History of the TSB


The following is a short snapshot of highlights at the TSB throughout its first 25 years.

2014-15

Highlights for the year:

  • Kathy Fox assumes Chair of TSB following retirement of Wendy A. Tadros
  • Release of Watchlist 2014

2014 saw the completion of the Lac-Megantic (R13D0054) investigation. The report underscored the need for more effective oversight of the railway industry, additional defenses to prevent runaway rolling stock, emergency response assistance plans, route planning and analysis and stronger tank cars.

The transportation of oil by rail continued to be an issue as early 2015 also saw investigations opened for two derailment and fire occurrences involving unit crude oil trains near Gogama, ON (R15H0013 and R15H0021). Other investigations included the forced landing of an Air Tindi Cessna 208 on Great Slave Lake in the Northwest Territories (A14W0181), the fatal derailment of a Quebec-North Shore and Labrador Railway train north of Sept-Iles, Quebec (R14Q0045), and the grounding of the tanker Nanny (M14C0219) in Chesterfield Inlet, Nunavut. The Board also announced its intention to open a Safety Issues Investigation into Air Taxi (CAR 703) operations.


2013-14

Highlights for the year:

  • Release of the investigation report into the fatal derailment of a VIA Rail Canada train near Burlington, Ontario (R12T0038)
  • Release of the investigation report into the fatal crash of a First Air Boeing 737 in Resolute Bay, Nunavut (A11H0002)

The Board also completed two investigation reports (A10H0004 and A11H0003) involving runway excursions at the Ottawa International Airport involving Embraer 145s. As a result, the Ottawa International Airport Authority resurfaced and grooved its runways and built 300m runway end safety areas (RESAs) – the first airport in Canada to do so.

The investigation into the tragic derailment and fire involving a unit crude oil train in Lac-Mégantic, Quebec (R13D0054) was opened. This would become one of the largest, most complex rail investigations undertaken by the TSB. The TSB also opened investigations into the fatal collision between a bus and passenger train in Ottawa, Ontario, and the collision with water involving a helicopter operated by the Canadian Coast Guard.


2012-13

Highlights for the year:

  • Release of Watchlist 2012
  • Release of the Safety Issues Investigation on Fishing Safety (M09Z0001)

The Safety Issues Investigation on Fishing Safety involved a great deal of collaboration with various sectors of the fishing industry in order to gain a better understanding of the complex, interrelated and interdependent issues that must be solved to improve safety.

The year also saw the conclusion of an investigation into a fatal Beech 100 King Air landing accident in St-Honoré, Quebec (A09Q0203), which called for improved documentation for non-precision approach procedures and stabilized constant descent angle approaches (A12-01 and A12-02).

The investigation into the fatal crash of an Air Tindi flight near Lutselk'e, Northwest Territories (A11W0151), led to improvements to how Emergency Locator Transmitters (ELTs) are fastened aboard aircraft, which will increase the chances that a signal will be sent or received following an accident.

Investigations were opened into the fatal loss of control and collision with terrain involving a Keystone Air Service Piper Navajo in North Spirit Lake, Ontario (A12C0005), the crash during landing of a Fairchild Metroliner operated by Perimeter Aviation in Sanikiluaq, Nunavut (A12Q0216), and a crude oil pipeline leak near Wrigley, Northwest Territories (P13H0013).


2011-12

Highlights for the year:

  • Release of vessel Concordia report(M10F0003)

The Board opened investigations into the crash of a First Air Boeing 737 in Resolute Bay, Nunavut (A11H0002), a runway excursion involving of a United Express Embraer 145 (A11H0003) and the derailment of a VIA Rail Canada passenger train near Burlington, Onatio (R12T0038).

