincial regulators. The Safety Advisory outlined safety issues related to potential employee injury from ejection of pipeline pigs that have been lodged in receiving traps. Additionally, it itemized actions for organizations to take to address that risk in the future.

2.9 Rail Sector

2.9.1 Annual Statistics

A total of 1,144 rail accidents were reported to the TSB in 2006, an 8 per cent decrease from the 2005 total of 1,247 but a 5 per cent increase from the 2001-2005 average of 1,091. Rail activity is estimated to be comparable to 2005 and to have increased by 4 per cent over the five-year average. The accident rate decreased to 11.9 accidents per million train-miles in 2006, compared to 13.0 in 2005 and the five-year rate of 11.9. Rail-related fatalities totalled 95 in 2006, compared to 103 in 2005 and the five-year average of 96.

Three main-track collisions occurred in 2006, compared to six in 2005 and the five-year average of six. In 2006, there were 133 main-track derailments, a decrease of 31 per cent from the 2005 total of 194 and 10 per cent from the five-year average of 148. Non-main-track derailments decreased to 480 in 2006 from 540 in 2005, but increased from the five-year average of 422.

In 2006, crossing accidents decreased to 248 from the 2005 total of 269 and from the five-year average of 260. Crossing-related fatalities numbered 28, down from 37 in 2005 and the five-year average of 35. Trespasser accidents decreased by 8 per cent to 59 in 2006 from 64 in 2005, but increased by 4 per cent over the five-year average of 57. With a total of 94 fatalities in 2006, trespasser accidents continue to account for the majority of rail fatalities.

In 2006, 181 rail accidents involved dangerous goods (this also includes crossing accidents in which the motor vehicle is carrying a dangerous good), down from 214 in 2005 and from the five-year average of 215. Three of these accidents resulted in a release of product.

In 2006, rail incidents reported to the TSB in accordance with the mandatory reporting requirements reached a 24-year low of 226, down from 243 in 2005 and the five-year average of 283. For the first time, movements exceeding limits of authority incidents (101) comprised the largest proportion of the 226 reportable incidents, surpassing dangerous goods leaker incidents (86).

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 2005 to 2.4 in 2006. Over the past 10 years, the downward trend approaches statistical significance.

Figure 9. Main-Track Accident Rates[D]f9

2.9.2 Investigations

A total of 18 rail investigations were undertaken in 2006-2007 compared to 9 the previous year.The number of investigations completed also slightly increased from 9 to 12 this fiscal year. The average duration of completed investigations increased to 598 days compared to 519 days the year before. A complete list of all rail reports released in 2006-2007 can be found in Appendix A.

Table 11: Rail Productivity

Note: Results can fluctuate significantly from year to year due to a number of factors such as staff turnover, the complexity of investigations and the investigation of major occurrences.

2.9.3 Link to Resources Utilized

Table 12 provides a picture of the net cost to Canadians of rail investigations. The net cost of rail investigations increased slightly compared to the previous year. The average net cost per investigation completed decreased by 22.4 per cent compared to the previous year. The number of investigations started by investigator doubled and the number of investigations completed by investigator increased by 42 per cent. These differences can be attributed to the fact that many of the investigations completed were started in previous years.

Table 12: Rail Resources

2.9.4 Safety Actions Taken

Two rail safety recommendations were issued in 2006-2007.

The Rail Branch reassessed responses to 118 recommendations issued in previous years. With Board approval, 29 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.

2.9.4.1 Rail Recommendations Issued in 2006-2007

Report No. R04T0008: Main-Track Derailment, Canadian Pacific Railway Train, Whitby, Ontario, 14 January 2004

Report No. R05T0030: Pedestrian Fatality, Canadian National Train, Brockville, Ontario, 17 February 2005

2.9.4.2 Other Rail Safety Actions

In response to Rail Safety Advisory 03/06 (TSB Occurrence R06T0022), Canadian National (CN) and Canadian Pacific Railway (CPR) accelerated the inspection and removal from service of certain wheel sets that had been identified as having a risk for developing a loose wheel condition.

In response to Rail Safety Advisory 06/06 (TSB Occurrence R06V0136), CN took action with a "blitz" campaign to test locomotive check valves, and defective valves were replaced. Additionally, the mandatory replacement frequency for these valves was increased.

In response to two other Rail Safety Advisories (07/06 and 08/06) concerning TSB Occurrence R06V0183, Transport Canada (TC) issued two Notices under Section 31 of the Railway Safety Act to the White Pass & Yukon Route railway on 12 separate operational/equipment issues requiring explanations on how the issues would be resolved.

