Once implemented, the amendment would mitigate the risk associated with this safety deficiency. The TSB also suggested that the periodic inspection procedures for these transmitters be revised so that such faults can be detected and corrected. NAV CANADA and local management continue to concentrate efforts on ensuring adequate staffing resources for the Montreal Terminal as well as all other specialties. The TSB issued additional safety advisories and safety information letters in 2019–20 as part of investigations into occurrences during the year: Of the 36 aviation recommendations the Board assessed and reassessed in 2019–20, 12 were closed. On 20 March 2020, the Chair and the Director of Investigations for the Air Branch appeared before the committee to answer questions about the aircraft certification process in Canada. Rail Safety Advisory 617-02/20 suggested that Transport Canada further review and modify key train speeds, as appropriate, based on various train risk profiles, while also considering other factors that influence the severity of a derailment. The TSB further advised Transport Canada that it needs to review current inspection methods to ensure they are a reliable way to identify the unsafe condition. TSB staff deployed to 36 aviation occurrences in 2019–20—two fewer than in 2018–19— began 39 investigations and completed 28. There were narrowed road approaches due to the median barriers, causing vehicular traffic to veer towards the sidewalks. Building on the successful 2018 introduction of the new Policy on Occurrence Classification, 2019–20 saw us working through a large caseload—with 84 investigations in progress at year-end. They were fixed in place with lag bolts. The company also posted labels inside the cab of machines that are restricted from working while trains are passing on an adjacent track. The Trail Airport took a number of safety actions: Employees reviewed the airport’s procedure for communicating a near-miss incident and met to discuss informal radio operating procedures, including what to do when the other operator does not respond to a radio communication, and shared responsibility for safety and communication. For enquiries, contact us. This solid foundation will serve us well as we continue to advance transportation safety during what promises to be a time of substantial change, not only in how and where we do our work but also in the transportation industry itself. This solid foundation will serve us well as we continue to advance transportation safety during what promises to be a time of substantial change, not only in how and where we do our work but also in the transportation industry itself. The Air Transport Association of Canada, while supporting a review of the gaps in Subpart 703 of the Canadian Aviation Regulations and associated standards, expects due consultation on any necessary amendments through the Canadian Aviation Regulation Advisory Council consultation process. This is down from the 2018 rate of 1.6 and continues the overall reduction since 2011. The trusted agents who handle SECURITAS reports on behalf of the TSB closed 261 reports over the course of 2019–20. Under the strategy, the TSB held awareness training for investigators and media relations staff, reached out to national Indigenous associations and developed guidance for investigators. While the pilot and one passenger escaped the submerged fuselage, the remaining three passengers did not. This occurrence, involving the Spirit of Vancouver Island, also took place at the Swartz Bay Ferry Terminal, a few months after the Queen of Cumberland occurrence. The TSB encouraged Transport Canada to work with the manufacturer to amend the procedure to include specific information about the possibility that the aircraft may not respond to anti-skid brakes and nose wheel steering input if two proximity sensors have failed. Main-track derailment, Canadian National Railway Company, freight train M36921-23, L’Assomption, Quebec, 24 April 2019. However, the master did not determine whether the vessel had sufficient reserves of stability that would allow it to be safely modified. This was because the lateral movement of a top-heavy load that had not been properly secured had led to a boxcar striking a section of stock rail that had fallen from the A-frame flat car that preceded it and derailing. CYBG PLC Annual Report and Accounts 2018 website. We also shared more information about transportation safety with the public than ever before through our limited-scope investigation reports and other communications vehicles. fleet-wide Operations Bulletin advising of the occurrence and prohibiting the use of all luffing davits throughout the fleet, except in emergencies; and. In light of this, the Board recommended (Recommendation A99-02) to Transport Canada and the European Joint Aviation Authorities that, as of 1 January 2005, all aircraft that require both a flight data recorder and a CVR be required to be fitted with a CVR having a recording capacity of at least two hours. The Board is concerned about the slow progress on these older recommendations—an issue that has been on the TSB Watchlist of key safety issues since 2016. It is the railway’s responsibility to determine what type of work can be performed with CROR Rule 42 protection, including when a train is passing on an adjacent track, and to ensure that all personnel working in the vicinity of rail traffic can safely carry out their assigned duties. In its assessment of this response, the Board was encouraged that Transport Canada has initiated work to address this safety deficiency, as a change in the definition of “safety belt,” when fully implemented, will mitigate the risk associated with the safety deficiency identified in this recommendation. You will not receive a reply. In its investigation, the TSB identified 15 causal and contributing factors and issued five recommendations. In the third lifeboat-related investigation completed in 2019–20 (M18P0257), the TSB determined that a combination of inadequate risk assessment, informal practices and insufficient supervision led to two crew members’ falling from a rescue boat during a passenger ferry emergency drill. The TSB issued Marine Safety Advisory MSA 04/18 regarding the models of the release hooks involved in this occurrence. They work in collaboration with engineering and technical specialists, human factors investigators and industry analysts, all of whom are supported by small teams of communications specialists, corporate services professionals and