Annual Report to Parliament 2021–22

Place du Centre, 4th floor
200 Promenade du Portage
Gatineau QC K1A 1K8

15 June 2022

The Honourable Bill Blair, P.C., M.P.
President of the Queen’s Privy Council for Canada
House of Commons
Ottawa ON K1A 0A3

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 1 April 2021 to 31 March 2022.

Yours sincerely,

Original signed by
Kathleen Fox
Chair

Message from the Chair

The end of fiscal year 2021–22 marks the second year of working remotely for most of the employees of the Transportation Safety Board of Canada during the COVID-19 pandemic. Despite the substantial changes brought on by the pandemic, our employees continued to show determination and resilience in fulfilling our mandate to advance transportation safety.

This year we focused on completing some of our more detailed and complex safety investigations.

In the spring of 2021, we launched a rail safety issue investigation to understand why there is an increase in the rate of railway crossing accidents involving motor vehicles during winter months in Canada. In December, we released our safety issue investigation report that examined a series of 18 occurrences between 2013 and 2018 in Quebec and Nunavut on runways that were reduced in width during construction work. This led to a recommendation to NAV CANADA to publish graphic depictions of runway closures to accompany notices to airmen (NOTAMs ).

This year also saw the completion of three highly complex and lengthy investigations. In May 2021, we released our report into the 2018 grounding of the passenger vessel Akademik Ioffe in the Canadian Arctic, in which we recommended that Transport Canada, in collaboration with Fisheries and Oceans Canada, develop and implement mandatory risk mitigation measures for all passenger vessels operating in Canadian Arctic coastal waters. Following the investigation, the Canadian Hydrographic Service amended its navigation chart for the area of the occurrence. In October 2021, we released our report into a fatal aircraft accident in 2017 on the territory of the Fond Du Lac Denesųłiné First Nation in Saskatchewan, for which we had issued two  recommendations to Transport Canada in 2018. This investigation shed light on the importance of having adequate de-icing equipment in remote northern airports in Canada. In March 2022, we released our report into the fatal loss of control and main-track train derailment near Field, British Columbia, in 2019, in which we issued three recommendations to enhance safety of train operations in cold weather through mountainous territory.

In keeping with our commitment to engage with our stakeholders, beginning in the fall of 2021 and early 2022, we met with industry for our Watchlist mid-cycle consultations to gauge progress made and discuss any emerging safety issues. The results of these sessions will inform Watchlist 2022, which will be released this fall.

Working toward our objective of becoming digital by default, we began the implementation phase of our new project tracking tool aimed at supporting the management of TSB projects. Next year, the Communications Branch will start using the tool to track projects, enabling them to manage workflow more efficiently. With restrictions around the COVID-19 pandemic easing across the country, we will be implementing a flexible, hybrid work model, incorporating a mixture of remote and in-office work. Regardless of where we work from, we will continue to conduct our critical work of advancing transportation safety from coast to coast to coast.

Kathleen Fox

The year in results

In 2021–22, staff from the Transportation Safety Board of Canada (TSB) assessed thousands of accidents and incidents that occurred across Canada in the air, marine, pipeline and rail transportation sectors (see the definitions in the Policy on Occurrence Classification).

TSB personnel deployed to the sites of some of these occurrences, virtually or in person, to collect data and carry out analysis in order to identify what happened and why, and highlight known and emerging safety issues—all in an effort to improve transportation safety in Canada.

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The total number of occurrences reported to the TSB (as required under the Transportation Safety Board Regulations) in the 2021 calendar year (3111) was 1% higher than the 2020 total of 3080.

In 2021, there were 1450 accidents reported, 2% above the 2020 total of 1422, but 9% below the 10-year average of 1597.

There were 10% more fatalities (103) across all transportation sectors in 2021 than there were in 2020 (94). The 2021 total represents a 23% decrease in fatalities from the 10-year average of 133.

The total of 1661 incidents reported to the TSB in 2021 is almost unchanged from the 2020 total of 1658, and a 10% decrease from the 10-year average of 1853. The latter partly results from changes made in 2014 to TSB reporting requirements.

The TSB at work

Deployments

TSB investigators deployed 46 times during 2021–22 (up from 29 the previous year) in response to occurrences in all sectors. These deployments took staff from the TSB regional offices and head office to locations across the country.

Investigations

In 2021–22, the TSB began 54 new investigations and completed 39 across all four transportation sectors (air, marine, pipeline, and rail) and in four investigative classes (from in-depth and complex to limited scope).

Average completion times increased, both overall and for the various classes of investigations. Class 4 investigations accounted for 44% of the total investigations completed during the reporting year. In these limited scope investigations, the TSB gathers data, conducts a limited analysis and reports the facts regarding less complex occurrences to raise awareness of relevant safety issues.

In support of TSB investigations, engineers, technical specialists and human factors investigators began 167 projects and completed 175 technical reports in 2021–22. They also began 17 projects and completed 15 technical reports for foreign investigation agencies.

Safety communications products

Each year, the Board reassesses progress made on outstanding recommendations as part of ongoing efforts to urge stakeholders to act on the safety issues identified as a result of the TSB’s investigations. In 2021–22, the Board reassessed 2 responses to outstanding recommendations as Fully Satisfactory: 1 on air transportation safety, and 1 on marine transportation safety.

Since 1990, the Board has made 617 recommendations. By the end of 2021–22, it had given 84.1% of the responses to these recommendations the highest rating of Fully Satisfactory. This means that stakeholders, including Transport Canada (TC), have acted to substantially reduce the safety deficiencies the Board identified.

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At 31 March 2022, there were 84 outstanding recommendations, slightly less than half of which date from 10 years ago or more.

Watchlist 2020

The TSB published the latest edition of its Watchlist in 2020. Therefore, in 2021–22, the TSB organized Watchlist mid-cycle consultations to engage with its stakeholders to gauge progress made and discuss any emerging issues. The results of these sessions will inform the next edition of the Watchlist, which will be released in the fall of 2022.

In the fall of 2021, the TSB sent questionnaires to a number of key stakeholders to solicit their input. The survey responses informed subsequent panel presentations and other discussions the TSB held with industry members at meetings of the Air Transport Association of Canada, the Helicopter Association of Canada and the Canadian Marine Advisory Council in November 2021. Consultations are planned with other stakeholders in the air and rail transportation sectors early in the new fiscal year.

SECURITAS

Through the TSB’s SECURITAS program, transportation industry employees and the public can report, in confidence, unsafe actions and conditions they observe.

The TSB received a total of 172 SECURITAS reports in 2021–22. This number is slightly lower than the 189 reports received the previous year.

Of the 93 SECURITAS reports of air transportation safety concerns that were submitted to the TSB, the majority (91%) were of a regulatory nature. These reports were redirected to TC. Other reports submitted were about an unreported accident and information related to an ongoing investigation.

In 2021–22, the TSB received 44 reports of marine transportation safety concerns, representing an increase of 76% from the previous year (25). This increase was likely influenced by the easing of COVID-19 restrictions for the marine transportation industry. All regulatory matters were resolved in collaboration with TC. In total, 19 safety communications were sent out to TC or vessel owners and operators in response to SECURITAS reports.

This year the TSB received 35 SECURITAS reports of rail transportation safety concerns. Among these, the TSB received a report about crossings blocked in excess of 5 minutes, which was redirected to TC for follow-up.

By year-end, the trusted agents had closed all of the SECURITAS reports that the TSB had received.

Communications and outreach

Regular communications and outreach are important aspects of the TSB’s efforts to advance transportation safety. Through its website, social media channels, and participation in in-person and virtual events, the TSB reaches industry and government stakeholders, as well as media and members of the public across Canada and around the world.

