Annual Report to Parliament 2022–23

Following the occurrence, North Star Air Ltd. implemented a flight operations quality assurance program.

In December 2020, TC conducted a process inspection (PI), focusing on the evaluation and effectiveness of the long-term corrective action plan related to the flight operations findings from the December 2019 PI. TC concluded that the long-term corrective actions taken by North Star Air Ltd. were effective.

The Board is not aware of any safety action taken following this occurrence.

On 09 December 2020, Calm Air International LP issued Flight Operations Bulletin 2020-07, which describes a condition known as “pitch lock.” It further describes:

• possible causes for this condition;
• how to identify it; and
• what action to take if this condition is suspected.

In February 2021, the operator introduced to its ATR 42 recurrent simulator training scenarios in which the propeller enters a pitch-lock condition.

On 30 November 2020, the TSB issued Aviation Safety Advisory A20O0029-D1-A1 to highlight the importance of accurate flight status data being validated and transmitted by transponders and how this data is received, validated, and used by runway monitoring and conflict alert (RMCA) systems to ensure maximum safety benefit.

The safety advisory encouraged manufacturers of aircraft transponder systems and of advanced surface movement guidance and control systems (A-SMGCSs) with RMCA systems, along with certification authorities and air traffic service providers, to work together to ensure that these systems interact effectively to transmit, receive, and validate an accurate airborne status and that alerts work as intended to reduce the risk of collisions on runways.

On 08 December 2020, NAV CANADA published Urgent Air Traffic Control Information Bulletin (2020-003) for all Toronto Tower personnel. The bulletin cautioned controllers that runway incursion monitoring and conflict alert sub-system (RIMCAS) stage 1 and stage 2 alerts may not be generated when Embraer E-jets and some aircraft manufactured by Dassault, Gulfstream, Learjet, and Textron Aviation (formerly Cessna) are departing. The bulletin also advised that stage 1 and stage 2 alerts may not be produced for aircraft or vehicles approaching the active runway when one of these aircraft types is departing, and reminded to monitor these situations closely.

On 03 May 2021, TC published Civil Aviation Safety Alert (CASA) No. 2021‑03 to raise awareness to aircraft owners, operators, and air navigation services providers of the potential for inaccurate airborne status transmitted by transponders and its effect on runway monitoring and conflict alert (RMCA) systems.

On 20 December 2021, TC published an update to CASA No. 2021-03. The changes address potential variability of transponder airborne status thresholds, their variability from aircraft to aircraft, and how these can be adjusted by the original equipment manufacturers and not specifically the transponder manufacturers.

After the occurrence, Forest Protection Limited revised its Fire Suppression Manual in a focus group with its most experienced fire suppression pilots and in consultation with the Provincial Forest Firefighting Centre. The manual was amended to include the following new practices:

• High-level and low-level inspection runs are to be conducted by the Bird Dog team to verify hazards.
• Tanker pilots must ensure that they are in level flight before they reach the target.
• Tanker pilot procedures for an aborted drop were developed, including the requirement for 2 positive rates of climb before returning for a 2nd attempt.

Forest Protection Limited also amended its training to include:

• Annual mountain flying training.
• An approach to stall recovery with a loaded aircraft during the airborne portion of training. This training exercise was previously completed by all FPL tanker pilots; however, it was not clearly stated in the training document.
• More frequent fire practice missions with deliberate objectives, including operations in various stack configurations, locations, and terrain.

Following the occurrence, MAG Aerospace Canada Corp. (MAG Canada) took the following safety actions:

• On 18 August 2021, issued a Maintenance Memo requiring an inspection of the pilot seat locking mechanism and seat rails on all MAG Canada Aero Commander 690 and 500 aircraft.
• On 19 August 2021, issued a Flight Operations Memo reminding pilots to ensure that their seat lock is positively engaged with the seat rail before engine start and once again before beginning the take-off roll.
• On 21 August 2021, suspended all flight operations and held a company-wide Safety Stand-Down meeting that was attended by all employees. Safety topics covered during these sessions included:
• MAG Canada’s safety policy;
• Compliance with standard operating procedures and safe practices;
• Normalization of deviance and acceptance of unsafe practices;
• The need for eradication of a “cowboy” or “hot dog” culture in the aviation community;
• Reiteration of the company’s anonymous, non-punitive safety reporting program; and
• A refresher on how to submit an anonymous hazard report.
• On 28 August 2021, issued a Flight Operations Memo implementing enhanced training on engine failures during the take-off roll and at the most critical flight stage. All MAG Canada Aero Commander 690 pilots underwent this training, which covered both on-ground and in-air materials.
• Invited the SMS Director of its U.S. affiliate, MAG Aero, to conduct an audit of its safety management system (SMS). The audit included a review of the company’s SMS as well as interviews with key personnel. No significant or non-compliant findings were found, and recommendations for improvement areas were reported to management.
• Updated its crew resource management (CRM) training materials to include more information on managing stress and internal/external pressures as well as the normalization of deviance. This material will be covered with in all future initial and recurrent CRM training.
• Issued an amendment to its Company Operations Manual. The amendment included new sections on day visual flight rules minimum altitudes and distances, and permissible low-altitude flight to reiterate the regulations under sections 602.14 and 602.15 of the Canadian Aviation Regulations.
• On 30 November 2022, issued an in-house service bulletin (MAG-2022-SB-001) specifying scheduled inspections of trim cables and pulleys at station 386.82 of their Twin Commander 690 aircraft. The inspections are to be completed by using a borescope camera, as current visual inspections are inadequate due to poor accessibility of the area.

The Board is not aware of any safety action taken following this occurrence.

The York Regional Police has amended its Command Directive LE-388 to include the addition of a pre-flight risk assessment tool and an updated Remotely Piloted Aircraft Pilot Checklist. There is also additional guidance for the role of visual observer, including a quick reference card outlining their roles and responsibilities, as well as a requirement to have a visual observer present for all operational remotely piloted aircraft flights.

The Board is not aware of any safety action taken following this occurrence.

The aircraft operator, I.M.P. Group Limited, has updated procedures to include the task of notifying the airport operator of planned arrivals when environmental conditions may be affecting the runway condition, and to require pilots to request updated runway condition reports if conditions warrant.

As a result of the accident, Airspan Helicopters Ltd.:

• suspended operations and maintenance until it completed an all-staff debrief to discuss details and initial lessons learned;
• suspended Bell 212 operations until it completed a maintenance review;
• held a formal critical incident stress management session for personnel;
• developed a pre-flight risk assessment that includes specific thresholds for severe turbulence;
• completed an internal safety investigation in accordance with its safety management system policy;
• implemented new procedures for securing smaller items to ensure they are secure in flight; and
• created and distributed a safety memo to company pilots detailing:
• pre-flight turbulence analysis
• en route turbulence awareness/avoidance
• mitigating actions for turbulence.

Atleo River Air Service Ltd., through its scheduling, has increased the time between flights by an additional 15 minutes to provide the pilots with more time to complete their pre-flight duties.

On 08 February 2022, the TSB issued Marine Safety Information Letter MSI 01/22 advising TC that there are no speed limits for vessels in the Tofino harbour and that the local authorities in Tofino were unaware of the Vessel Operation Restriction Regulations (VORR). TC responded to the TSB by reiterating that the local authority has the responsibility to apply for vessel operations restrictions. TC does not plan to take further action to raise awareness about the VORR.

Since the accident, flight training at Tofino Air has included more complete scanning techniques (moving torso to scan, scanning to pick up on any stationary object illusions, and addressing blind spots) and a “landing scan” check box was added to Tofino Air’s flight training form.

On 04 November 2021, the pilot completed additional training on emergency procedures, including the different types of personal flotation devices and their limitations.

On 26 April 2022, TC reached out to the Nuu-chah-nulth Tribal Council regarding occurrences in and near the Tofino harbour in 2021 and early 2022. TC offered a follow-up discussion to share information about the current regulatory regime and better understand the Council’s perspectives about transportation safety in the Tofino area.

The Board is not aware of any safety action taken following this occurrence.

Following this accident, Hydro-Québec

• hired 2 aviation safety advisors who hold valid helicopter pilot licences;
• instructed the new aviation safety advisors to examine all charters before awarding them to air operators;
• prohibited the use of a short sling to transport external loads with low weight and high wind resistance;
• created a web-based platform for pilots to receive annual training on Hydro-Québec operations;
• added a training course for suppliers that covers various elements that they need to know before carrying out work for Hydro-Québec;
• developed frameworks, including for sling operations, to better supervise the work of its employees and pilots;
• added site visits and surprise audits to check that pilots have the necessary tools to perform the work and that its employees are aware of the safety standards when working near a helicopter.

The Board is not aware of any safety action taken following this occurrence.

The Board is not aware of any safety action taken following this occurrence.