In response to a Rail Safety Information letter (02/06), CPR took action to ensure that emergency response communications protocols between the Ontario Provincial Police and the company were enhanced and that training procedures were developed and communicated.

In response to Rail Safety Information letter 03/06 (TSB Occurrence R05C0082), TC indicated that future audits will put more emphasis on locomotive side bearing clearance and bolster bowl liner condition.

In response to Rail Safety Information letter 04/06 (TSB Occurrence R05C0082), TC indicated that future inspections and audits will put more emphasis on the inspection of locomotive truck bolster stops.

2.10 Air Sector

2.10.1 Annual Statistics

Canadian-registered aircraft, other than ultralights, were involved in 262 reported accidents in 2006, a 2 per cent increase from the 2005 total of 258 but a 5 per cent decrease from the 2001-2005 average of 275. The estimate of flying activity for 2006 is 4,161,000 hours, yielding an accident rate of 6.2 accidents per 100,000 flying hours, unchanged from the 2005 rate but down from the five-year rate of 7.1. Canadian-registered aircraft, other than ultralights, were involved in 31 fatal occurrences with 52 fatalities in 2006, comparable to the 34 fatal occurrences with 51 fatalities in 2005 and the five-year average of 31 fatal occurrences with 52 fatalities. A total of 15 fatal occurrences involved commercial aircraft (6 aeroplanes and 9 helicopters), and 12 of the remaining 16 fatal occurrences involved privately operated aeroplanes.

The number of accidents involving ultralights decreased to 27 in 2006 from 31 in 2005, and the number of fatal accidents decreased substantially to 1 in 2006 from 5 in 2005.

The number of foreign-registered aircraft accidents in Canada decreased to 14 in 2006 from 18 in 2005. Fatal accidents decreased to 2 in 2006 from 6 in 2005.

In 2006, a total of 823 incidents were reported to the TSB in accordance with the mandatory reporting requirements. This is comparable to the 2005 total of 822 and a 4 per cent decrease from the 2001-2005 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 2006, this rate remained unchanged from the 2005 rate of 6.2 accidents per 100,000 hours, but was below the five-year average of 7.1. The trend line also shows a downward direction over the past 10 years.

Figure 11. Canadian-Registered Aircraft Accident Rates[D]f11

2.10.2 Investigations

A total of 41 air investigations were started in 2006-2007 and 36 investigations were completed. This represents a decrease in the number of investigations started compared to the previous year (50) and in the number of investigations completed (53). The average duration of completed investigations increased to 516 days, compared to 404 days the year before. This is attributable to concentrated efforts to complete older investigations. A complete list of all air reports released in 2006-2007 can be found in Appendix A.

Table 13: Air Productivity

Note: Results can fluctuate significantly from year to year due to a number of factors such as staff turnover, the complexity of investigations and the investigation of major occurrences.

2.10.3 Link to Resources Utilized

Table 14 provides a picture of the net cost to Canadians of air investigations. Compared to the previous year, the net cost of investigations decreased slightly. However, the average net cost per investigation completed increased by 39.3 per cent because of the scope of the investigations conducted in Canada, as well as the increased costs associated with supporting foreign investigations involving Canadian-certified operators and products. The number of investigations started and completed per investigator decreased respectively by 21.7 per cent and 35 per cent.

Table 14: Air Resources

2.10.4 Safety Actions Taken

Four air safety recommendations were issued in 2006-2007. One response was assessed as Satisfactory Intent, and initial assessments are pending for the other three.

The Air Branch assessed responses to 6 recommendations issued in 2005-2006 (details can be found in Appendix B) and reassessed responses to 35 recommendations issued in previous years. With Board approval, 7 recommendations went from active to inactive status. At the end of fiscal year 2006-2007, there were 37 active recommendations. The Board's reassessments were communicated to the appropriate change agent(s) for information and action.