Outreach activities

The TSB took part in 54 industry events and meetings during the year, some online and others in person.

Among these was the Air Transport Association of Canada conference on 17 November 2021 in Montreal, Quebec. Chair Kathy Fox and Board Member Yoan Marier were present to gather feedback on the five Watchlist 2020 issues facing the air transportation industry. During this 90-minute session, the TSB posed a series of questions, and candidly discussed the challenges and concerns shared by the industry.

Further consultations were held with the Helicopter Association of Canada during its virtual conference on 24 November 2021. The Watchlist 2020 issues of fatigue, safety management, and regulatory surveillance made up the discussion, with a lot of feedback provided on the challenges experienced by helicopter operators in Canada.

On 7 April 2021, Board Member Ken Potter presented on the topic of the Akademik Ioffe investigation (M18C0225) at the Prairie and Northern Canadian Marine Advisory Council conference. Also, on 23 November 2021, Ken Potter, along with Senior Investigator – Marine Glenn Budden, led an online discussion about the four Watchlist 2020 issues facing the marine transportation industry as part of the national Canadian Marine Advisory Council fall conference.

Behind the scenes

In the spring, we launched a rail transportation safety issue investigation (SII) (R20H0082) to understand why there is an increase in the rate of railway crossing accidents involving motor vehicles during winter months in Canada. An SII is broad in scope and involves looking at multiple occurrences in order to identify the underlying safety issues. Research outcomes from this SII will be communicated in a final TSB report, which will provide findings and, potentially, recommendations for improving road-rail level crossing safety, especially during winter months.

Working toward the TSB’s strategic objective of becoming digital by default, we began the implementation phase of our new project tracking tool aimed at supporting the tracking, monitoring, searching, and reporting of TSB projects. This new tool will also provide a single, centralized location for recording project information, and a means for standardizing project information across the organization. After having onboarded our Engineering Laboratory to support the TSB’s engineering and human factors projects in 2021-22, this fiscal year our Communications Branch will start using the tool to help them manage workflow more efficiently.

With restrictions around the COVID-19 pandemic easing across the country, this year we have been developing a flexible, hybrid work model for TSB employees. Adopted by many other government departments, this work model means that, on any given day, some employees will be working on-site and some off-site. Some employees will be working on-site full-time, some will be working off-site part-time and others will be working off-site full-time.

Air transportation safety

The year in review

The TSB received 689 reports of air occurrences in 2021 (190 accidents and 499 incidents), including 32 fatalities.

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The total number of accidents reported in 2021 (190) is 12% higher than the previous year’s total of 170 accidents but 21% below the yearly average of 239 accidents reported in the previous 10 years, 2011 to 2020. Most (183) of the accidents in 2021 took place in Canada and involved Canadian-registered aircraft. In general, the number of air transportation accidents has been decreasing in the last decade.

The TSB recorded 22 fatal air transportation accidents involving 32 fatalities in 2021. This is up considerably from 12 fatal accidents involving 16 fatalities in 2020, but is still 21% below the average of 28 fatal accidents involving 47 fatalities over the ten-year period of 2011 to 2020. Eight of the 32 air transportation fatalities in 2021 involved commercial operations: 1 of them under air taxi regulations (operations subject to Canadian Aviation Regulations [CARs] Subpart 703), and 7 under aerial work (operations subject to CARs Subpart 702). There were no fatalities involving airliner operations (subject to CARs Subpart 705), commuter operations (subject to CARs Subpart 704), or flight training operations (subject to CARs Subpart 406) in 2021. The remaining 24 (of 32) fatalities in 2021 were linked to privately registered aircraft and involved recreational operators. Eight accidents in 2021 involved a release of dangerous goods. This is above the average of 4.6 per year over the previous 10 years.

In addition, 499 air transportation incidents were reported under the Transportation Safety Board Regulations. This represents an increase of 19% from the 421 that were reported in 2020, and is 34% below the average of 751 incidents per year between 2011 and 2020. The majority of incidents in 2021 (401 or 80%) occurred in Canada and involved Canadian-registered aircraft.

Accident rate: A measure of air transportation safety

The overall air transportation accident rate of 4.8 accidents per 100 000 hours flown in 2021 is based on 164 accidents in Canada and abroad involving Canadian-registered airplanes and helicopters (ultralights, gyroplanes, gliders, and remotely piloted aircraft systems are excluded) and the estimated 3.422 million hours flown by Canadian-registered aircraft. This rate is equal to the 2020 rate, and slightly (4%) above the average rate of 4.6 over the previous 10 years. While the number of hours flown in 2021 increased by 10% compared to 2020, the number of reported accidents increased by a similar amount – around 10%. Taken together this means the accident rate statistic held steady.

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Investigations

TSB staff deployed to 27 air transportation occurrences in 2021–22 (up from 15 in 2020–21), began 37 investigations and completed 21.

* This was a comprehensive, five-year study of safety issues involving runways undergoing construction in Quebec and Nunavut.

** One of the class 2 investigations completed in 2021–22 was into the fatal airplane crash in Fond-du-Lac, Saskatchewan, on 13 December 2017.

Deficiencies in regulatory surveillance related to the safety of flight operations during airport construction

This safety issue investigation conducted by the TSB examined a series of 18 occurrences between 2013 and 2018 that took place at certain airports undergoing construction in Quebec and Nunavut (A18Q0140). A summary review of these occurrences revealed a particularity in the method used to carry out the construction: the width of the runway was reduced rather than the length. In all but two cases, aircraft had manoeuvred on the closed portion of the runway during takeoff or landing.

The investigation found that information pertaining to airport construction, which is temporary and may be complex, can be difficult to communicate clearly and effectively in a NOTAM. As a result of this safety issue investigation, the Board recommended that NAV CANADA make available, in a timely manner, graphic depictions of closures and other significant changes related to aerodrome or runway operations to accompany the associated NOTAMs so that the information communicated on these hazards is more easily understood (A21-01).

In addition, although the occurrences under review took place primarily in Quebec and Nunavut, the investigation determined that these deficiencies all resulted from systemic underlying causes or contributing factors that a national safety program should have identified. Inevitably, it begs the question as to whether the situation is the same in other regions. In light of this, the Board is concerned that if Transport Canada Civil Aviation does not provide adequate surveillance of airports in Canada, the risk of an accident related to flight operations at airports increases, particularly when the airports are undergoing construction.

The results of this investigation reflect the TSB’s ongoing concerns about safety management and regulatory surveillance, both issues on the TSB’s Watchlist 2020.

Better de-icing equipment and practices in remote and northern airports are needed

In its investigation report, the TSB determined that the lack of adequate de-icing equipment and the practice of taking off without de-icing led to the fatal December 2017 accident involving a West Wind Aviation^{Footnote 1} ATR-42 aircraft on the territory of the Fond Du Lac Denesųłiné First Nation in Saskatchewan (A17C0146).

Shortly after takeoff, the aircraft collided with terrain. The aircraft was destroyed and all 22 passengers and three crew members were injured, ten of them seriously. One passenger died 12 days following the accident.

Early in the investigation, it was determined that the aircraft took off from the Fond-du-Lac Airport with contamination on the aircraft’s critical surfaces. In 2018, the Board issued two recommendations. The first one was aimed at making sure adequate de-icing and anti-icing equipment is available for those operators who need it (A18-02). The second urged Transport Canada (TC) to take action to improve compliance with the regulations to reduce the likelihood that crews take off with snow or ice
contamination (A18-03).