The Board is not aware of any safety action taken following this occurrence.

• The Board is not aware of any safety action taken following this occurrence.

On 05 July 2021, Bell Textron Inc. (Bell) issued 4 alert service bulletins covering model 204B, 205, 205B, and 212 helicopter fleets. The alerts required the review of the aircraft’s technical record to determine if any main rotor hub strap retaining pins with the serial number prefix FNFS were installed. If pins with the affected prefix were installed, they were to be replaced with pins of a different serial prefix before further flight.

On 05 July 2021, TC issued an emergency airworthiness directive (CF-2021-23) mandating compliance with the Bell alert service bulletins affecting model 204, 205, and 212 aircraft fleets in Canada before further flight.

On 06 July 2021, the U.S. Federal Aviation Administration (FAA) issued an emergency airworthiness directive (AD 2021-15-51), mandating compliance, before further flight, with Bell alert service bulletins affecting model 204, 205, and 212 aircraft fleets. In March 2022, the FAA issued a follow-on AD (AD 2022-06-03), which included the Bell 210 model and clarified wording in the original AD.

On 08 July 2021, the European Aviation Safety Administration (EASA) issued an emergency airworthiness directive (AD 2021-165-E), mandating the replacement of main rotor hub strap pins with the serial number prefix FNFS on European-registered model 204, 205, and 212 aircraft fleets before further flight.

On the evening of 28 June 2021, shortly after the occurrence, Yellowhead Helicopters Ltd. stood down all aircraft operations. On the afternoon of 29 June 2021, the Bell 206 and Airbus AS350 fleets were returned to service. The Yellowhead Helicopters Ltd. Bell 212 fleet remained grounded until the Bell alert service bulletin 212-21-165 was issued, and it had been confirmed that the remaining aircraft did not have main rotor hub strap retaining pins with the affected serial number range installed. The Bell 212 fleet was returned to service on the afternoon of 05 July 2021.

On 11 January 2023, the Transportation Safety Board of Canada issued Air Transportation Safety Advisory Letter A21W0089-D2-A1 to TC. The letter informs TC that not all physicians are aware of the requirement to report medical issues for their patients that hold a pilot licence. It also encourages TC to work with the Canadian Medical Association to develop communication strategies to increase the awareness of the reporting requirements for physicians under the Aeronautics Act.

On 19 January 2023, TC responded to the TSB’s Safety Advisory Letter A21W0089-D2-A1. It its response, TC stated that TC Civil Aviation Medicine had coordinated with the Canadian Medical Association to increase awareness of the reporting requirements for physicians.

Safety action required: Screening tools for pilot medical exams

On 09 October 2021, the privately registered, amateur-built Cavalier SA102.5 aircraft (registration C-FBWF, serial number 6958) was conducting a local recreational flight from Lacombe Aerodrome, Alberta, with 1 pilot and 1 passenger on board. When the aircraft was 14 nautical miles east of the aerodrome, it entered an aerodynamic stall, resulting in a left-hand spin and collision with terrain. The pilot, who was seated in the left seat, was fatally injured; the passenger received serious injuries. The aircraft was substantially damaged; there was no post-impact fire.

The Office of the Chief Medical Examiner in Alberta reported that the cause of death was attributed to blunt force trauma with cardiovascular disease as a significant contributing factor. The report also noted that the pilot had evidence of a heart attack, although it was not possible to determine the exact time of this event.

The pilot’s Category 1 medical certificate, which was valid until 01 February 2022, did not list any limitations.

The occurrence pilot, who was older than 40, regularly attended a TC medical examination every 12 months as required for his airline transport pilot licence. For each visit, a medical examination report was completed as required. However, for his most recent medical certificate, issued in 2021, the pilot did not undergo a medical examination. Instead, he completed and signed an attestation that he did not have any limitations or restrictions or other conditions that could impair his ability to exercise the privileges of the licence. This attestation was allowed in accordance with an exemption issued by TC^{Footnote 1} due to the global COVID-19 pandemic.

There was no cardiovascular risk profiling performed as part of any of the pilot’s medical examinations. However, using data from the Civil Aviation Medical Examiner (CAME) medical examinations, the blood lipids from the family physician’s records, and various risk-profiling methods, including the Framingham risk scoring tool, an independent cardiology review performed for this investigation confirmed that the pilot’s calculated annual risk for a cardiovascular event was approximately 1% per year. This is considered a low-to-average risk for his age, and acceptable for commercial pilot operations. Even if the CAME had performed risk profiling, these results would not have triggered secondary screening testing for underlying coronary disease.

The independent cardiology review highlighted that, although most cardiovascular disease is indicative via blood lipids, some 10–20% of heart attack victims do not present with these traditional risk factors. Therefore, cardiologists advise that other mechanisms may also be required to screen for coronary atherosclerosis. For example, elevated lipoprotein Lp(a) has been identified as a significant additional hereditary risk factor in some individuals. Lipoprotein Lp(a) measurement has been incorporated into the recommended periodic screening for cardiovascular risk.^{Footnote 2}

An independent cardiology review performed for another TSB investigation^{Footnote 3} highlighted that, based on the consensus of a multinational consortium of aviation cardiologists published in 2019,^{Footnote 4} cardiovascular risk screening should be required for all pilots over the age of 40, and for those pilots identified to be at an increased risk (based on risk calculation). Such screening should always include an assessment of blood lipids and, in some cases, other methods might be needed for the 10–20% of heart attack victims that do not present with traditional risk factors.

Current TC CAME guidelines, which were published in 2012, only recommend—they do not mandate—enhanced screening using laboratory data, such as screening for blood lipids. Given that it is not policy to screen using laboratory data, CAMEs are not required to use such screening for periodic certification examinations, even for those applicants over the age of 40.

The cardiology reviews conducted for both this occurrence and for TSB Air Transportation Safety Investigation A19P0142 indicate that the TC Civil Aviation Medicine Cardiovascular Guidelines from 2012 have not been updated to include the significant advances in the recommended approach to screening for coronary atherosclerosis. The cardiology review for this occurrence also stated that options for screening could include blood lipids and potentially enhanced laboratory testing for Lp(a), as well as CT (computed tomography) cardiac imaging where possible.

In this occurrence, the cardiologist concluded that if such screening methods were followed, risk factors contributing to the pilot’s heart attack may have been identified.

In 2011, following the TSB investigation into a loss of control and collision with terrain that took place in Miramichi, New Brunswick, on 23 April 2010,^{Footnote 5} the Board issued the following Safety Concern:

The Board is concerned that medical practitioners may not always be aware of the need or importance of transmitting reportable medical conditions and, further, that deficiencies exist in the guidelines designed to screen for cardiovascular risks. As a consequence, there continues to be a risk that cardiovascular risk factors will go undetected in aviation personnel.

In 2012, the TC Civil Aviation Medicine Cardiovascular Guidelines were updated.

As of October 2022, there were 32 900 pilots in Canada with Category 1 medical certificates. Of these, 16 607 (approximately 50%) were over the age of 40. Since 2000, there have been 8 accidents, including this one, involving commercial pilots in which cardiovascular disease was identified as a finding as to risk^{Footnote 6} or finding as to cause.^{Footnote 7}

If TC guidance material and the civil aviation medical examination report do not include up-to-date cardiovascular screening methods to perform a global cardiovascular assessment when appropriate, there is an increased risk that cardiovascular disease will remain unidentified and pilots may become incapacitated while operating an aircraft. Therefore, the Board recommends that

After the accident, TC learned of the pilot’s use of a non-approved prescription medication and suspended the pilot’s medical certificate until further reassessment is completed.

The following actions were taken by Air Tindi Ltd. after the occurrence:

• Individual de-briefs were conducted with each flight crew member that flies the DHC-6.
• A company memo was sent to flight crews, emphasizing the requirement to follow all procedures and checklists.
• A company memo was sent to flight crews requiring the captain to verify fuel uplift and sign an acknowledgement on every fuel slip before engine start.
• A company memo was sent to flight crews to inform them of the requirement to communicate fuel on board to the Operations Control Centre before each departure.
• The fleet challenge – response checklists were revised to become challenge – response – verification checklists.
• Amendments to the company standard operating procedures were made to reflect the new checklist revisions.

The Board is not aware of any safety action taken following this occurrence.

The Board is not aware of any safety action taken following this occurrence.

The Board is not aware of any safety action taken following this occurrence.

The Board is not aware of any safety action taken following this occurrence.

The Board is not aware of any safety action taken following this occurrence.

The Board is not aware of any safety action taken following this occurrence.

The Board is not aware of any safety action taken following this occurrence.

The Board is not aware of any safety action taken following this occurrence.