Transport Canada introduced regulations requiring the installation of Terrain Awareness and Warning Systems (TAWS) aboard a greater number of private and commercial aircraft. This will further reduce the risk of controlled flight into terrain accidents. Another investigation (R10T0020) led to industry and regulators in North America to develop strategies to address issues regarding attachment of equipment to tank car shells, material properties and tank car inspection standards and methods. Following the investigation into a Bell 407 helicopter engine failure near Blue River, British Columbia (A10P0388), the engine manufacturer made improvements to the engine to address deficiencies identified in the investigation.


2010-11

Highlights for the year:

  • Release of the Cougar Helicopter report (A09A0016)
  • Release of the Saturna Island crash of a Beaver floatplane report (A09P0397)

The TSB opened investigations into the 2010 runway excursion of a United Express Embraer 145 (A10H0004), the fatal crash after takeoff of an Aeropro Beech 100 King Air (A10Q0098) in Quebec City, the 2011 pitch excursion involving an Air Canada Boeing 767 over the Atlantic Ocean, and the 2010 grounding of the passenger vessel Clipper Adventurer in Nunavut.
The Canadian Coast Guard developed and implemented new policies and procedures for towing vessels in ice conditions in response to the findings of the investigation of the fatal capsizing under tow of the fishing vessel L'Acadien II in 2008. (M08M0010).


2009-10

Highlights for the year:

  • 20th anniversary of the TSB
  • Publication of the first Watchlist, which identified 9 issues in the aviation, marine and railway modes which posed the greatest risks to Canadians

During the year, the TSB called for advance, low-clearance vehicle signs for railway crossings (R09-04) following its investigation into a crossing collision between a VIA Rail Canada passenger train and a lowboy trailer in Mallorytown, Ontario (R08T0158).

The Board also began its investigation into a fatal controlled flight into terrain involving an Exact Air Beech A100 King Air near Chicoutimi/St-Honoré Airport (A09Q0203) in Quebec.

Transport Canada re-assumed responsibility for the certification and oversight of business aircraft operators following the TSB investigation into the 2007 touchdown short of the runway involving a Bombardier Global 5000 business jet in Fox Harbour, Nova Scotia (A07A0134).


2008-09

Highlights for the year:

  • Completion of the investigation into the 2005 runway overrun of an Air France Airbus A340 at Toronto/Pearson airport (A05H0002)
  • Recommendations calling for an equivalent level of safety for fare-paying balloon passengers as those in other commercial air services (A07C0151)

An investigation was opened into the 2008 bounced landing and go-around after touchdown involving a Kelowna Flightcraft Boeing 727 cargo aircraft. The aircraft sustained damage during the occurrence.

A TSB rail investigation completed this year found an assembly defect in railway wheel sets that led to numerous loose-wheel occurrences and derailments. The Board recommended that these wheels be removed from service and that better means of tracking wheel sets are adopted (R08-01 and R08-02) (R06T0022). Transport Canada issued emergency directives to remove these from service and to put a system in place to track major components. Approximately 43,000 wheel sets were affected.


2007-08

Highlights for the year:

  • Completion of the Queen of the North (M06W0052) investigation
  • Completion of the investigation into derailment and spill of sodium hydroxide into Cheakamus River (R05V0141)

Investigations opened this year include the 2007 hard landing and fire of a hot air balloon in Winnipeg, Manitoba (A07C0151), and the touchdown short of the runway of a Bombardier Global 5000 business jet in Fox Harbour, Nova Scotia (A07A0134).


2006-07

Highlights for the year:

  • Wendy A. Tadros becomes Chair

TSB began investigations into the collision with terrain of a Transwest Air Beech 100 King Air in Sandy Bay, Saskatchewan (A07C0001), a fatal runaway and derailment involving a CN freight train near Lillooet, British Columbia (R07V0136), and a fatal runaway and derailment of a White Pass & Yukon work train near Log Cabin, British Columbia (R07V0183).

Safety action taken following TSB investigations include the requirements for stability information for a greater number of fishing vessels following the Ryan's Commander accident (M04N0086) and new standard weights for passengers and carry-on luggage used for calculating aircraft and balance (A04H0001). The Federal Aviation Administration (FAA) also 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.