This highly complex and lengthy investigation also revealed a number of instances in which TC’s surveillance policies and procedures were inconsistently applied to the oversight of the operator despite several concerns identified between 2010 and 2013 with its safety management system.

The results of this investigation reflect the TSB’s ongoing concerns about safety management and regulatory surveillance, both issues on the TSB’s Watchlist 2020.

Following the occurrence, TC reached out to stakeholders, and provided educational and awareness material regarding the hazards of aircraft taking off with contaminated critical surfaces. The operator implemented new risk assessment requirements, provided its scheduled service and regular charter destinations with equipment capable of inspecting and de-icing all of its aircraft types, and amended its training programs, among other things.

Fatigue management among factors leading to two runway overruns in Halifax

During its investigation into a runway overrun of a Sky Lease Cargo Boeing 747-412F at the Halifax/Stanfield International Airport in Nova Scotia, the TSB identified multiple contributing factors that led to the occurrence (A18A0085). In this occurrence, the 3 crew members received minor injuries and the sole passenger was uninjured.

During the overrun, the aircraft crossed a significant drop of 2.8 m approximately 166 m past the end of the runway and was damaged beyond repair. While this uneven terrain was beyond the 150 m (492 feet) runway end safety area proposed by TC, it was within the recommended International Civil Aviation Organization (ICAO) runway end safety area of 300 m (984 feet). The Board has previously recommended to increase Code 4 runway end safety areas to meet the ICAO recommendation (Recommendation A07-06).

The investigation also identified the presence of two fatigue risk factors that would have degraded the crew’s performance during the approach and landing: the timing of the flight and insufficient restorative sleep in the 24-hour period leading up to the occurrence.

This year the TSB released another investigation report on a runway overrun at the Halifax/Stanfield International Airport (A20A0001). In this occurrence, a WestJet Airlines Boeing 737-8CT touched down with a tailwind component on the wet, snow-covered runway. Following touchdown, the aircraft could not be stopped and it overran the end of Runway 14. The aircraft came to rest in snow approximately 300 feet (91 m) beyond the runway end. There were no injuries or damage to the aircraft.

The results of these investigations reflect the TSB’s ongoing concerns about runway overruns and fatigue management, both issues on the TSB’s Watchlist 2020.

Helicopter enhanced ground proximity warning systems still not required by regulation

In its investigation report, the TSB found that, while conducting a visual approach to an offshore helideck platform in instrument meteorological conditions near Sable Island, Nova Scotia, a Sikorsky S-92A helicopter inadvertently entered a descent before the pilots regained control of the aircraft within approximately 13 feet of the water (A19A0055). In this occurrence, there were no injuries to the 2 crew members or 11 passengers.

The investigation determined that the helicopter entered a low-energy state: it was flying at low airspeed with a high rate of descent, a nose-up pitch attitude, and at a low power setting. The helicopter’s low-energy state went undetected by the flight crew, who were focused on the helideck, which was sitting above the fog and in an area without a discernible horizon. The degraded visual environment made it difficult for the pilots to recognize the unstable approach.

Despite the helicopter’s very high rate of descent into the fog bank at low airspeed with the landing gear extended, its enhanced ground proximity warning system (EGPWS) did not alert the crew to the situation. This is the result of a gap, previously identified by the TSB (investigation A13H0001), in the coverage provided by the S-92 EGPWS. If an inadvertent descent occurs with the gear down at airspeeds below 50 knots indicated airspeed, the EGPWS will provide no warning against controlled flight into terrain.

In 2016, the Board issued Recommendation A16-10 calling for terrain awareness and warning systems for commercial helicopters that operate at night or in instrument meteorological conditions. At the present time, these systems are still not required by regulation. As a result, helicopter manufacturers and operators are free to disable EGPWS modes. Until EGPWS or helicopter terrain awareness and warning systems become mandatory for Canadian commercial helicopters that operate at night or in instrument meteorological conditions, flight crew and passengers aboard these flights are at increased risk of controlled flight into terrain.

Flap malfunction and handling of procedure led to landing accident

In its investigation report, the TSB determined that a flap malfunction of a Bombardier Challenger 605 combined with the flight crew’s handling of the flaps fail landing procedure led to a loss of pitch control and subsequent contact of the rear fuselage with the runway while landing in Calgary, Alberta (A20W0016).

A Bombardier Challenger 605 operated by the Canadian Pacific Railway Company (CP) departed Palm Beach International Airport, Florida, United States, for Calgary International Airport, Alberta, with three crew members and 10 passengers on board. During the descent, the flight crew attempted to deploy the flaps and immediately received a “FLAPS FAIL” caution message. The flight crew proceeded to complete the flaps fail landing procedure from the Quick Reference Handbook (QRH).

The investigation found that the flap failure occurred when one of the flap flexible drive shafts failed. Moisture entered the flap flexible drive shaft casing, likely through the undetected puncture holes and the drive shaft casing to flap actuator interface, which led to the subsequent corrosion and failure of the inner drive shaft. As the aircraft’s actual annual utilization was approximately half of that expected by the manufacturer, the calendar time interval between maintenance inspections increased. As a result, the corrosion that developed was not detected because the shaft had not yet reached the flight-hour maintenance interval at which it would have been inspected next.

The investigation also found that the pilot monitoring did not read the cautions included on the flaps fail checklist out loud to the pilot flying during the completion of the QRH procedure. As a result, information critical to the safe operation of the aircraft was not brought to the pilot flying’s attention.

During its investigation, the TSB issued Air Safety Information Letter A20W0016-D1-L1 to Bombardier Aviation about the inspection interval of the Challenger 605 series flap system and cross-fleet product improvement to the Challenger CL60 series, calling for follow-up action.

Following the occurrence, CP amended its procedures to address the differences between the caution and warning notes published in the aircraft flight manual and QRH. Bombardier issued a temporary revision to the QRH flaps fail landing procedure.

Safety advisories and safety information letters

The TSB issued air transportation safety advisories and information letters as part of its investigations in 2021–22.

Absence of standards, recommended practices and guidelines pertaining to the safety of operations at airports under construction

As part of safety issue investigation A18Q0140, the TSB issued Aviation Safety Advisory A18Q0140-D1-A1 to TC in August 2021 about the absence of standards, recommended practices and guidelines pertaining to the safety of operations at airports under construction, and calling for the implementation of corrective measures as soon as possible.

Failure of a blade actuating pin

As part of Air Transportation Safety Investigation A20C0103 into a rejected takeoff, the TSB issued Air Safety Information Letter A20C0103-D1-L1 to TC in April 2021 about a McCauley Propeller Systems blade actuating pin that failed due to a fatigue fracture, calling for follow-up action.

Visual approach slope indicator systems angle not harmonized with glide path angle of approach procedures with vertical guidance

As part of Air Transportation Safety Investigation A21O0066 into a runway overrun, a class 5 investigation,^{Footnote 2} the TSB issued Air Transportation Safety Information Letter A21O0066-D1-L1 to TC in March 2022 about approach procedures with vertical guidance to aerodromes with shorter runways that may not be harmonized with the visual approach slope indicator systems, calling for follow-up action.

Progress on outstanding recommendations

Of the 26 responses to air transportation safety recommendations the Board assessed or reassessed in 2021–22, 2 were closed, one after receiving a rating of Fully Satisfactory, and the other after receiving a rating of Unsatisfactory, with no further action from the United States Federal Aviation Administration expected. The remaining 24 recommendations the Board assessed or reassessed in 2021–22 obtained the following ratings: Satisfactory Intent (10), Satisfactory in Part (10), Unable to Assess (1), and Unsatisfactory (3).