Following the accident, Kootenay Valley Helicopters Ltd. implemented a policy of in-flight briefing, which was reviewed with all pilots: before starting the approach to a blasting site, the crew must hold a briefing to discuss the suitability of the avalanche start zone, current weather conditions, and the adequacy of visual reference for approach, deployment of the charge, and departure from the blasting site. If, during the approach phase, a new site is selected, the approach is discontinued. A thorough assessment of the new location is subsequently conducted and briefed, and a new approach is initiated.

In compliance with WorkSafeBC requirements, the BC Ministry of Transportation and Infrastructure (MOTI) completed an internal investigation of its avalanche control operations. The MOTI examined in-depth several aspects of the operations and arrived at several findings and recommendations pertaining to the work activity, work conditions, execution, materials and equipment, communications, training, safe-work procedures, emergency procedures, personal protective equipment , and other factors such as post-occurrence worker assistance, and general coordination and planning.

The Board is not aware of any safety action taken following this occurrence.

The Board is not aware of any safety action taken following this occurrence.

The Board is not aware of any safety action taken following this occurrence.

The Board is not aware of any safety action taken following this occurrence.

The Board is not aware of any safety action taken following this occurrence.

The Board is not aware of any safety action taken following this occurrence.

The Board is not aware of any safety action taken following this occurrence.

On 17 March 2019, after boarding the Apollo, the TSB notified TC that there were safety issues on the vessel relating to the vessel’s watertight integrity, electrical wiring, and firefighting system. On 17 May 2019, the TSB followed up with TC by issuing Marine Safety Advisory Letter 01/19 about the safety issues. The TSB requested to be informed of any action taken by TC. A response was received on 14 June 2019 that indicated that TC had inspected the Apollo on 21 March 2019 and had issued a restriction from sailing.

Following the occurrence, the Société des traversiers du Québec (STQ) conducted a risk assessment and internal investigation. The report from the internal investigation found that the bow thruster was not functioning and that the master did not have indicators allowing him to determine the wind speed, the rpm of the main engines and bow thruster, or the vessel’s course over ground, all of which were essential for him to judge the situation and effect an adequate manoeuvre.

The STQ’s report also made mention of a general pressure that was present, especially after the earlier striking in February 2019, that mostly related to the vessel’s operation and came from both internal sources (as a result of a desire to continue offering service on this route) and external sources (as a result of media coverage).

The report made the following recommendations:

• Make the STQ departments aware of their roles in the case of an event that has a major impact on the organization.
• Put in place training or an information session on fatigue prevention and stress management. Make it available to all employees so they have the means to quickly identify the symptoms associated with fatigue and stress.
• Remind masters of their responsibilities associated with their roles versus the continuity of service.
• Put in place shore-side resources with technical competencies in navigation to support masters, which would facilitate decision making in regards to continuity and safety in precarious situations like poor weather.
• Obtain the historical maintenance records before buying an existing vessel.
• Do a pre-purchase survey that focuses on critical equipment without emphasizing the urgency of restoring service.
• Put in place a risk analysis program that is adapted to everyday operations which allows the crew to easily and quickly carry out risk analysis on their own, without needing to consult head office.
• Ensure that command positions have been equipped adequately so that the master can evaluate the situation effectively and carry out an adequate manoeuvre.
• Add an item to the bridge watchkeeping procedure that requires each vessel to test its controls before each manoeuvre.
• Modify the adverse weather procedure so that it takes into account the master’s familiarity with the vessel.

In response to the recommendations, the STQ took the following actions:

• A presentation was made to all ferry management to make departments aware of their roles in the case of an event that has a major impact on the organization.
• A governance committee was established that includes the chairperson-chief executive officer, the vice president of operations, the vice president of human resources, the director of operations, the director of the maritime service, the director of the engineering service, and the director of health, safety, and well-being. The governance committee deals with maritime incidents and safety.
• The STQ director of safety and the environment participated in TC training on fatigue management in the maritime domain and then met with human resources to set up a working group for internal training on the subject.
• All masters were verbally reminded about their responsibilities associated with their roles versus the continuity of service.
• The STQ created and implemented an assistant director position for each of the STQ’s crossings. The main function of this position is focused on safety linked directly to operations and compliance with procedures, including those relating to difficult weather conditions.
• The maritime service department was advised of the need to obtain historical maintenance records before buying an existing vessel.
• The maritime service department was made aware of the need to do a pre-purchase survey that focuses on critical equipment without emphasizing the urgency of restoring service, and this was implemented during the recent purchase of a vessel, the MV Saaremaa I.
• The maritime service department was advised of the need to ensure that command positions are equipped adequately.
• A 3-day training course was provided to the new assistant directors in order to familiarize them with their new responsibilities. Part of this training included risk analysis and the assistant directors were advised that risk assessments for their crossings are their responsibility.
• Both of the changes to the procedures that were required in the internal report’s recommendations were completed.

On 26 June 2020, the TSB issued Marine Safety Advisory Letter No. 01/20, entitled “Shipboard firefighting capabilities of fire departments neighboring Canadian ports” to the Association of Canadian Port Authorities, copying related authorities. The letter highlighted the fact that few Canadian ports have access to fire brigades that are trained in marine firefighting and that the lack of training prevents firefighters from boarding vessels to help with suppression of shipboard fires. The letter also identified that few shore-based fire brigades are aware of the existence of international shore connections. Finally, the letter noted that few Canadian port authorities have emergency preparedness plans to address firefighting on board vessels docked at the port.

In June 2022, TC began revising the advanced firefighting portion of the current TP 4957 Marine Emergency Duties training courses to include additional mandatory knowledge requirements about how to monitor before re-entering a compartment following a fire.

Lower Lakes Towing Ltd. took the following safety actions:

• Discussed the incident with senior officers with a focus on lessons learned.
• Reminded masters and senior officers that in the absence of exceptional circumstances (such as missing crew members thought to be trapped inside), no attempt to re-enter the engine room or other action that could compromise the airtightness of the sealed engine room should be made once CO2 is released, until after the temperature drops below the auto-ignition point.
• Provided near-miss training to masters and senior officers and reinforced the importance of near-miss reporting in the safety management system.
• Provided masters with electronic data on near-miss reporting to present to crews during fit-out.
• Changed the software used for maintenance planning and tracking.
• Implemented new software for reporting drills, work permits, inspections, and near-misses to improve safety management.
• Appointed third-party auditors for each vessel to look at the planned maintenance system, policies and procedures, regulatory and environmental procedures, and training requirements.
• Increased the number of internal inspections and revised its audit forms to improve the quality of audits.

In 1996, following a fire on board the self-unloading bulk carrier Ambassador, the Board identified concerns with training of shore-based fire brigades. In response, the Board recommended that

Following this recommendation, the Canadian Association of Fire Chiefs (CAFC), with the assistance of TC, circulated a short questionnaire to assess the firefighting capabilities of municipal fire departments responsible for fighting fires in Canadian ports.

In February 1998, in light of preliminary information coming from a subsequent investigation into an explosion and fire on board the tanker Petrolab, the TSB issued Marine Safety Advisory 03/98 to TC and the CAFC. They were asked to expedite their safety audit and review of risks and contingency measures in Canadian ports and harbours that contained oil terminals and wherever the installations were more susceptible to catastrophic damage should a fire break out on board a vessel at the dock.

By July 1998, the CAFC had received a limited response to the survey questionnaire. However, the CAFC found that the survey provided enough information to raise concerns that the firefighting services available in municipalities with public ports might not be adequate to provide firefighting services in the event of a fire on board a vessel. The CAFC indicated that it was interested in working with TC to pursue research in this area.

Following a fire on board the bulk carrier Windoc in August 2001 that resulted in the vessel’s total constructive loss, the TSB found that, among other factors, the responding fire department’s lack of training and experience in fighting shipboard fires hindered an effective firefighting response.

When Recommendation M96-07 was issued in 1996, TC had regulatory authority over most of Canada’s ports but had begun to transfer port facility ownership and operations to interested parties. In 1998, control of 18 ports was transferred to individual Canada Port Authorities (CPAs),^{Footnote 8} which operate at arm’s length from the federal government. Although the CPAs fall under the Canada Marine Act and its associated regulations, they operate as self-sufficient commercial entities with no federal funding. Since then, the responsibility for port operations, including the responsibility for shore-based firefighting, was moved to the individual port authorities.

Recommendation M96-07 was closed in March 2016, with the Board’s final assessment of the response being Satisfactory in Part; the Board noted, however, that the safety deficiency remained in some ports. The Board also noted that the responsibility for firefighting now rested with individual port authorities, and that it would take into account the effectiveness of the ports’ responses to a ship-based fire in future investigations.