administrative officers. The non-profit foundation is a national forum to connect marine stakeholders to work together to increase the number of Canadians that choose marine careers in the public and private sector. With Recommendation M18-02, the Board recommended that Transport Canada require vessel owners whose watchkeepers’ work and rest periods are regulated by the Marine Personnel Regulations to implement a comprehensive fatigue management plan tailored specifically for their operation, to reduce the risk of fatigue. Registered in Scotland, no. While this is similar to 2018 (seven), it is higher than the average over the previous decade of about four per year. The remaining 22% of marine accidents in 2019 were accidents aboard ship, above the 10-year annual average of 17%. This event had the largest attendance in its history, with approximately 80 participants, including TSB investigators, Board members, government representatives and industry stakeholders, such as airlines, manufacturers and aircrew labour unions. Training will also be enhanced for both pilots and maintenance engineers in light of the overall decrease in workforce experience in the aviation industry. Onboard fatality, bulk carrier Sage Amazon, Port-Daniel-Gascons, Quebec, 17 March 2018. Passenger injury, VIA Rail Canada Inc., passenger train VIA 600, Mile 199.24, Canadian National Railway Company Lac St-Jean Subdivision, Jonquière, Quebec, 28 May 2019. The proportion of incidents involving product release (42%) in 2019 is approximately equal to the proportion in 2018 (38%) and far below the 10-year average (73%). These communications may suggest remedial action to reduce safety risks or share observations to promote greater safety. Transport Canada expected to submit the related documentation for consultation through the Canadian Aviation Regulation Advisory Council process early in 2020. The Quebec North Shore and Labrador Railway conducted an internal investigation and took the following actions: Crossing accident, Canadian National Railway Company, freight train Q10521-21, Mile 71.13, Yale Subdivision, Chilliwack, British Columbia, 26 May 2018. Employment and Social Development Canada has proposed to better align the code with international standards and improved employee work-life balance. Permanent TSB plc - Annual Report 2019 1. As a result, the TSB and other investigative agencies have been advocating for changes to the door design. Not knowing when this will happen, Transport Canada reported that it is planning to take proactive action by issuing a unilateral airworthiness directive to remove the punch test as an inspection method for detecting lift strut corrosion. Among the 2019 fatalities, 38 involved trespassers, compared to 34 in 2018 and the 10-year average of 43. A precise timeframe for implementing this unilateral airworthiness directive has not been determined. Among these recommendations were four that progressed from various ratings to Satisfactory Intent. Transport Canada is also reviewing other airworthiness directives that refer to the punch test to determine whether they should be revised. 2019 was a year where Permanent TSB (‘the Bank’) continued to deliver commercial growth, evolve in a challenging business environment and drive cultural change. An important focus looking forward will be to respond to the effects of the COVID-19 pandemic. Island Express Air Inc. voluntarily suspended operations, and Transport Canada suspended the company’s operating certificates until it had undergone recertification. Air taxi operators play a crucial role in moving people and goods—particularly in remote locations—but have a troubling and persistent accident history. The Canada Energy Regulator restricted operating pressures until it approved the engineering assessments submitted by the operator to ensure safe operation of the relevant segments of the pipeline. Operation Lifesaver indicated in its response that it would continue to focus on delivering anti-trespassing messages to Canadians in an effort to reduce the number of trespassing incidents. The single occupant was fatally injured. The investigation determined that the rescue boats on board the Spirit of Vancouver Island had been replaced with another model that had different physical characteristics from the original, including having a greater overall height. issued Circular No. Transport Canada issued a letter of non-compliance and concern to Canadian National Railway Company on 28 May 2019. While investigations are ongoing, the TSB issues safety advisories and safety information letters to notify regulatory and industry stakeholders of unsafe conditions. Investigating the possibility of a fleet airworthiness issue: Based on the condition of the failed lift strut documented in the TSB laboratory report, Transport Canada said it was of the view that if the inspections required by FAA’s Airworthiness Directive had been carried out, the failed strut would most likely have been removed from service. 2 Permanent TSB plc - Annual Report 2019. Air In consultation with the railway, city officials finalized engineering drawings for various measures to improve pedestrian safety at the crossing, including modifying the pedestrian walkway and renewing the pavement marking to delineate the sidewalk. Runway excursion during take-off roll, Air Creebec Inc., de Havilland DHC-8-102, C-GTCO (commercially operated aircraft), Rouyn-Noranda Airport, Quebec, 23 January 2019. In particular, André Lapointe, a seasoned public service executive, became the TSB’s new Chief Operating Officer. The airport manager published guidelines concerning these tasks in the Airport Staff Training Manual and trained staff on these guidelines. After the modifications were completed, no stability assessment was conducted, nor was a record of stability prepared, as is required by the Fishing Vessel Safety Regulations. The TSB informed the owner that, due to the extent of the damage, it fell under the definition of an accident. However, it did not release its report, since the death was the result of a fatigue-induced heart attack. The Regulator also conducted field inspections to ensure regulatory requirements were met. The safety advisory noted unauthorized pathways near an overpass barrier leading to a railway right-of-way, indicating that frequent trespassing was highly likely. Trespassing accident, Canadian Pacific Railway, freight train 141-17, Mile 16.82, Galt Subdivision, Mississauga, Ontario, 18 March 2018. 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