TC’s amendments to the Canadian Aviation Regulations (CARs) published this year in the Canada Gazette, Part II, will eliminate the ambiguity associated with the use of safety belts on board aircraft. The response to Recommendation A19-01 was therefore reassessed by the Board as Fully Satisfactory. Two recommendations issued to TC in 2018 during an investigation into a loss of control and collision with terrain (A17C0146) were assessed by the Board this year as showing Satisfactory Intent (A18-02 and A18-03), meaning that progress is being made to ensure that proper de-icing and anti-icing equipment is available in airports across Canada and that the likelihood of aircraft taking off with contaminated critical surfaces is being reduced.

Responses to two recent recommendations made as a result of an investigation into a runway overrun on landing (A18Q0030) show that progress is being made toward simplifying operating minima for approaches and landings at Canadian aerodromes and introducing a mechanism to stop approaches and landings that are actually banned (A20-01 and A20-02). The responses were reassessed by the Board as showing Satisfactory Intent.

While amendments to the CARs published this year in the Canada Gazette, Part II, will reduce the risks associated with runway overruns, there is however residual risk represented by a gap between TC’s regulations and an ICAO standard. Therefore, TC’s response to Recommendation A07-06, which was issued as a result of an investigation on a runway overrun (A05H0002), was reassessed by the Board as being Satisfactory in Part.

The response to a recommendation on runway incursions (A18-05) was also reassessed by the Board as being Satisfactory in Part, meaning that, while there is still work to be done on this issue, the Board acknowledges the steps taken to address the risk of runway incursions at Toronto/Lester B. Pearson International Airport, in Ontario.

Two responses to recommendations pertaining to Watchlist 2020 issues, safety management and regulatory surveillance, have been assessed by the Board as Satisfactory in Part (A16-13 and A16-04). TC has made good progress on improving its surveillance methodology and on enhancing its oversight policies and training.

Unfortunately, other responses show that insufficient action has been planned or taken. The actions taken in response to Recommendation A16-10, in which the Board recommended to TC to require terrain awareness and warning systems for commercial helicopters that operate at night or in instrument meteorological conditions, also relevant to a more recent TSB investigation on an inadvertent descent of a helicopter during an approach (A19A0055), were considered insufficient. Also, because the risks associated with the timing of post-landing procedures, identified in Recommendation A18-06, were not addressed, the United States Federal Aviation Administration’s response was considered by the Board to be Unsatisfactory.

In addition, the response to Recommendation A16-12, in which the Board recommended that TC require all commercial aviation operators in Canada to implement a formal safety management system, could not be assessed by the Board, because there is no clear indication as to whether TC will initiate regulatory changes to address this deficiency.

For all active recommendations, the TSB will continue to monitor the progress of planned actions and call for action to reduce or eliminate these deficiencies.

Marine transportation safety

The year in review

The TSB received 1075 reports of marine transportation occurrences in 2021 (220 accidents and 855 incidents), including 11 fatalities.

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The total of 220 marine transportation accidents represents a decrease from the 264 accidents in 2020 and is lower than the 10-year average of 284. In 2021, 80% of accidents were shipping accidents (when a ship sinks, founders or capsizes, for example), compared to 82% on average over the previous 10 years. The remaining 20% of accidents in 2021 were accidents aboard ship (when a person is killed or seriously injured when boarding a ship or by falling overboard, for example), compared to the 10-year annual average of 18%.

The 11 marine transportation fatalities are fewer than the 2020 total of 18 and the 10-year average of 15.6. Of the 11 fatalities, 9 involved shipping accidents. Over the previous 10 years, fatalities have been fairly evenly divided between shipping accidents and accidents aboard ship.

As in previous years, the majority of the fatalities (8 of the 11) were related to commercial fishing (Canadian-flag vessels in Canadian waters). Due to this continuing trend, commercial fishing safety remains a key safety issue on the TSB’s Watchlist.

There were 200 vessels involved in the 177 shipping accidents that took place in 2021. In 2020, 257 vessels were involved in 221 shipping accidents. The decrease was observed in all regions.

The 855 marine transportation incidents reported to the TSB in 2021 represents an 8% decrease from 2020 but a 20% increase from the 10-year average of 712. As in previous years, most reportable incidents (85%) were related to the total failure of machinery or technical systems. The increase in incidents of this type is due largely to changes made in 2014 to TSB reporting requirements.

Accident rate: A measure of marine transportation safety

According to Transport Canada (TC), 2021 marine activity (commercial vessel-kilometres) for Canadian commercial non-fishing vessels with a gross tonnage of over 15 (excluding passenger vessels and cruise ships) was 7% above the 2015-to-2020 average. The 2021 accident rate was 3.0 accidents per million commercial vessel-kilometres, substantially lower than the 2015-to-2020 average of 4.8. (TC now provides a comprehensive distance-based metric of commercial marine activity in Canadian waters beginning from 2015. However, a seven-year series is too short to test for meaningful trends, and vessel movements are no longer captured.)

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Investigations

TSB staff deployed to 7 marine transportation occurrences in 2021–22 (slightly less than in 2020–21), began 8 investigations and also completed 8.

Risk mitigation measures are needed for vessels transiting Canadian Arctic waters

In its investigation report on the 2018 grounding of the passenger vessel Akademik Ioffe (M18C0225), the TSB determined that there are unique risks associated with operating in the Canadian Arctic that require additional mitigation measures in order to ensure the safety of passenger vessels, and to protect the vulnerable Arctic environment.

The investigation found that the Akademik Ioffe ran aground in a remote area of the Canadian Arctic that was not surveyed to modern or adequate hydrographic standards, and where none of the vessel crew had ever been. Until the coastal waters surrounding the Canadian Arctic Archipelago are surveyed to modern or adequate hydrographic standards, and if alternate mitigation measures are not put in place, there is a persistent risk that vessels will make unforeseen contact with the sea bottom. The Board therefore recommended that TC, in collaboration with Fisheries and Oceans Canada, develops and implements mandatory risk mitigation measures for all passenger vessels operating in Canadian Arctic coastal waters (M21-01).

Following the occurrence, the Canadian Hydrographic Service amended its navigation chart for the area of the occurrence to include the rocky shoal on which the Akademik Ioffe ran aground. In addition, the authorized representative for the Akademik Ioffe indicated that all deficiencies had been corrected, following the issuance of a letter of warning from TC. The Russian Federal Authority for Transport Oversight (Rostransnadzor) carried out a safety investigation and produced a marine casualty investigation report, and the P.P. Shirshov Institute of Oceanology of Russian Academy of Sciences corrected the Akademik Ioffe’s bridge watch crew bridge equipment familiarization checklist.

Breakdowns in situational awareness and communications led to striking

In its investigation report on the 2019 striking of the anchored bulk carrier Pan Acacia by the bulk carrier Caravos Harmony in Vancouver Harbour, British Columbia, the TSB determined that communication breakdowns impacted the team’s situational awareness and resulted in different understandings of the emerging circumstances (M19P0057).

The Caravos Harmony, under the conduct of a pilot and with 22 people on board, struck the Pan Acacia while proceeding to anchorage D in Vancouver Harbour. Both vessels sustained damage, and no pollution or injuries were reported.

During the occurrence, the pilot and bridge crew did not share critical information to build a common and accurate understanding of the situation and this impeded timely and effective coordination of actions to safely manoeuvre the vessel and avoid the striking.