During the investigation into the Tecumseh, similar issues arose to those highlighted in Recommendation M96-07, which again raises concerns about the current status of training for shore-based fire brigades. For example, the investigation confirmed that the Windsor Fire Service did not have staff specifically trained for fighting shipboard fires, and that the Windsor Fire Service would respond to a vessel fire at a dock in the port, but firefighters would not be allowed to board or enter the vessel. As well, the investigation identified that neither the Windsor Fire Service nor the Windsor Port Authority had an international shore connection.

On 26 June 2020, the TSB sent Marine Safety Advisory Letter 01/20 to the Association of Canadian Port Authorities and the Port of Windsor about the need for local shore-based firefighting resources to be properly trained and equipped to support crews in fighting shipboard fires. In its response to this letter, the Port of Windsor indicated that, among other things, they were not required to have an international shore connection.

The Board believes that shore-based resources must be trained and equipped to respond to major vessel fires in order to minimize the consequences of a fire in the close confines of a port or harbour. Therefore, the Board is concerned that some Canadian ports and harbours authorities may lack the proper equipment, training, and resources to respond effectively to shipboard fires occurring within their jurisdiction, which could result in fires that endanger crews, the general public, property, and the environment. The Board will continue to monitor this issue with a view to assessing the need for further safety action.

Registration raises awareness of the vessel to TC, affording an opportunity for improved safety oversight by the regulator, including providing the owner access to safety initiatives and programs. In addition, accurate and up-to-date registration also provides search and rescue authorities critical information about the vessel and its owner in the event of emergency situations.

In August 2021, the TSB issued Marine Safety Advisory Letter 02/21 to the Canadian Council of Professional Fish Harvesters regarding information on the council’s website stating that fishing vessels of less than 15 gross tons were below the size for mandatory Transport Canada registration. No response was received.

On 25 May 2020 shortly after midnight, the fishing vessel Sarah Anne, with 4 people on board, departed St. Lawrence, Newfoundland and Labrador, to fish snow crab in Placentia Bay. The Marine Communications and Traffic Services Centre in Placentia, Newfoundland and Labrador, received an overdue report at 1945 that evening. A search was launched using several vessels and aircraft. The bodies of 3 crew members were recovered the following day. The body of the 4th crew member was recovered from the shore on 06 June 2020. The vessel was not found.

There were a number of contributing factors involved in the loss of life: no distress call was received, no life raft was available to the crew, personal flotation devices (PFDs) were not worn, the vessel was not monitored by a third party, the vessel was not equipped with an emergency position indicating radio beacon (EPIRB), and the stability limits of the vessel were not known to the crew.

The investigation also revealed that thousands more commercial fishing vessels were registered with Fisheries and Oceans Canada (DFO) in the Atlantic Region than were registered with TC. That is, DFO was issuing a license to harvest marine resources commercially without verification that the vessel was correctly registered with TC, the department responsible for surveillance of safety requirements.

Commercial vessels must be registered with TC, even those that are not inspected for certification. Vessel registration with TC is not only a legislative requirement of the Canada Shipping Act, 2001, but also it gives TC the opportunity to provide safety oversight and guidance to vessel owners regarding their responsibility for compliance. In addition, up-to-date registration data mean accurate information is available to search and rescue authorities, and reliable data are available for safety regulators and other organizations in the marine safety system.

Harvesters are more likely to comply with regulatory requirements related to harvesting resources, partly because DFO upholds its mandate robustly through licence conditions and enforcement measures for non-compliance. In contrast, TC’s less robust enforcement regime means that there are no such direct incentives to register with TC, nor to keep registration information up-to-date. In addition, the investigation identified that communication with fish harvesters in regard to the requirement for registration with TC is inconsistent and not always well understood.

Internationally, the importance of current and accurate vessel registration with the safety regulator has also been recognized, and many countries link fishing vessel licenses to vessel registration and inspection. In Canada, the connection between safety considerations and the granting of fishing licenses has long been recognized, but has not been adequately addressed. Driven largely by initiatives created by regional staff, efforts are underway within both TC and DFO to address the issue. Nationally, TC and DFO report that they are each changing their database structures to include the other department’s unique registration number. However, without any enforceable requirements, these initiatives remain an informal arrangement and are not a permanent solution. DFO can continue to issue licenses to harvest marine resources on vessels that do not have a current and accurate TC registration. Since DFO is a part of the Government of Canada, issuing a licence may give fish harvesters the impression that they have satisfied all government requirements before conducting commercial operations.

In many countries, including Canada, one solution to coordinating service delivery when an issue falls under the responsibility of one or more departments has been a “whole of government” or “horizontal government” approach. This approach was developed in response to situations where issues are interdependent, such as the safety of the fishing industry, and where the government’s objectives cannot be achieved unless 2 or more departments begin working together. For the Canadian fishing industry, this means TC and DFO must work together to ensure that fish harvesters meet all requirements before they can operate commercially. Given that fish harvesters have more frequent contact with the Government of Canada through DFO, a key step in advancing commercial fishing safety will be using this relationship to promote regulatory compliance with TC safety requirements.

If fishing vessels are not registered in a TC register, and there are no mechanisms in place to ensure the accuracy of the register information, there is a risk that fish harvesters will not know about, understand, or adhere to regulations intended to increase fishing safety. Given that current and accurate TC registration is the first step in safety oversight of commercial fishing vessels, the Board therefore recommends that

Following the occurrence, Yarmouth Sea Products Limited required vessel masters to leave crew lists with the safety officer before departure.

On 15 December 2020, the fishing vessel Chief William Saulis was returning from scallop fishing when the Joint Rescue Coordination Centre in Halifax, Nova Scotia, received a signal from its emergency position‑indicating radio beacon (EPIRB), 12 nautical miles NNE of Digby, Nova Scotia. Search and rescue efforts were initiated after the vessel could not be reached via very high frequency (VHF) radio or phone. The body of 1 crew member was recovered; as of December 2022, the other crew members remained missing.

The investigation determined that the vessel departed the fishing grounds with unshucked scallops on deck, and the freeing ports were likely covered either mechanically or by scallops, so that water from the heavy beam sea also accumulated on deck. The resulting free surface effect from shifting scallops and water and the rolling motion from the heavy beam sea likely caused the vessel to capsize and sink.

Both the Canada Shipping Act, 2001 and the Fishing Vessel Safety Regulations (FVSR) require a vessel’s authorized representative (AR) to provide written safety procedures that familiarize persons on board with various operational and emergency activities. Yarmouth Sea Products Limited (YSP), the AR for the Chief William Saulis, had provided the Chief William Saulis and the other 24 vessels in the YSP fleet with a manual for vessel operations. Most of the safety procedures in the manual were based on templates provided by TC. However, these templates do not cover all required procedures, and the manual did not include all procedures required by regulation. In particular, the manual did not have any written procedures to guide the use of the freeing ports, or for how scallops should be stowed on deck, 2 elements critical for the stability of the Chief William Saulis. The investigation determined that, if guidance provided by TC for written safety procedures required by the Fishing Vessel Safety Regulations, including templates, only partially covers regulatory requirements for effective safety procedures, there is a risk that organizations will not develop complete written safety procedures.

For fishing vessels such as the Chief William Saulis, TC’s certification program is the primary oversight mechanism to ensure compliance with regulations. Although written safety procedures are required by regulation, TC does not require them to be approved, does not verify their content during inspections, and does not determine if the crew are knowledgeable about the procedures.

TC inspection records indicate that from July 2017 to December 2020, 84 separate inspections were conducted on the 25 vessels operated by YSP. None of the records indicated any deficiencies relating to the vessels’ safety procedures. The investigation found that, if the vessel certification process does not identify gaps in safety procedures and provide education, there is a risk that masters, owners, and others filling the role of AR will allow vessels to operate without effective safe work practices.

Concentrated Inspection Campaigns (CICs) are one form of TC oversight that is independent of the regular certification program. In these campaigns, TC focuses on a specific area of safety concern for Canadian vessels. In 2021/2022, TC conducted a CIC that focused on fishing vessels and especially on compliance with the FVSR, including regulatory requirements for effective safety procedures. The CIC found deficiencies that had not been identified through TC’s certification program and issued deficiency notices to 62% of the 101 vessels inspected. The largest number of deficiencies were related to ensuring the safety of vessel and crew: vessels had deficiencies related to drills and drill records (41%), the completeness and accessibility of safety procedures (30%), and the crews’ knowledge of safety procedures (28%).

TC’s oversight is not always effective and so the issue of regulatory oversight remains on the TSB Watchlist 2022.

Without TC oversight to validate that the written procedures required by regulation on board fishing vessels have been developed and that crew are knowledgeable of their content, there is a risk that fishing operations will continue without guidance critical to support the safety of the crew and the vessel. The Board therefore recommends that

On 01 February 2021, the TSB sent Marine Safety Advisory Letter MSA 01/21 to McKeil Marine regarding the effectiveness of the Florence Spirit’s rudder angle in relation to the vessel’s speed.