2005-06

Highlights for the year:

  • Charles H. Simpson steps down as Acting Chair
  • Wendy A. Tadros becomes Acting Chair
  • Release of Safety Issues Investigation into a series of train derailments on secondary main lines in western Canada involving broken rails (SII R05-01)

Investigations were opened on the sinking of the BC Ferry Queen of the North (M06W0052), the runway overrun and fire of Air France Airbus A340 at Toronto/Lester Pearson International Airport (A05H0003), the capsizing and loss of life aboard the Melina and Keith II off the coast of Newfoundland and Labrador (M05N0072), and the fatal loss of control and collision with terrain of a Morningstar Air Express Cessna 208 in Winnipeg, Manitoba (A05C0187).

In response to a TSB Rail Safety Advisory concerning shattered rim defects in Southern CH36 wheels manufactured in 1995 and the resultant derailments, the Association of American Railways (AAR) declared that those wheels must be removed from the North American car fleet whenever the cars are in a repair shop and must not be put on another car. The Field Manual of the AAR Interchange Rules was revised accordingly. Canadian National and Canadian Pacific Rail removed all Southern wheels from their equipment and instructed their suppliers not to install Southern wheels on any cars owned or leased by them.

The TSB also issued recommendations regarding the operation of Cessna 208 aircraft in icing conditions following a fatal accident in Winnipeg (A05C0187). This led to positive safety action in subsequent years, including enhanced procedures, training and new anti-ice equipment.

Recommendations following a rudder separation involving an Air Transat A310 aircraft led to new inspection methods for carbon fiber parts (A05F0047).


2004-05

Highlights for the year:

  • Release of Lady Duck report (M02C0030)

The TSB began investigations into the crash of a MK Airlines Boeing 747 cargo aircraft in Halifax, Nova Scotia (A04H0004), the capsizing and loss of life aboard the fishing vessel Ryan's Commander off the coast of Newfoundland and Labrador (M04N0086), and a derailment involving a petroleum product unit train near Lévis, Quebec (R04Q0040).

New technology to manage in-train forces during emergency braking was introduced following a TSB recommendation (R04-01 – investigation R01M0061). This would reduce the risk of derailments.


2003-04

Highlights for the year:

  • Camille Theriault steps down as Chair of TSB
  • Charles H. Simpson assumes role of Acting Chair

The Board completed its investigation report of a fatal derailment and fire involving a freight train in McBride, British Columbia (R03V0083).

The TSB opened an investigation into a fatal Cessna 208 accident in Pelee Island, Ontario (A04H0003). This investigation subsequently led to TC revising the standard passenger weights used for calculating aircraft weight and balance. The Board also began a Safety Issues Investigation into a series of train derailments on secondary main lines in western Canada involving broken rails (SII R05-01).


2002-03

Highlights for the year:

  • Release of Swissair Flight 111 report (A98H0003)
  • Report (A98H0003) resulted in 23 aviation safety recommendations in areas of use of thermal acoustical insulation materials, flammability standards, in-flight firefighting techniques, and flight recorder duration and power

The Board began investigation into fatal sinking of the passenger vessel Lady Duck in Ottawa, ON (M02C0030).

The TSB also completed its investigation into a 1999 derailment and collision of 2 freight trains near Mont St. Hilaire, Quebec. This accident also involved an extensive spill and fire involving liquid hydrocarbons. This led to adoption of more stringent crashworthiness standards for locomotive event recorders (R99H0010).


2001-02

Highlights for the year:

  • Benoit Bouchard retires as Chair
  • Charles H. Simpson becomes Acting Chair

The TSB opened investigations into the fatal controlled flight into terrain of a Fairchild Metroliner MEDEVAC flight in Shamattawa, Manitoba (A01C0236), a cargo bay fire aboard an Air Canada Boeing 767 at the Toronto/Lester B. Pearson International Airport (A02O0123), and the striking of a bridge and fire involving the bulk carrier Windoc in Allanburg, Ontario (M01C0054).