Following the occurrence, all parties involved took safety action to reduce the chances of a similar occurrence in the future. TC conducted port state control inspections of the Pan Acacia and the Caravos Harmony, the Vancouver Fraser Port Authority amended its rules for vessels refuelling at English Bay, and the Pacific Pilotage Authority and British Columbia Coast Pilots Ltd. issued recommendations as a result of their risk assessment on loaded bulk carriers entering Vancouver Harbour on a strong flood tide.

Fall overboard caused by unmitigated mooring line hazards

The TSB found safety deficiencies associated with the use of workboats, including the unmitigated hazards associated with the uncontrolled movement of mooring lines, as a result of its investigation involving a self-unloading Great Lakes bulk carrier, the Manitoulin (M20C0101).

On the day of the occurrence, three of the Manitoulin’s crew members were crossing over a submerged mooring line in the vessel’s workboat while proceeding to shore near Sombra, Ontario, when tension came on the line and it struck the workboat. The impact caused all of the crew members to fall overboard. One of the crew members swam to shore and the other two re-boarded the workboat. No injuries were reported.

The investigation found that, if hazards associated with the use of a workboat are not adequately addressed through risk mitigation measures and if compliance with these measures is not monitored, occurrences involving workboats will continue to happen.

The results of these investigations reflect the TSB’s ongoing concerns about safety management, an issue on the TSB’s Watchlist 2020.

Following the occurrence, the operator issued a policy on the prevention of falls overboard and shared it with all captains, engineers, and officers through a memorandum. The manufacturer of the workboat changed the recommended safe limits for the power and weight of engines used with this model of workboat as a result of a flotation test.

Safety advisories and safety information letters

The TSB issued marine transportation safety advisories and information letters as part of its investigations in 2021–22.

Need for registration of commercial fishing vessels

As part of Marine Transportation Safety Investigation M20A0160 into the sinking of the fishing vessel Sarah Anne, the TSB issued Marine Safety Advisory No. 02/21 to the Canadian Council of Professional Fish Harvesters in August 2021 to request the correction of an error in a report implying that fishing vessels of less than 15 gross tonnage do not require registration.

Safe speed for vessels in Tofino Harbour

The TSB issued Marine Safety Information Letter No. 01/22 to TC in February 2022 to draw attention to the fact that not all local authorities are aware of their role in the process for creating vessel speed restrictions. This information letter was issued as part of the TSB’s investigation, led by both the TSB’s Air and Marine branches, into the collision between the water taxi Rocky Pass and a float-equipped De Havilland DHC-2 Beaver aircraft (A21P0111).

Progress on outstanding recommendations

Of the 18 responses to marine transportation safety recommendations the Board assessed or reassessed in 2021–22, 1 was closed after receiving a rating of Fully Satisfactory.

This year the Large Fishing Vessel Inspection Regulations were amended to require that large fishing vessels be fitted with water level detectors in all watertight compartments below the waterline that are not intended to carry liquids. Because the changes contained in these new regulations are expected to mitigate the risk associated with the safety deficiency identified during marine investigation M90L3034, TC’s response to Recommendation M94-06 was considered by the Board to be Fully Satisfactory.

Meaningful progress has been made this year by TC to address the safety deficiency identified in Recommendation M11-01. With a regulatory proposal to be pre-published in the Canada Gazette, Part I, in late 2022 that will eliminate sailing vessel endorsements in the Marine Personnel Regulations, the Board reassessed the response to the recommendation as showing Satisfactory Intent.

This year the Board also reassessed the Province of Ontario’s response to Recommendation M99-02, in which the Board recommended that the provinces review their workplace legislation with a view to presenting it in a manner that will be readily understood by those to whom it applies, to help ensure that the enforcement mechanism and the regulatory regime complement each other. New safety initiatives taken by the province prompted the Board to reassess its response as showing Satisfactory Intent.

Unfortunately, other responses show that insufficient action has been planned or taken on the identified safety deficiencies. The actions taken in response to Recommendation M16-03 calling for stability assessments and adequate stability information for all small fishing vessels were considered insufficient by the Board. Therefore, the overall response to this recommendation was considered to be Unsatisfactory.

For all active recommendations, the TSB will continue to monitor the progress of planned actions and call for action to reduce or eliminate these deficiencies.

Pipeline transportation safety

The year in review

The TSB received 115 reports of pipeline transportation occurrences in 2021, of which 113 were incidents and 2 were accidents. There were no fatalities arising directly from the operation of any federally regulated pipeline, as has been the case since the TSB’s inception in 1990.

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The number of occurrences for 2021 is 39% higher than in 2020 and approximates the average of 117 for the previous 10 years. The two accidents in 2021 were up from zero in 2020 but below the average of three accidents per year over the previous decade. Changes that were introduced in 2014 to the occurrence reporting criteria continue to distinguish more recent years from the years prior to 2014.

Of the 115 occurrences in 2021, 23 involved a release of product:

• This represents 20% of the occurrences in 2021, far below the 10-year average (65%).
• The majority of these occurrences involved a release of hydrocarbon gas (57%), as has been the case each year since 2015.
• Seven occurrences involved the release of product other than of hydrocarbons, namely papermaking process water.

The TSB’s Statistical Summary: Pipeline Transportation Occurrences in 2021 contains more information on product releases during the year.

In 2021, 55 occurrences involved geotechnical, hydrotechnical or environmental activity—slope movements or river erosion, for example—representing more than twice the number reported in 2020, and well above the average of 11 such events per year over the previous 10 years. The higher level of reported occurrences since 2017 may be related to varied weather patterns and hydrotechnical activity over the last five years, as well as increased regulatory oversight, company inspections and reporting.

The most occurrences in 2021 took place in British Columbia (46 out of 115), with 28 in Alberta, 16 in Ontario and 10 in Quebec. Of the remaining occurrences, 8 were in New Brunswick, 4 in Saskatchewan, 2 in Manitoba and 1 in the Northwest Territories.

Occurrence rate: A measure of pipeline transportation safety

There were 69 400 km of federally regulated pipeline operating in Canada in 2021, according to the Canada Energy Regulator. The 115 pipeline transportation occurrences reported to the TSB for the year resulted in an occurrence rate per 1000 km of operating pipeline of 1.7. This is up from the revised 2020 rate of 1.2, but is a return to the average of 1.7 occurrences per 1000 km from 2011 to 2020.

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Investigations

TSB staff deployed to 1 pipeline transportation occurrence in 2021–22 (same as for 2020–21), began 1 investigation and completed 1.

Improper installation of tubing system led to release of crude oil

In its investigation report on the 2020 release of crude oil at Trans Mountain Pipeline ULC’s Sumas Pump Station in Abbotsford, British Columbia, the TSB determined that the tubing systems were not properly installed (P20H0023).

This investigation highlights the importance of pipeline companies having standards and procedures that incorporate inspections to ensure that tubing systems are properly installed. It also sheds light on the importance of having the station emergency shutdown and isolation systems properly configured to minimize the quantity of release and having a means of isolation on secondary containment systems, such as the oil-water separator, in order to prevent any off-site migration of released product.

Following the occurrence, the Canada Energy Regulator conducted emergency management and environmental protection field inspections and monitored the progress of site remediation activities. Trans Mountain Pipeline ULC developed procedures and an internal standard regarding its tubing systems, and upgraded the Sumas Pump Station, among other things.

Safety advisories and safety information letters

The TSB issued a pipeline transportation safety advisory as part of an investigation in 2021–22.

External risks to pipelines in agricultural areas

As part of Pipeline Transportation Safety Investigation P21H0123 into third-party damage to a natural gas pipeline, the TSB issued Pipeline Safety Advisory Letter 01/22 to Manitoba Hydro in March 2022 to bring awareness to external risks to pipelines in agricultural areas.