On 15 July 2021, TC conducted a flag state inspection and identified deficiencies related to McKeil Marine’s quality safety management system. The deficiencies included:

• ineffective company procedures for safe navigation in confined waters;
• an absence of protocols and procedures for when the vessel’s master or mate is undergoing pilotage training with a piloting master trainer on board; and
• inadequate coverage in the safety management system of communications protocols regarding the use of authorized communication devices for the safe navigation of the vessel.

Additionally, TC identified 2 deficiencies to McKeil Marine for violating its own company policies. The vessel’s speed in the Welland Canal violated McKeil Marine’s under-keel clearance policy. There was no record of this breach, although it was required by company policy to be reported.

As a result of the inspection, TC issued administrative monetary penalties to McKeil Marine.

Following the occurrence, McKeil Marine reviewed the incident and produced an internal investigation report that was shared with all masters. It also took the following actions:

• Issued a fleet advisory on bank effect and bridge conduct
• Held a pilotage trainer meeting to review bridge conduct, communication, and bank effect
• Added a training module on bank effect to its Great Lakes Marine Pilotage Certificate Training Program and modified other modules to include more guidance on the dynamics between the trainer and trainee
• Conducted rudder timing and efficiency tests on company vessels and updated the vessels’ manoeuvring characteristics posted on the bridge
• Ensured that new and upcoming masters took ship-handling simulator training
• Required piloting mates to complete additional training in the Seaway simulator
• Required the occurrence master to complete 2 sessions of simulator training and extended the number of training trips that he was required to complete in the Welland Canal to 25

Following the occurrence, the Great Lakes Pilotage Authority (GLPA) reviewed the incident with a focus on compliance with the Pilotage Act and its regulations.

On 08 September 2020, the GLPA implemented a process requiring restrictions to be placed on newly issued pilotage certificates when a candidate

• has a certificate of competency with a capacity limitation;
• is on a vessel that does not transit in the whole district (such as a vessel that remains in a particular port); or
• has a medical condition.

As of 12 April 2021, the GLPA had issued 3 pilotage certificates with restrictions. The restrictions related to vessel size, vessel type, company of operation, geographic area (such as a port), and capacity limitations on the candidate’s certificate of competency.

On 08 March 2022, the GLPA emphasized to companies with Great Lakes Marine Pilotage Certificate Training Programs that their programs need to clearly define the roles and responsibilities of all bridge team members.

On 21 March 2022, the GLPA amended its policy concerning the use of electronic devices to emphasize prohibiting the use of electronic devices while employees are engaged in pilotage duties on the bridge of a vessel.

Following the occurrence, the St. Lawrence Seaway Management Corporation conducted a review of speed management. The following actions were taken:

• Seaway Notice No. 10 was issued in March 2021, indicating that although speed limits listed in the Seaway Handbook would remain unchanged, tighter tolerances would be applied for the majority of locations throughout the Seaway to ensure the speed limits listed in the Seaway Handbook are followed more closely.
• Seaway Notice No. 16 was issued in May 2021, indicating that the speed limits specified in the Seaway Handbook are to be followed and deviations are to be short and strictly for navigational safety.

The Laurentian Pilotage Authority (LPA) conducted a case study of this occurrence and sent letters to the pilot and the master informing them of the study’s conclusions.

Before this occurrence, the LPA had prepared a detailed policy on the exchange of information between masters and pilots, entitled Policy on Master-Pilot Exchange, which came into effect on 23 June 2020. Following this occurrence, this policy was sent to the pilot and the master at the same time as the study’s conclusions.

The Board is not aware of any safety action taken following this occurrence.

Apollonia Lines S.A. took the following steps after the occurrence:

• replaced the failed sling assembly, including the failed lifting brackets, with a newly manufactured, load tested, and certified sling assembly and brackets;
• included the lifeboat sling assembly in the Blue Bosporus’s wires and ropes inspection log;
• sent safety management system circular 05/2020 to all vessels operating under Apollonia lines S.A. the day after the accident. This circular requested that an extra safety meeting be carried out with all crew participating in order to update them on the occurrence and avoid a recurrence.

The circular reminded crews to ensure that

• all information about the maintenance of lifeboats and associated equipment is available on board;
• all personnel carrying out inspections and maintenance of lifeboats and associated equipment are fully trained and familiar with their duties;
• the maintenance of lifeboats and associated equipment is carried out in adherence with approved practices;
• health and safety requirements are applied to drills in the same way that they are to real procedures;
• lifeboat drills are conducted in accordance with applicable International Convention for the Safety of Life at Sea (SOLAS) regulations;
• any personnel carrying out maintenance or repair are qualified for the job;
• lifeboat inspections are regular and thorough;
• all equipment is easily accessible and durable in rough conditions; and
• all tests for safety and life-saving equipment are conducted to International Maritime Organization guidelines.

In addition, Apollonia Lines S.A.

• carried out an unscheduled internal audit of the Blue Bosporus on 05 and 06 December 2020;
• completed an incident investigation report, which was sent to all vessels and masters operating under Apollonia Lines S.A.;
• established that the slings and wires associated with the lifeboat be replaced during the lifeboat’s 5-year dynamic load testing regardless of their condition; and
• established an annual safe working test of the slings by an authorized lifeboat technician.

The Board is not aware of any safety action taken following this occurrence.

Following the occurrence, Wainwright Marine Services carried out a review of all crew certification and worked with all existing and new crew to ensure that their certification was not restricted to other organizations or vessels. In addition, Wainwright Marine Services hired an individual to provide training to crew members on decision making, stability, and girding. Finally, Wainwright Marine Services digitized its safety management system to facilitate updates and to ensure that company employees can access it at any time.

In January 2022, TC established the Pacific Coast Tow and Workboat Safety Advisory Group, which includes representatives from industry, labour, and the government of British Columbia. The group’s purpose is to raise issues, develop initiatives, and put forward practical solutions and industry best practices. It also presents findings and makes recommendations to federal marine safety regulators and provincial occupational health and safety regulators regarding potential changes to regulatory, enforcement, and health and safety regimes.

TC has also increased its outreach efforts to enrol tugs of 15 GT or less in the Small Vessel Compliance Program for Tugs. The authorized representatives for all of these tugs were contacted directly by TC. In the Pacific region, a targeted monitoring inspection campaign was initiated in January 2022 to verify compliance of tugs of 15 GT or less. At September 2022, more than 50 compliance inspections had been conducted.

Finally, the scope of the existing memorandum of understanding between TC and WorkSafeBC is being expanded to include all commercial vessels in British Columbia, including tugs. Previously, the memorandum of understanding was limited to sharing information on operational or occupational health and safety concerns about fishing vessels.

On 10 February 2021, the tug Ingenika, with 3 crew members on board, was towing the loaded barge Miller 204 in the Gardner Canal when the tug sank approximately 16 nautical miles west‑southwest of Kemano Bay, British Columbia (BC). The barge subsequently drifted and went aground about 2.5 nautical miles southwest from where the tug sank. The search and rescue operation located 1 surviving crew member on land and recovered the bodies of the 2 other crew members from the water. The barge was recovered; the tug was not found. At the time of the occurrence, the tug had 3500 L of diesel fuel in tanks on board.

At September 2022, there were approximately 1343 tugs of 15 GT or less registered in Canada, approximately 1035 of which were registered in BC. Since 2015, the TSB has investigated 6 occurrences involving tugs of 15 GT or less operating on the west coast of Canada that have raised issues around the adequacy of regulatory surveillance.

TC does not certify tugs of 15 GT or less, nor are these vessels required to undergo regular inspections. By comparison, before being certified by TC under the Vessel Safety Certificates Regulations, tugs of greater than 15 GT but of less than 150 GT are required to be inspected every 4 years, and tugs of 150 GT and greater are required to be inspected annually. Although TC has set an annual target of inspecting 3% of tugs of 15 GT or less nationwide, most will go years between inspections and may never be inspected over the life of the vessel. For example, the Ingenika was built in 1968 and had been in operation for over 50 years before this occurrence; the investigation found that there were no records of TC performing an inspection at any point in the tug’s operational life.

The TSB also recently investigated another occurrence involving a tug of 15 GT or less, the Risco Warrior which was built in 1961 and had never been inspected. That investigation found that, in the absence of comprehensive regulatory surveillance and enforcement, there is a risk that tugs of 15 GT or less will continue to be operated with unsafe equipment and operating practices. While vessel owners and operators have the primary responsibility to manage safety, it is vital that TC provide effective oversight and proactively intervene to ensure that vessel owners and operators comply with regulations and standards and can manage the safety of their operations effectively.

From April to October 2022, TC conducted 30 risk-based monitoring inspections of tugs of 15 GT or less. Overall, 21 of these inspections resulted in a total of 62 deficiencies, including 13 related to lifesaving equipment, 12 related to structure or stability, 8 related to crew certificates, 6 related to fire safety, and 5 related to navigation safety.