2.10.4.1 Air Recommendations Issued in 2006-2007

Report No. A04H0004: Reduced Power at Take-off and Collision with Terrain, MK Airlines Limited, Boeing 747-422SF, Halifax International Airport, Nova Scotia, 14 October 2004

Report No. SII A05-01: Post-Impact Fires Resulting from Small-Aircraft Accidents, Safety Issues Investigation

2.10.4.2 Other Air Safety Actions

As a result of Recommendation A04-02 from investigation A04H0001, Transport Canada (TC) re-evaluated the standard weights for passengers and carry-on baggage and adjusted them for all aircraft to reflect current realities. The Federal Aviation Administration (FAA) issued Airworthiness Directive (AD) 2005-07-01 for the Cessna 208 and 208B aircraft. This AD was issued as a result of several accidents and incidents involving Cessna 208 and 208B operating in icing conditions, including this occurrence. The purpose of the AD was to ensure that pilots have enough information to prevent loss of control of the aircraft while in flight during icing conditions.

Following the receipt of TSB Safety Advisory A040058, generated by TSB investigation A04H0004, TC advised that it was developing and would soon dispatch a Commercial and Business Aviation Advisory letter concerning the need for accurate aircraft load control. As well, as a result of TSB Safety Advisory A040059 on erroneous runway slope information, TC sent an Aerodrome Safety Urgent Bulletin to airports and registered aerodromes reminding them of the need to verify published data.

During a TSB risk of collision investigation (A04Q0089), NAV CANADA undertook a major rewrite of the basic visual flight rules air traffic control training course delivered at its training facility and implemented the new curriculum. Emergency procedures are taught in instructor-led classroom activities that include the associated phraseology. Non-compliance situations by a pilot are taught in the classroom, and are practised in a number of exercises in the dynamic 360-degree airport simulator throughout the course.

During the progress of a TSB investigation into a risk of collision incident at Vancouver International Airport, British Columbia (A04P0397), the Vancouver International Airport tower manager issued an Operations Bulletin to remind controllers to adhere to the Air Traffic Control Manual of Operations (ATC MANOPS) direction to state the name of the intersection or taxiway when issuing taxi to position instructions or take-off clearances from an intersection. NAV CANADA proposed an amendment to Section RAC 4.2.8 of the Aeronautical Information Manual (AIM), which would recommend that pilots include their location with the runway number when requesting take-off clearance.

Pursuant to Safety Advisory A050012 (A05Q0024), TC indicated that it would examine the possibility of adding information on the level of runway certification to the Canada Flight Supplement, which would provide more information and details to pilots regarding any change to the certification status of a given runway.

Following occurrence investigation A05O0112 and the subsequent audit by TC, Rapid Aircraft Repair Inc. hired a Director of Quality Assurance and designated this person as the person responsible for maintenance. The company amended its Quality Assurance Program to ensure closer scrutiny in all aspects of maintenance than was previously possible; implemented a process for regular discussions on process control; implemented the process of a full-control travel check before disassembly; implemented additional training on human factors, improving the reporting of potential problems; and began implementing a safety management system.

Following the commencement of an investigation concerning an inadvertent stick shaker at high altitude (A05W0109), Bombardier Aerospace issued a message to all operators of the CRJ705/900 variants of the CL-65 emphasizing that flight operations should not be conducted below minimum drag speed as defined in the General Speed Section of the Flight Planning Cruise Control Manual for the aircraft type. Air Canada Jazz introduced a nine-module "High Altitude and High Speed Training" program for all CRJ705 pilots. TC published Commercial and Business Aviation Advisory Circular 0247 providing guidance and recommendations to operators for stall recovery training and checking, with the goal of ensuring that flight crews recognize early indications of an approach to a stall and apply the appropriate recovery actions to prevent an aeroplane from entering a stall or upset.

Following a power loss and collision with terrain investigation (A05O0125), the aircraft kit manufacturer posted aircraft information to the technical website used by international owners describing the dangers of using a particular stick grip to actuate trim and flaps.

As a result of TSB investigation A05O0147 (collision with water), the TSB determined that the pilot was able to manoeuvre into the right seat after the aircraft became inverted, but was unable to exit the aircraft. TC undertook a risk assessment, "Egress from Submerged Floatplanes," to identify the risks related to egress from submerged seaplanes and to identify the most effective means of mitigating those risks.

Following the investigation into a helicopter in-flight break-up (A05P0269), Columbia Helicopters Incorporated advised all Boeing 107 helicopter crews of the recurrent procedures to check the operation and serviceability of the speed trim actuator switches. Boeing Aerospace Support-Philadelphia issued Service Bulletin 107-67-1001, requesting that all operators of Model 107 helicopters (BV and KV) and 107 derivatives inspect and functionally test the longitudinal cyclic trim actuator limit switches. Boeing recommended that this test be accomplished before the next flight and before each subsequent flight until further notice.

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