Progress on outstanding recommendations

The Board did not issue any pipeline transportation safety recommendations in 2021–22 and had previously assessed all responses to pipeline transportation safety recommendations as Fully Satisfactory.

Rail transportation safety

The year in review

TSB received 1232 reports of rail transportation occurrences in 2021 (1038 accidents and 194 incidents), including 60 fatalities.

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The 1038 accidents represent a 5% increase from 2020 but a 3% decrease from the 10-year average of 1071.

The 60 rail transportation-related fatalities reported in 2021 are the same as in the previous year but below the 10-year average of 71. Among the fatalities, 42 involved trespassers, compared to 40 in 2020 and the 10-year average of 40.

The number of crossing accident fatalities decreased in 2021 (16) compared to 2020 (18) and is lower than the 10-year average of 23. The TSB is conducting ongoing research to better understand crossing accidents in the winter in a safety issue investigation (R20H0082).

Among all rail transportation accidents, 86 involved dangerous goods. This is up from 82 in 2020 but is lower than the 10-year average of 125. Two accidents in 2021 resulted in dangerous goods being released.

There were 194 rail transportation incidents reported to the TSB in 2021, a 15% decrease from 2020 (229), and a 30% decrease from the 10-year average (277). Incidents involving movements that exceeded limits of authority accounted for 56% (109) of all rail transportation incidents in 2021—40 less than in 2020 and below the 10-year average of 129.

Accident rate: A measure of rail transportation safety

According to Transport Canada (TC) data, 2021 main-track (non-yard) rail activity decreased by 1% from 2020. The main-track accident rate in 2021 was 4.8 accidents per million main-track train-miles, up from 2.8 in 2020 and above the 10-year average of 2.5. As in 2019 and 2020, a portion of main-track accidents in 2021 consists of an unusually high number of right-of-way fires reported to the TSB in 2021 (137), which primarily accounts for the increase in the main-track accident rate.

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Investigations

TSB staff deployed to 11 rail transportation occurrences in 2021–22 (an increase from 2020–21), began 8 investigations and completed 9.

Enhancing safety of train operations in cold weather through mountainous territory

As a result of its investigation report into the 2019 derailment of 2 locomotives and 99 cars of a 112-car grain train, in which the three crew members were fatally injured near Field, British Columbia (R19C0015), the Board issued three recommendations to make train operations in cold weather safer through mountainous territory.

In its recommendations, the Board is calling for enhanced test standards and requirements for time-based maintenance of brake cylinders on freight cars operating on steep descending grades in cold ambient temperatures (R22-01); the implementation of a schedule for the installation of automatic parking brakes on freight cars, prioritizing the retrofit of cars used in bulk commodity unit trains in mountain grade territory (R22-02); and the Canadian Pacific Railway Company (CP) to demonstrate to TC that its safety management system can effectively identify hazards arising from operations using all available information, including employee hazard reports and data trends; assess the associated risks; and implement mitigation measures and validate that they are effective (R22-03).

The findings of this investigation reflect the TSB’s ongoing concerns about unplanned or uncontrolled movement of rail equipment and safety management, both issues on the TSB’s Watchlist 2020.

Following the occurrence, the TSB sent rail safety advisory letters to TC on the prevention of uncontrolled movements for trains stopped in emergency on grades of less than 1.8%, on air brake system inspection and maintenance on grain hopper cars used in CP unit train operation, and on the effectiveness of the No. 1 brake test.

TC took several initiatives after the occurrence, such as approving the railway industry’s proposed new Rule 66 of the Canadian Rail Operating Rules (CROR) as well as the use of automated train brake effectiveness technology in lieu of No. 1 air brake test requirements on CP’s unit grain trains operating between points in Western Canada and the Port of Vancouver.

Following the occurrence, CP proceeded, among other things, to remove over 5000 grain cars from service for repair.

Failure of a rail car coupler led to rail yard collision

In its investigation report, the TSB found that the failure of a rail car coupler knuckle led to an uncontrolled movement, followed by a collision and a derailment at the CP Alyth Classification Yard in Calgary, Alberta, in 2019 (R19C0002).

A crew was switching cars eastward into the Alyth Classification Yard in Calgary when 56 cars disconnected from the yard assignment and ran uncontrolled down the lead track into the designated emergency track, contacting a cut of stationary loaded hopper cars. As a result of the collision, a total of 22 cars derailed. The investigation found that the collision and derailment occurred when a knuckle on a car being switched failed while the cut of 75 cars was in motion.

The findings of this investigation reflect the TSB’s ongoing concerns about unplanned or uncontrolled movement of rail equipment, an issue on the TSB’s Watchlist 2020.

Following the occurrence, the TSB issued Rail Safety Advisory Letter 01/20 to TC and the Association of American Railroads regarding the defects found in the broken knuckle. CP made changes to its Alyth Classification Yard operation, including a fixed designated emergency track for all switching operations, increasing the number of cars that have air brakes, and limiting tonnage while switching. CP also added retarders to help prevent cars from exiting tracks in the Alyth Classification Yard and to slow the cars down during an emergency.

Employee fatigue contributed to collision between passenger train and track unit

The TSB’s investigation report into the collision of a VIA Rail passenger train and an unoccupied CN hi-rail track unit in Les Cèdres, Quebec, highlights the importance of implementing physical defences to prevent employee fatigue from contributing to occurrences (R20D0088).

The passenger train was travelling east at the authorized speed (95 mph) on the north main track of the Canadian National Railway Company (CN) Kingston Subdivision, when the two locomotive engineers noticed a bright light in the distance. When one of them realized that the light appeared to be coming from rolling stock on the same track as the train, a full-service air brake application was initiated and the locomotive horn and bell were sounded. A few seconds later, the train, still travelling at nearly 83 mph, struck an unoccupied pick-up truck type hi-rail track unit at Mile 30.5, in the municipality of Les Cèdres. There was no derailment and no one was injured.

An analysis was conducted to assess the fatigue of the signal maintainer in this occurrence. From this analysis, it was determined that the employee had probably accumulated a sleep debt, a condition that contributes to fatigue, given his numerous consecutive night shifts involving long hours and the fact that he was sleeping during the day, when quality of sleep is reduced.

As this occurrence demonstrates, work schedules that increase the risk of fatigue in railway employees may create high-risk situations with potentially serious consequences. Fatigue poses a risk to transportation safety because of its potential to degrade several aspects of human performance. This is why fatigue management is on the TSB’s Watchlist 2020.

Following the occurrence, TC sent a notice to CN indicating that the measures implemented to prevent events such as this occurrence had been deemed insufficient. Later, CN informed TC that it had developed an employee assessment tool to check their knowledge of the regulations governing the protection of track work.

Ensuring sufficient braking capacity to prevent uncontrolled movements

In its investigation report into a non–main-track uncontrolled movement in Prince George, British Columbia, the TSB highlighted the importance for operators and employees to ensure sufficient braking capacity to enable the control of rolling stock when switching (R20V0230).

A Canadian National Railway Company (CN) yard foreman and a helper were performing switching operations in the South Yard of CN’s Prince George Terminal in Prince George using a remote control locomotive system, when an uncontrolled movement occurred. It accelerated to approximately 17 mph, ran through a crossover switch that was lined against the movement’s direction of travel, damaging the switch, and subsequently came to a stop about 1250 feet before the entrance of the main track of the Fraser Subdivision. No dangerous goods were involved, and the movement did not derail. No one was injured.