From April to October 2022, TC also conducted 120 statutory inspections of tugs of greater than 15 GT. Sixty-four of these inspections resulted in the identification of deficiencies. Statutory inspections are generally more comprehensive than risk-based monitoring inspections. In addition, TC conducted 30 risk-based monitoring inspections of tugs of greater than 15 GT on the basis of findings from the statutory inspections. Of these 30 risk-based monitoring inspections, 19 resulted in the identification of deficiencies.

In 2018–19, TC conducted a concentrated inspection campaign on domestic vessels. According to the campaign report, 83 vessels were inspected nationwide, 49 of which were inspected under the annual inspection category and 34 through quadrennial inspections per the Hull Inspection Regulations. Nineteen of the vessels inspected were tugs, but none were of 15 GT or less. The data showed that vessels inspected every 4 years had more deficiencies than those inspected annually.

TC also focused on tugs in a concentrated inspection campaign conducted in BC from January to March 2017. Thirty tugs of 15 GT or less and 30 tugs of greater than 15 GT were selected for inspection. TC concluded that tugs of 15 GT or less had significantly more instances of regulatory non-compliance than tugs of greater than 15 GT

For tugs of 15 GT or less, the onus is on the authorized representative (AR) to ensure compliance with the regulations and the safe operation of the vessel. However, in its Watchlist 2022, the TSB highlighted that many ARs of small vessels, such as the Ingenika, have limited awareness of key sections of the Canada Shipping Act, 2001 and of the broader regulatory framework. Other ARs may not be motivated to comply with regulations, given that it is well known that TC is unlikely to inspect their vessels and so the probability of enforcement is low.

Recognizing the level of risk present, in 2016, the Board issued a safety concern on the issue of regulatory surveillance for tugs of 15 GT or less. On 25 June 2022, TC pre-published the proposed Marine Safety Management System Regulations, which will require tugs of 15 GT or less to develop a safety management system and obtain a Canadian safety management certificate. TC also developed and implemented the Small Vessel Compliance Program for Tugs (SVCP-T), which provides a simplified description of regulatory requirements and useful information that companies and ARs can use to evaluate their regulatory compliance. Although these are encouraging initiatives, neither are a replacement for vessel inspections under a broader program of regulatory surveillance, which would provide an opportunity to examine a vessel and its equipment to verify that it is in compliance with the regulatory requirements and being operated safely. Without adequate surveillance by TC, shortcomings in the safety management and operations of tugs of 15 GT or less will continue to go unaddressed, leading to accidents. Therefore, the Board recommends that

The TSB has noted that, in addition to the need for regulatory surveillance for tugs of 15 GT or less, there is currently no requirement for towing companies operating these tugs to assess any of the risks that might be present in their operations, even when it comes to something as essential as assessing the suitability of their tugs for the towing operations they are undertaking. Although the present investigation focused on tugs of 15 GT or less, it was noted that there are also no requirements for risk assessments for tugs of greater than 15 GT.

Although the Canada Shipping Act, 2001 requires the AR of any vessel to develop safe operating procedures and requires the master to ensure the safety of the vessel and anyone on board, what constitutes safe operating procedures is open to interpretation, and these requirements have not resulted in the effective management of risk on tugs of 15 GT or less. Combined with the fact that tugs in this category go largely uninspected and have no restrictions on their operations, there is the potential for accidents like the one involving the Ingenika to occur.

Requirements for risk assessment do exist for some towing vessels; TC requires a risk assessment to be performed when a vessel is towing a vessel carrying oil or dangerous chemicals in bulk. These types of risk assessments provide an opportunity to look at each aspect of the towing operation, such as the weather, hazards posed by the cargo, and suitability of the tug for the tow. TC’s recently developed SVCP-T also provides useful data that can be used in risk assessments to support safe towing operations.

Since the occurrence involving the Ingenika, TC has taken some initiatives to improve tug safety through the development of the SVCP-T and the pre-publication of the proposed Marine Safety Management System Regulations in the Canada Gazette, Part I. The proposed regulations, in particular, give TC an opportunity to develop regulatory provisions to ensure that companies operating tugs of 15 GT or less incorporate risk assessments into their operations. However, although the SVCP-T and the proposed regulations are positive steps forward, in their present forms, they do not explicitly require tug operators to conduct risk assessments. This means that risks in towing operations will continue to go undetected and unmitigated, placing crews, tugs, tows, and the environment in danger. Therefore, the Board recommends that

At the time of the occurrence, the Ingenika was operating in a compulsory pilotage area that falls under the responsibility of the Pacific Pilotage Authority (PPA). The PPA is a Crown corporation that has a mandate to establish, operate, maintain, and administer safe and efficient pilotage services in British Columbia. Pilotage services are provided by licensed pilots, who are highly trained navigators that use their knowledge of local waters to direct a vessel and navigate it using the safest route.

The PPA has a pilotage waiver system under which some vessels, mainly tugs, may obtain waivers that exempt them from having to take a licensed pilot on board in designated pilotage areas if the operators and tugs meet certain requirements. However, when a company requests a pilotage waiver, the PPA does not check the information submitted to ensure that it meets regulatory requirements, and the PPA relies on operators to ensure that they are complying with waiver conditions once a waiver is granted. In BC, there are currently 364 tugs, owned by 85 different companies, that operate under pilotage waivers.

This investigation identified that, although the master of the Ingenika had been issued a pilotage waiver, he held a certificate of competency that was restricted to passenger vessels operated by a specific company and therefore should not have been eligible for a waiver on a towing vessel. As well, one of the deckhands had, on various occasions, been put in charge of a navigational watch on board the Ingenika, but he did not hold a certificate of competency or a pilotage waiver. Further, the tug was not fitted with a bridge navigational watch alarm system and did not have a Class A automatic identification system, both of which are requirements for a vessel operating under a waiver.

This investigation is not the first to identify shortcomings around the PPA’s process for issuing waivers and its reliance on companies to ensure ongoing compliance with waiver conditions. The TSB found similar issues in occurrences involving the tug Ocean Monarch in 2017and the tug Nathan E. Stewart in 2016.

Without an effective process to verify that crew members and vessels meet PPA waiver requirements, there is a risk that non-compliance with waiver requirements will go undetected and compromise safety in compulsory pilotage waters. Given the need to ensure that waivered vessels are operating at a level of safety comparable to that afforded by a licensed pilot, the Board recommends that

On 26 April 2022, TC reached out to the Nuu-chah-nulth Tribal Council regarding occurrences in and near Tofino harbour in 2021 and early 2022. TC offered a follow-up discussion to share information about the current regulatory regime and better understand the Council’s perspectives about transportation safety in the Tofino area.

The TSB issued Pipeline Safety Advisory Letter 01/22, “External risks to pipelines in agricultural areas,” to Manitoba Hydro on 15 March 2022.

The letter indicated that pipeline operators need to be aware of the depth of cover (DOC) over their pipelines to ensure that they are sufficiently buried or otherwise protected against normal agricultural activities that do not require explicit authorization.

Given the risk of damage to underground pipelines by activities conducted on agricultural land, the letter indicated that Manitoba Hydro may wish to review the management practices associated with its damage prevention program to ensure that the Minell Pipeline is adequately protected.

Manitoba Hydro took or initiated the following actions:

• Contacted all landowners along the right-of-way to suspend agricultural cultivations and heavy load traffic from 13 October 2021 to 12 November 2021
• Sent a pipeline safety awareness alert to the Keystone Agricultural Producers and the Association of Manitoba Municipalities
• Completed a DOC survey between 12 and 22 October 2021 for the entire Minell Pipeline. Ten locations were found to have cover less than 0.65 m. The locations were staked and/or barricaded. Manitoba Hydro met with the affected landowners and provided written notifications in November 2021 prohibiting agricultural work, vehicle crossings and other ground disturbance activities in the staked/barricaded areas. The landowners were contacted in person or by telephone in May 2022 to remind them of the restrictions.
• Added a new measure to the Pipeline System Integrity Management Program to report on the progress of planned insufficient cover remediations

On 09 October 2021, the Canada Energy Regulator (CER) issued order MEL-001-2021 to Manitoba Hydro with respect to the occurrence. Among other things, the order required Manitoba Hydro to

• notify affected landowners (including any persons who are engaged or are likely to be engaged in agricultural activities, rent or lease the land, or work as service providers or employees) as soon as practicable of temporary safety measures, including requirements to contact Manitoba Hydro to request a locate before performing an agricultural activity on the pipeline right-of-way until such time as the landowner is advised that adequate DOC has been confirmed by Manitoba Hydro for the lands of the landowner; and
• complete a DOC survey for its entire Minell Pipeline as soon as practicable and beginning no later than 12 October 2021.