Transport Canada clarified Transportation of Dangerous Goods regulations following a recommendation made during the investigation into a 1999 collision between a passenger train and some stationary rail cars carrying dangerous goods in Thamesville, Ontario (R99H0007).

2000-01

Highlights for the year:

  • Release ofKey Safety Issues – 2001, a predecessor to today's Watchlist, as an insert to this year's edition of the Annual Report

Following the adoption by numerous air accident investigation agencies and other parties, the TSB commercialized its Recording, Analysis and Presentation System (RAPS) software, which is used to decode, analyze and present flight data recorder (FDR) information from aircraft involved in occurrences.

The Board completed its investigation into the fatal breakup and sinking of the bulk carrier FLARE (M98N0001) resulting in 5 Board recommendations.

The TSB began investigations into the sinking and loss of life of the passenger vessel True North II in Georgian Bay, Ontario (M00C0033), a runway overrun of a Boeing 727 at the Ottawa International Airport (A00H0004), and a collision with terrain of a Piper Navajo near the Winnipeg Airport (A00C0260).


1999-2000

Highlights for the year:

  • Release of Key Safety Issues – 2000, a predecessor to today's Watchlist as an insert to this edition of the Annual Report

The Board opened its investigation into the derailment and collision between two freight trains in Mont-Saint-Hilaire, Quebec. This involved a very large fire that forced the evacuation of hundreds of people from the surrounding area (R99H0010). An investigation was also opened into a collision between a passenger train and some stationary rail cars carrying dangerous goods in Thamesville, Ontario (R99H0007).


1998-99

Highlights for the year:

  • Investigation opened into the 2 September 1998 crash of Swissair Flight 111 (A98H0003) off Peggy's Cove, Nova Scotia. This would become one of the largest and most complex investigations that the agency has undertaken.
  • The Board also opened its investigation into the fatal breakup and sinking of the bulk carrier FLARE (M98N0001). Twenty-one crewmembers aboard perished in this accident.

1997

Highlights for the year:

  • Released Key Safety Issues – 1997, a predecessor to today's Watchlist, as an insert to this edition of the Annual Report.

The TSB opened its investigation into the derailment of a VIA Rail train near Biggar, Saskatchewan. Seventy-nine of 198 people aboard the train were injured (R97H0009). An investigation was also opened into the crash of an Air Canada Canadair Regional Jet at the Fredericton Airport in New Brunswick (A97H0011). This investigation raised concerns about landing approaches in low-visibility conditions and go-around procedures.


1996

Highlight for the year:

  • Benoit Bouchard became Chair
  • John William Stants retires as Chair

TSB links to the internet with its web site. The web site is an immediate success, averaging 14,000 visits per week. The site contains reports published since 1995 as well as other information on TSB operations.

TSB opened an investigation on a Main-Track Collision near Edson, Alberta, in which a west bound CN freight train collided with an uncontrolled cut of 20 rail cars that had rolled out of the Edson rail yard (R96C0172).


1995

Highlights for the year:

  • Revision of the TSB Occurrence Classification Policy to put increased emphasis on investigating occurrences most likely to reveal significant safety deficiencies
  • The CTAISB Act Review Commission made several recommendations
  • The confidential multi-modal reporting program SECURITAS was established, to enable individuals to report in-confidence concerns about safety in the marine, pipeline, rail and air modes of transportation

1995 was a transition year for the Canadian transportation sector. Air Canada, CN, the air navigation system and other state-owned services were privatized.

TSB concluded Marine Safety Study of the Operational Relationship between Ship Masters/Watchkeeping Officers and Marine Pilots. This led to 6 recommendations (MS9501).

TSB recommendations (P92-01 thru 03) led to a public inquiry by the National Energy Board into stress corrosion cracking on Canadian oil and gas pipelines.

Air safety study led to several recommendations to improve passenger safety during evacuations of large aircraft. (SA9501).