The results of this investigation reflect the TSB’s ongoing concerns about unplanned or uncontrolled movement of rail equipment, an issue on the TSB’s Watchlist 2020.

After the occurrence, CN management carried out a safety blitz for crews operating in the Prince George Terminal, to reinforce the rules and instructions for operating in the point protection zone, and TC revised Rule 113.3 of the Canadian Rail Operating Rules to require the use of air brakes to control movements during switching on grades greater than 0.4% and with more than 2000 tons.

Safety advisories and safety information letters

The TSB issued rail transportation safety advisories as part of its investigations in 2021–22.

Roller bearing failure resulting in derailment of Ottawa Light Rail Transit vehicle

As part of Rail Transportation Safety Investigation R21H0099 into a derailment of an Ottawa Light Rail Transit train in Ottawa, Ontario, the TSB issued Rail Safety Advisory Letter No. 02/21 to Ottawa’s City Manager in September 2021 about the failure of a roller bearing on a light rail vehicle in commuter passenger service and the use of heat detection systems to monitor temperatures of cartridge roller bearing assemblies.

Work procedures for Ottawa Light Rail Transit vehicle maintenance

As part of Rail Transportation Safety Investigation R21H0121 into a main-track derailment of an Ottawa Light Rail Transit train in Ottawa, Ontario, the TSB issued Rail Safety Advisory Letter No. 03/21 to Ottawa’s City Manager in November 2021 about the work procedures for Ottawa Light Rail Transit vehicle maintenance, suggesting that an in-depth review of the work performed on safety-critical components be conducted.

Conflicting authority to enter main track without obtaining a train location report

As part of Rail Transportation Safety Investigation R21H0114 into a collision between two CN freight trains in Prescott, Ontario, the TSB issued Rail Safety Advisory Letter No. 01/22 to TC in January 2022 about conflicting authority to enter the main track without obtaining a train location report, suggesting that a review be performed of rail traffic controller systems software prompts of all safety-critical tasks that can be overridden when equipment is already in the block.

Progress on outstanding recommendations

Of the nine responses to rail transportation safety recommendations the Board assessed or reassessed in 2021–22, none were closed as Fully Satisfactory. The nine responses obtained the following ratings: Satisfactory Intent (4) and Satisfactory in Part (5).

This year, TC continued its work to update the regulatory regime for railway employee qualifications and training. This means that, while the action is not yet sufficiently advanced to reduce the risks to transportation safety, progress is being made toward addressing the safety deficiency identified in Recommendation R18-02 calling for training and qualification standards for railway employees in safety-critical positions. The Board therefore reassessed the response to the recommendation as showing Satisfactory Intent.

The Board also reassessed the response to Recommendation R14-05 on the auditing of safety management systems, one of the recommendations issued as a result of the TSB’s investigation into the 2013 runaway and main-track derailment in Lac-Mégantic, Quebec (R13D0054). TC indicated that it completed audits of all federally regulated railway companies’ safety management systems and that it is in the early stages of implementing a targeted audit framework for measuring the effectiveness of the safety management system processes. The Board is encouraged by the progress and therefore considers this response to show Satisfactory Intent.

Regarding Recommendation R13-01 on physical fail-safe train controls, the Board considers the responses from the Railway Association of Canada and TC to be Satisfactory in Part and strongly encourages both organizations to accelerate the pace of enhanced train control implementation. The underlying safety deficiency was identified as a result of the TSB’s investigation into a rear-end train collision over 20 years ago (Railway Investigation Report R98V0148; Recommendation R00-04).

For all active recommendations, the TSB will continue to monitor the progress of planned actions and call for action to reduce or eliminate these deficiencies.

Who we are and what we do

The Transportation Safety Board of Canada (TSB) advances transportation safety in the air, marine, pipeline and rail transportation sectors in Canada:

• It conducts independent investigations into selected occurrences and makes findings about their causes and any contributing factors.
• It identifies safety deficiencies arising in transportation occurrences and makes recommendations to eliminate or reduce them.
• It reports publicly about its investigations and findings.

As part of its investigations, the TSB reviews developments in transportation safety and identifies safety risks that governments and the transportation industry must address in order to reduce the risk of injury and loss.

Role of the Board

The Board, which comprises up to five members, including the Chair, approves all investigation reports, makes findings and issues recommendations.

The Board

The TSB website contains biographies of each Board member.

In making findings, the Board does not assign fault or determine civil or criminal liability for an occurrence. Rather, it seeks to find out what happened and why in an objective manner, independent from government, and all other departments and agencies involved in transportation, and free from any conflict of interest. It also draws impartial conclusions and makes recommendations to those best placed to act.

About the TSB

A staff of 226, led by the Chief Operating Officer and senior management, supports the Board. The work of the organization is guided by a five-year strategic plan and five core values:

• Respect: We are committed to inclusiveness and to treating all individuals and organizations with consideration, courtesy, discretion, and fairness.
• Openness: We actively share and exchange information to advance transportation safety.
• Safety: We maintain and promote a positive and proactive safety culture.
• Integrity: We are guided by honesty, transparency, impartiality, propriety, and accountability for our actions and decisions.
• Excellence: We maintain a highly skilled and knowledgeable team of professionals through leadership, innovation, and commitment to continuous improvement in the delivery of our products and services.

TSB investigators are professionals with years of experience in the various transportation modes the TSB covers. 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 TSB’s head office is in Gatineau, Quebec. The TSB also has a laboratory in Ottawa, and regional offices in Vancouver, Edmonton, Calgary, Winnipeg, Toronto, Montréal, Québec, and Dartmouth.

The investigation process

There are three main phases of the investigation process. During the field phase, investigators collect data and assess the occurrence. This generally involves travelling to the scene of the occurrence, securing the site and documenting it, conducting interviews and selecting wreckage for further examination. Unless the investigation is limited to data collection, an investigation page is created and posted to the website, and is updated periodically as the investigation progresses.

During the examination and analysis phase, investigators review the data to determine the sequence of events leading to the occurrence and the underlying causes and contributing factors.

In the report phase, investigators draft a report on the investigation, which then goes through a review and approval process, prior to public release.

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Appendices

Appendix A: Investigation reports released in 2021–22 and related safety actions

The following is a list of the investigation reports the Transportation Safety Board of Canada (TSB) released during 2021–22. Each entry includes details of any safety actions taken during the investigation and after the report was published, and a link to the main page for the investigation. The list is organized by transportation sector and in the order in which the occurrences took place.

These safety actions taken by industry stakeholders and regulators in the air, marine, pipeline, and rail transportation sectors are the tangible outcome of the TSB’s investigative work to advance transportation safety. Their efforts as a result of our findings contribute to making our transportation system even safer.