On 13 April 2022, the CER issued Safety Advisory SA 2022-01, “Depth of Cover in Agricultural Areas,” to all regulated companies, and provided specific guidance on how to interpret the regulatory requirements for the prevention of pipeline damage, including preventive actions that companies can incorporate into their damage prevention programs.

On 12 August 2022, following a compliance verification activity, the CER issued 4 notices of non-compliance to Manitoba Hydro.

In October 2022, following a field inspection, the CER identified additional requirements for DOC survey spacing and requirements for right-of way patrol and monitoring, which are being addressed with Manitoba Hydro.

TC undertook an investigation under the Canada Labour Code, Part II (CLC II), and as a result, 2 directions were issued to the Canadian National Railway Company (CN): one on 15 August 2019, and another one on 11 October 2019.

TC reviewed the corrective measures implemented by CN and deemed them to be satisfactory.

The CLC II investigation has been completed and the results shared with the employer and its workplace health and safety committee as per CLC II requirements.

On 15 August 2019, CN issued Notice No. 1908-15 which contained revised instructions for S-Yard industrial released cars. The notice identified that effective immediately and until otherwise notified:

• All loaded releases from S-Yard (S031/S032) and the metal distribution centre (W109/W110) must not be positioned on track W100 to be humped at the dual hump.
• The cars on W100 track (W100) will be pulled by itself (i.e., cars are not to be doubled from other tracks to W100 to be humped).
• Movements from W100 onto the west pullback are not to exceed 8 mph.

On 21 August 2019, CN issued Notice No. 1908-21 which contained revised instructions for pulling W100 and S-Yard industrial released cars. The notice identified that the instructions were effective immediately and until otherwise notified.

Due to the high-degree curvature at the north end of W100, CN eliminated the need to stop and restart movements to detrain at the W100 switch in order to eliminate in-train forces and the potential for derailment in these curves. The new procedure requires that

• the yard operating employee (YOE) release the hand brakes on W100 then cross over to the south-east side of the track, being mindful of potential movements on the diesel shop inbound and outbound tracks;
• the northward pull commence only after the YOE has walked eastward to a point ahead of the locomotive consist and maintains at least a 50-foot distance from the W100 lead while cars are being pulled; and
• the entire cut of cars from W100 pass the crossing before the YOE walks up to line the W100 switch for the west pullback toward the crest.

Once movement has commenced and has been ramped up to the 8 mph speed selector position (the maximum allowed speed to pull cars from W100 onto the west pullback), except in case of emergency, the throttle selector lever should only be placed to the “Coast” position to bring the movement to a stop.

• Do not ramp down from 8 mph to another speed position, and
• The locomotive independent brake selector should not be used at all.

The instructions previously communicated in Notice No. 1908-15 for the S-Yard industrial released cars remained in effect.

CN has also implemented the following corrective measures:

• Training material has been updated to
• Highlight hazard areas for tracks with high curvature.
• Instruct CN employees to ride either the locomotive or trailing car on tracks with curves of over 12 degrees.
• The 15-degree left-hand curve on W100 has been reconfigured to reduce the track’s curvature from 15 degrees to 12 degrees.
• A process was developed to verify that safety-critical information communicated by a notice is also included in the next Summary Bulletin and, if required, the respective yard operating manual.
• Working with General Electric and Beltpack manufacturer Cattron Intellectual Property Corporation, changes were made to remote control locomotive systems (RCLS) programming to allow for a more gradual application of the locomotive throttle during RCLS operations.

On 18 January 2021, the TSB issued Rail Safety Advisory 01/21, which discussed second-train events at multi-track grade crossings. This advisory cited the risks posed by multi-track crossings situated near rail yards where slow-moving trains and switching assignments frequently occupy the crossing and delay pedestrians or cyclists, sometimes in excess of the regulatory limit (5 minutes).

The advisory indicated that, when delays involve a slow-moving switching assignment, crossing users may incorrectly assess the risks as being low, enter the crossing before the grade crossing warning devices deactivate, and proceed into the path of an oncoming second train.

The advisory suggested that it may be prudent for the parties involved to identify those multi-track crossings that experience frequent and extended crossing signal activations and that have a high level of pedestrian and cyclist traffic, assess the likelihood of a second-train event to occur, and consider additional safety measures to minimize the risks of an accident.

On 02 March 2021, TC responded to the TSB Rail Safety Advisory indicating that the accident occurred at a grade crossing that falls under provincial jurisdiction and that the Grade Crossings Regulations apply only to grade crossings under federal jurisdiction. Notwithstanding, TC indicated that CN and Metrolinx had begun performing joint audits of the Lancaster Street West crossing, and that they had been working collaboratively to identify possible improvements and action plans.

In an effort to raise the safety concerns associated with conducting switching operations in the vicinity of crossings with double tracks, TC asked the Railway Association of Canada to share Rail Safety Advisory 01/21 with its members and recommend that they assess their crossings to determine if additional measures are needed to reduce the risk of a similar accident occurring in the future.

Since the accident, Metrolinx has made a number of safety improvements at the crossing. Metrolinx has installed

• dedicated sidewalk pedestrian barrier arms with drop-down arm skirting on all 4 quadrants;
• sidewalk tactile plate inlays on all 4 crossing quadrants to identify the crossing approach to visually challenged pedestrians and to delineate a safe stopping point for them to wait for passing movements;
• dynamic LED signs displaying “Danger – Multiple Trains Expected” that are activated when a second train enters the crossing circuit; and
• static second-train event signage in all 4 quadrants of the road approach.

In addition, it has

• issued instructions to Metrolinx operating crews approaching the Lancaster Street West crossing who observe another movement, or equipment, on an adjacent track, occupying, or in the vicinity of, the crossing, to abide by Rule 14(f) of the Canadian Rail Operating Rules requiring a succession of several short sounds from the train whistle;
• developed and implemented a grade crossing safety plan to provide a standardized framework for grade crossing oversight, and incident review and analysis; and
• provided on-site education and hazard awareness information to crossing users while also enforcing safety regulations.

Metrolinx has also introduced a number of business processes to improve its crossing oversight:

• a Road and Rail Interface Risk Management and Oversight Committee chaired by the Chief Safety Officer and the Chief Engineer that meets monthly to review progress on annual risk assessments for all grade crossings, and actions and action plans for each crossing
• the Incident Investigation Recommendation Review Committee chaired by the Chief Risk Officer that ensures recommendations from investigations are implemented and tracked, and information is shared with internal and external interested parties
• a new regulatory oversight office with a Director of Regulatory Oversight to create a third layer of corporate assurance. This office is under the leadership of the Vice President of Audit Regulatory Compliance reporting directly to the Board.
• a practice of requiring all grade crossings to be risk assessed a minimum of every 12 months. Metrolinx is currently reviewing the effectiveness of whistle cessation and the risks associated with the practice, and a requirement for buses, other than school buses, to stop at all crossings.
• a new bylaw to enable fines to be issued by Metrolinx to vehicle drivers committing offences at grade crossings. This is part of a grade crossing camera enforcement program to reduce unsafe behaviours and non-compliance.

Metrolinx continues to monitor CN switching activities via closed-circuit television cameras and in-person observations at locations where CN trains interact with GO Transit trains, which includes the Lancaster Street West crossing. Results from the observations and analyses of the crossings have identified non-compliances, which have been shared with CN management. As of February 2023, Metrolinx continues to work with CN to manage and reduce any safety risk to railway operations and the public.

Since the accident, the Ministry of Transportation of Ontario (MTO) has begun to receive TC inspection reports, starting with the 2019 reports.

Both the agreement with TC and the agreement with Metrolinx were updated in January 2022, and each contains amendments and additions to the original agreement, such as

• explicitly noting the MTO’s authority to direct Metrolinx, where necessary, to address a non-compliance identified in an inspection report if Metrolinx has not taken appropriate corrective action. Metrolinx is required to comply with the direction issued;
• formalizing the process for and contacts within the MTO to receive inspection reports from TC inspectors; and
• updating the rules, standards, and regulations appendix to reflect the current applicable federal requirements.

In making these updates to the agreements, the MTO worked closely with TC to strengthen the MTO’s accountability role in the agreement, with respect to Metrolinx, to verify that non-compliances and deficiencies that may arise are appropriately addressed.

The MTO has identified a need to update the oversight framework for urban and regional rail transit in Ontario that would better support the province’s growing rail network and the diversity of operators. Early in 2021, the MTO began a review of the safety oversight framework for provincial railways; this review was ongoing as of February 2023. The review encompasses provincial shortline railways, the Ontario Northland Transportation Commission, and urban and regional transit systems with rail service (i.e., the Toronto Transit Commission, GO Transit and UP Express [Metrolinx], OC Transpo, and ION light rail [Grand River Transit]).