1994

Highlights for the year:

  • CTAISB Act Review Commission report is submitted
  • A Safety Study on the Survivability of Seaplane Accidents (SA9401) is published

SA9401 included 4 recommendations regarding personal flotation devices, lap belts and shoulder harnesses and pre-flight briefings and information. Many of these issues still persist today.

Investigators receive intensive training on the role of human factors in investigations.

TSB began an investigation into a fire aboard a VIA Rail passenger train that occurred after the train ran over a piece of rail intentionally placed on the track near Brighton, Ontario (R94T0357). This investigation highlighted the need for more crash-resistant fuel systems, minimizing the amount of track repair-related material left adjacent to tracks, and improved passenger safety standards. Investigations were also opened on 3 risk-of-collision occurrences within 2 minutes of the Winnipeg International Airport (A94C0232) and the collision with terrain of a Piper PA-32 sightseeing aircraft near Stewart, British Columbia, that killed 6 people (A94P0098).


1993

Highlights for the year:

  • Changes to the occurrence reporting requirements for each of the modes in the TSB Regulations

The government of Saudi Arabia released its investigation report into the fatal crash of a Nationair Douglas DC-8 in July 1991, in Jeddah, Saudi Arabia. This was the worst-ever accident involving a Canadian-registered aircraft. The TSB conducted several aspects of the investigation in support of the Saudi authorities.

A TSB investigator served as Investigator-in-Charge in the Nepalese investigation into an accident involving a Thai Airways Airbus A310 near Kathmandu, Nepal, in July 1992. The final report was released by Nepal in 1993, and contained several recommendations of interest to the Canadian aviation regulator and industry.

The TSB opened investigations into a fatal controlled flight into terrain accident involving a Cessna 310 in Sandy Bay, Saskatchewan (A93C0169), and a controlled flight into terrain accident near Sandy Lake, Ontario, involving a Hawker-Siddley HS 748 (A93H0023).


1992

Highlights for the year:

  • Investigation opened into a fatal accident which occurred while loading a passenger vehicle onto the ferry Queen of Westminster in Departure Bay, British Columbia (M92W1057)
  • Investigation opened into the fatal derailment into water of a freight train near Nakina, Ontario (R920183)

Three separate accidents involving broken axles on VIA LRC (light, rapid, comfortable) passenger trains occurred between January 1991, and March 1992. As per a TSB recommendation, the entire fleet of LRC cars was voluntarily taken out of service and all axles were inspected, revealing more cracks. The TSB then made further recommendations to reduce the risk of axle failures. Subsequently, VIA Rail replaced every axle on their LRC equipment.

A TSB investigation (A92O0013) into flight control difficulties on an Air Canada McDonnell-Douglas DC-9 led to an airworthiness directive to install a water drain system in DC-9 and MD-80 series aircraft to prevent similar occurrences due to ice formation in the future. This involved close coordination between the TSB, Air Canada, the United States Federal Aviation Administration and National Transportation Safety Board.


1991

Highlights for the year:

  • Investigations is opened into a runway excursion of a Piper PA-23 Aztec in Chilliwack, British Columbia (A91P0194)
  • TSB investigates the fatal collision between a Coast Guard vessel and fishing vessel in Lake Erie (M91C2004)

The TSB provided assistance to the government of Saudi Arabia for the investigation into the fatal 1991 crash of a Douglas DC-8 operated by Nationair, a (now defunct) Canadian airline. With 261 people killed, this was the worst accident in terms of fatalities involving a Canadian-registered aircraft.


1990

  • On March 29, 1990, the TSB is created
  • John William Stants is appointed as Chair

The Board opened investigations into a fatal controlled flight into terrain of a Piper Navajo in Terrace, British Columbia (A90P0340), the fatal sinking of the fishing vessel Nadine (M90L3034) in the Gulf of St. Lawrence and the disappearance of the fishing vessel Le bout de ligne (M90L3033)in the Gulf of St. Lawrence.

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