Air transportation sector

INVESTIGATION REPORT A18Q0140: Occurrences in Quebec and Nunavut on runways undergoing construction that are reduced in width

INVESTIGATION REPORT A17C0146: Loss of control and collision with terrain, West Wind Aviation L.P.,^{Footnote 6} Avions de Transport Régional ATR 42-320, C-GWEA, Fond-du-Lac, Saskatchewan, 13 December 2017

INVESTIGATION REPORT A18A0085: Runway overrun, Sky Lease Cargo, Boeing 747-412F, N908AR, Halifax/Stanfield International Airport, Nova Scotia, 7 November 2018

INVESTIGATION REPORT A19A0055: Inadvertent descent during approach, Canadian Helicopters Offshore, Sikorsky S-92A (helicopter), C-GICB, Halifax, Nova Scotia, 155 NM ESE, 24 July 2019

INVESTIGATION REPORT A20A0001: Runway overrun, WestJet Airlines Ltd., Boeing 737-8CT, C-FUJR, Halifax/Stanfield International Airport, Nova Scotia, 5 January 2020

INVESTIGATION REPORT A20Q0013: Hard landing and aft fuselage strike, Air Inuit Ltd., de Havilland DHC-8-314 (C-GXAI), Schefferville Airport, Quebec, 20 January 2020

INVESTIGATION REPORT A20Q0015: Controlled flight into terrain, Service aérien gouvernemental of Quebec, Bell 206L-4 (helicopter), C-GSQA, Lac Saint-Jean, Quebec, 22 January 2020

INVESTIGATION REPORT A20P0013: Runway excursion, WestJet Encore Ltd., De Havilland Aircraft of Canada Ltd. DHC-8-402, C-FKWE, Terrace Airport, British Columbia, 31 January 2020

INVESTIGATION REPORT A20W0016: Loss of pitch control on landing, Canadian Pacific Railway Company, Bombardier CL-600-2B16 (Challenger 605), C-GKCP, Calgary International Airport, Alberta, 23 February 2020

INVESTIGATION REPORT A20C0016: Runway excursion, Perimeter Aviation LP, Fairchild SA227-DC Metro 23, C-GJVB, Dryden Regional Airport (CYHD), Ontario, 24 February 2020

INVESTIGATION REPORT A20C0037: Runway excursion, Buffalo Airways Ltd., Beechcraft King Air A100, C-FCBZ, Kugaaruk Airport, Nunavut, 28 April 2020

INVESTIGATION REPORT A20P0105: Pilot fatally injured during ground operations, Wilderness Seaplanes Ltd., de Havilland DHC-2 Mk. I, C-FDSG, Port Hardy Water Aerodrome, British Columbia, 7 December 2020

INVESTIGATION REPORT A21P0001: Loss of control, Privately registered Mooney M20F, C-GYGN, vicinity of Upper Kananaskis Lake, Alberta, 3 January 2021

INVESTIGATION REPORT A21O0006: Loss of control and collision with terrain, Privately registered Blackshape S.P.A. Prime BS100, C-GPOT, Ottawa/Carp Airport, Ontario, 10 February 2021

INVESTIGATION REPORT A21Q0007: Loss of control and collision with terrain, Wag-A-Bond (amateur-built aircraft), C-GKGX, Barron Lake, Gore, Quebec, 3 March 2021

INVESTIGATION REPORT A21O0030: Unintentional gear-up landing on runway, Province of Ontario, Ministry of Northern Development, Mines, Natural Resources and Forestry, Canadair CL-215-6B11 (Series CL-415), C-GOGH, Sault Ste. Marie Airport, Ontario, 2 May 2021

INVESTIGATION REPORT A21C0052: Loss of control and collision with terrain, Helicopter Transport Services (Canada) Inc., Bell 214ST, C-GDYZ, Nipigon, Ontario, 14 NM NE, 7 June 2021

INVESTIGATION REPORT A21Q0052: Collision with a lawn tractor during landing, Nanchang CJ6A, Saint-Esprit, Quebec, 5 July 2021

INVESTIGATION REPORT A21O0066: Runway overrun, Thunder Airlines, Beechcraft A100 King Air, Moosonee Airport, Ontario, 6 August 2021

INVESTIGATION REPORT A21W0071: Collision with terrain, Mooney M20C, Slave Lake Airport, Alberta, 12 NM N, 31 August 2021

INVESTIGATION REPORT A21C0088: Rollover upon landing, Canadian Helicopters Limited (dba Acasta HeliFlight Inc.), Bell 206L-1 (helicopter), C-GIKX, Hope Bay Aerodrome, Nunavut, 8 NM SSW, 14 September 2021

Marine transportation sector

INVESTIGATION REPORT M18A0001: Bottom contact, passenger ferry Deer Island Princess II, Little Letete Passage, New Brunswick, 2 February 2018

INVESTIGATION REPORT M18C0225: Grounding, Passenger vessel Akademik Ioffe, Latitude 69 ° 43.043′ N, Longitude 091° 20.951′ W, Astronomical Society Islands, Nunavut, 24 August 2018

INVESTIGATION REPORT M19A0025: Sinking and loss of life, workboat Captain Jim, approximately 4 NM southeast of Halifax Harbour, Nova Scotia, 29 January 2019

INVESTIGATION REPORT M19P0057: Striking of the anchored vessel Pan Acacia, bulk carrier Caravos Harmony, Vancouver Harbour, British Columbia, 17 March 2019

INVESTIGATION REPORT M20C0101: Crew fall overboard after workboat struck by mooring line, unregistered workboat belonging to the bulk carrier Manitoulin, St. Clair River, near Sombra, Ontario, 12 May 2020

INVESTIGATION REPORT M20C0145: Striking of berth, bulk carrier CSL Tadoussac, Port of Québec, Québec, Quebec, 10 June 2020

INVESTIGATION REPORT M20P0320: Grounding, barge Lafarge Eagle, towed by tug Mauna Loa with tug Sea Imp XI assisting, Fraser River, British Columbia, 1 November 2020

Pipeline transportation sector

INVESTIGATION REPORT P20H0023: Release of crude oil incident, Trans Mountain Pipeline ULC, Sumas Pump Station, Abbotsford, British Columbia, 12 June 2020

Rail transportation sector

INVESTIGATION REPORT R19C0002: Non–main-track collision and derailment, Canadian Pacific Railway, Yard Assignment CW11-06, Alyth Classification Yard, Calgary, Alberta, 6 January 2019

INVESTIGATION REPORT R19C0015: Uncontrolled movement of rolling stock and main-track train derailment, Canadian Pacific Railway Company, Freight train 301-349, Mile 130.6, Laggan Subdivision, Yoho, British Columbia, 4 February 2019

INVESTIGATION REPORT R19E0147: Main-track train derailment, Canadian Pacific Railway, Train 201-27, Mile 7.52, Leduc Subdivision, Blackfalds, Alberta, 27 September 2019

INVESTIGATION REPORT R20V0230: Non–main-track uncontrolled movement, Canadian National Railway Company, Remote control locomotive system, Yard assignment 1500 North end, Mile 462.4, Chetwynd Subdivision, Prince George Terminal, South Yard, Prince George, British Columbia, 13 November 2020

INVESTIGATION REPORT R20D0088: Collision between a train and a track unit, VIA Rail Canada Inc. passenger train VIA 68 and STL 099285 hi-rail vehicle, Mile 30.5, Canadian National Railway Company, Kingston Subdivision, Les Cèdres, Quebec, 6 December 2020

INVESTIGATION REPORT R21D0001 : Employee fatality, Canadian National Railway Company, Yard assignment YPC011-06, Mile 1.9, Montreal Subdivision, Montréal, Quebec, 6 January 2021

INVESTIGATION REPORT R21M0002: Main-track train derailment, Canadian National Railway Company, Freight train M30631-25, Mile 8.04, Pelletier Subdivision, Albertine Station, New Brunswick, 26 January 2021

INVESTIGATION REPORT R21T0007: Uncontrolled movement resulting in a non–main-track train derailment, Goderich Exeter Railway, Train 581-01, Parrish & Heimbecker Limited elevator facility at the Port of Goderich, Mile 45.9, Goderich Subdivision, Goderich, Ontario, 1 February 2021

INVESTIGATION REPORT R21V0118: Main-track train derailment, Canadian National Railway Company, Freight train A47251-02, Mile 547.7, Chetwynd Subdivision, Hodda Station, British Columbia, 3 June 2021