TSB Quarterly Review — First quarter 2018-19

ISSN 2369-7954

July 2018

Chair's message

Over the last three months, the TSB deployed investigators to 13 occurrence sites across the country, started 20 new investigations, released 17 investigation reports, and provided one investigation update.

Furthermore, we held three news conferences during this first quarter of 2018. Our recently released investigation report into the grounding and subsequent sinking of the Nathan E. Stewart that occurred in 2016 near Bella Bella, British Columbia(M16P0378) led to two recommendations addressing the need to effectively and reliably manage the risk of fatigue in the marine industry. We also released our investigation report into the 2016 fatal loss of control and collision with terrain of a Cessna Citation 500 near Kelowna, BC (A16P0186). This high-profile investigation includes a recommendation calling on Transport Canada to require the mandatory installation of lightweight flight recording systems by all commercial and private business operators not currently required to carry them. Lastly, we released our investigation report (R16T0111) into the June 2016 uncontrolled movement of rolling stock at MacMillan Yard, Ontario, where the Board recommended that Transport Canada update the Railway Employee Qualification Standards Regulations to address existing gaps related to training, qualification and re-qualification standards, and regulatory oversight for employees in safety-critical positions.

The month of May was quite busy as we appeared before the Standing Committee on Transport, Infrastructure and Communities to discuss progress on the implementation of TSB safety recommendations. We also appeared before two other committees: the Standing Senate Committee on Legal and Constitutional Affairs, to discuss Bill C-46 and the TSB's recent recommendation on a comprehensive substance abuse program (A17-02); and the Standing Committee on Government Operations and Estimates.

Finally. as part of our ongoing modernization efforts, we released our new Occurrence Classification Policy and held a number of briefings with our stakeholders to explain the changes. The biggest change is the introduction of the new class 4 occurrences with limited scope investigations presenting a new way to communicate safety information in a timely manner.

Kathy Fox

Completed investigations

Developments

M17C0060 - Nord Quebec Animation

Investigations started

  • Baie-Comeau Airport, QC (Air)
  • Swartz Bay Terminal, BC (Marine)
  • Calgary Intl Airport, AB (Air)
  • Carburry, MB (Rail)
  • Chilliwack, BC (Rail)
  • Montréal/Pierre E. Trudeau Intl Airport, QC (Air)
  • Port Hood, NS (Marine)
  • Beach Cove Point, Port Medway, NS (Marine)
  • Sept-Îles yard, QC (Rail)
  • Rocky Point, PEI (Marine)
  • Calgary, AB(Air)
  • Swartz Bay, BC (Marine)
  • Winnipeg James Armstrong Richardson Intl Airport, MB (Air)
  • Toronto Yard, Toronto, ON (Rail)
  • Matane, QC (Marine)
  • Calgary, AB (Air)
  • Hecate Strait, BC (Marine)
  • Nanaimo Airport, BC (Air)
  • Port-Daniel-Gascons, QC (Marine)
  • Frying Pan Shoal, Canso Harbor, NS (Marine)

This is not a comprehensive list.

News conference to release investigation report (M16P0378) into the October 2016 grounding and sinking of the U.S.-registered tug Nathan E. Stewart in British Columbia. The report underlines the need to effectively and reliably manage the risk of fatigue in the marine industry.

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