Since the accident, bitKIDS Behaviour Consulting moved from its Victoria Street North location to a new location that has its own fenced play area. Street-safety skills are taught in the fenced play area. Once children have learned the skills, they practise these skills daily outside the fenced play area. In addition, the bitKIDS Behaviour Consulting handbook has been updated to include the following statement: “Obey all traffic laws when crossing streets, railway tracks, and crosswalks with or without traffic signals at all times.”

Safety concern: Regulatory oversight of Ontario provincial railways

Metrolinx was created in 2006 to improve the coordination and integration of public transit train and bus service for the Greater Toronto and Hamilton Area.^{Footnote 9} It oversees the operations of UP Express, the dedicated air–rail link between Union Station in downtown Toronto and Lester B. Pearson International Airport, as well as of the GO Transit regional public transit train and bus service. The GO Transit train service and UP Express operate over about 420 km of rail lines, 337 km of which are owned by Metrolinx. In 2019, they carried an average of about 229 000 riders each weekday, which represents the highest daily ridership in Canada.

In April 2020, the provincially regulated rail network in the Province of Ontario comprised 12 railways (including Metrolinx) that are governed by 3 provincial acts:

• the Shortline Railways Act, 1995 (SRA), which outlines safety requirements by reference to the federal Railway Safety Act (RSA)
• the Ontario Northland Transportation Commission Act
• the Metrolinx Act, 2006, which prescribes corporate structure but has no safety requirements

The MTO is responsible for the oversight of the provincially regulated railway system but it has no overall provincial regulatory framework and has not issued any regulations pursuant to the SRA. The MTO also does not have employees with the technical knowledge, experience, and expertise required to oversee the safety of railway operations; rather, it relies on various agreements with other parties in an effort to provide oversight. Specifically:

• The MTO has an inspection-services agreement with TC that requires TC to conduct inspections of Metrolinx and various shortline railways to federal regulations, rules, and standards.
• The Ontario Northland Transportation Commission conducts its own internal track inspections and hires third-party inspectors for some other inspections.

Metrolinx falls under the Metrolinx Act, 2006 when operating on its own provincially regulated track. Because this Act does not include safety-related provisions or subsequent offence provisions for violating them, it does not provide the Province of Ontario with a framework for taking enforcement action for safety-related deficiencies, when appropriate, against Metrolinx or other provincial railways operating on Metrolinx-owned property. Furthermore, TC inspectors do not have the authority to compel Metrolinx or other provincial railways operating on Metrolinx-owned property, to take action to address identified safety hazards.

With regard to enforcement, it is within the authority of the Ontario Minister of Transportation to require Metrolinx or the Ontario Northland Transportation Commission to implement any directives issued to either agency with respect to any matter arising under their respective legislation, including implementation of corrective action. For the provincial shortline railways that fall under the authority of the SRA, the Registrar of Shortline Railways can suspend or revoke a railway licence.

In accordance with its agreement with TC, the MTO was to receive all TC inspection reports and resolve any disputes from the implementation of the TC inspection agreement with Metrolinx. However, the MTO had not been receiving TC inspection reports and does not have employees with the technical knowledge, experience, and expertise required to evaluate TC inspection reports.

Given the current complex MTO regulatory framework that involves multiple agreements, there are gaps in the oversight processes that can lead to occasions when the MTO will not be able to provide effective safety oversight.

The MTO has identified a need to update the oversight framework for urban and regional rail transit in Ontario that would better support the province’s growing rail network and the diversity of operators. Early in 2021, the MTO began a review of the safety oversight framework for provincial railways; this review was ongoing as of February 2023. The review encompasses provincial shortline railways, the Ontario Northland Transportation Commission, and urban and regional transit systems with rail service (i.e., the Toronto Transit Commission, GO Transit and UP Express [Metrolinx], OC Transpo, and ION light rail [Grand River Transit]).

The Board is encouraged that the MTO has identified a need to update the oversight framework for urban and regional rail transit in Ontario. However, although such a framework may include updated legislation and the creation of a regulator to provide oversight and support safety practices across the provincial railway sector, no such framework has yet been established. Therefore, the Board is concerned that the Province of Ontario does not provide effective safety oversight of provincially regulated railways.

On 04 April 2019, following this occurrence, Canadian National Railway Company (CN) distributed System Notice No. 904 to all operating employees in Canada. The notice warned train crews that there had once again been a marked increase in Canadian Rail Operating Rules Rule 439 violations across the CN system. In these cases, train crews failed to stop at signal indications requiring them to do so, primarily due to a lack of focus on situational awareness.

It also noted that “operating crews must not be influenced by other information such as train lineups, detector broadcasts or other crew’s [sic] broadcasts until they themselves positively identify the next signal.”

Safety action required

Eastbound CN train M31851-01 (train 318) was proceeding on the south main track of the Rivers Subdivision. Train 318 was a key train operating on a key route, as defined by the TC–approved Rules Respecting Key Trains and Key Routes.

At 0906:54, train 318 was travelling at 42 mph, with Trip Optimizer (TO) engaged and the throttle in position 7, as it passed a Clear to Stop signal indication at Mile 52.2. The conductor had called out the signal in the locomotive cab and identified the Clear to Stop indication but did not hear the locomotive engineer (LE) verbally respond to acknowledge the signal.

At Mile 51.13, while travelling at 46 mph, train 318 passed the head end of train M31541-03 (train 315), which was westbound on the north track. The train 318 conductor then reminded the LE that they were operating under a Clear to Stop signal indication. Once reminded, the LE disengaged TO and made a full service brake application at 0908:34; 24 seconds later, he inadvertently placed the brake handle into the suppression position, and then applied the locomotive independent brake.

At 0909:08, train 318 was proceeding at 39 mph at Mile 50.57 when the LE recognized that a collision was inevitable and placed the train in emergency. By 0909:30, train 318 had slowed to 23 mph when it side-collided with the 95th car of train 315 at Mile 50.37, as train 318 negotiated the equilateral turnout.

The investigation concluded that:

• The train 318 operating crew did not respond appropriately to the signal indications displayed in the field at Mile 52.2 and Mile 50.4, which ultimately led to the collision.
• It is likely that the low workload associated with operating train 318 using TO, together with fatigue, reduced the LE’s arousal levels and affected his ability to maintain vigilance and situational awareness.
• In particular, in the absence of a physical defence such as an enhanced train control system, there was no automatic intervention to slow or stop the train when the crew did not initially respond to the Clear to Stop signal displayed in the field.
• Due to the inexperience of the train 318 conductor and the authority gradient that existed between the crew members, the conductor deferred to the LE without questioning the operation of the train and, as a result, the crew’s actions to slow and stop the train before Controlled Signal 504S were delayed and ineffective.

Enhanced train control for key routes

The rail transportation system is complex. The defence-in-depth philosophy advocated by safety specialists for complex systems seeks multiple and diverse lines of defence to mitigate the risks of normal human errors. Wherever possible, a combination of rules-based (i.e., administrative) defences and physical defences should be implemented to address normal slips, lapses, and mistakes that characterize human behaviour. Although newer circuitry has been integrated over the years, the basic design of centralized traffic control (CTC) signalling systems in Canada is well established. Despite this newer circuitry, railway operations still rely predominantly on administrative defences, which are the least effective method for mitigating risk.

Administrative defences, such as the Canadian Rail Operating Rules, railway general operating instructions, and bulletins, place an over-reliance on a train crew to follow the rules and do not consider the human factors that affect behaviour in everyday life. For example, the CTC train control system in this case had the administrative requirement for train crews to follow the signal indications displayed in the field. Safe train operations are contingent on train crews observing each signal indication, broadcasting it, and then taking the appropriate actions.

A signalled CTC system does not provide any advance warning to either the train crew or the rail traffic controller if a train crew does not observe a signal indication or does not take the appropriate action. CTC also does not provide automatic enforcement to comply with speed restrictions in order to slow or stop a train before it passes a restrictive signal.

In instances where a train crew misperceives, misinterprets or does not follow a signal indication, the administrative defences as a whole fail. As demonstrated in this and other occurrences, when an administrative defence fails and there is no secondary defence, it can result in an accident that otherwise could have been prevented.

In contrast to the administrative defences for train control systems available in Canada, Class 1 railways that operate in the United States (U.S.) have implemented physical fail-safe train control systems known as positive train control (PTC). PTC is designed to prevent train-to-train collisions, overspeed derailments, incursions into work zones, and movement of a train through a switch left in the wrong position. In Canada, the term “enhanced train control” (ETC) has been adopted to describe such systems.

A PTC/ETC system would address the risk of crews misinterpreting or not following signal indications by automatically intervening to slow or stop a train in the event that an operating crew does not respond appropriately to a signal displayed in the field. A fully functioning PTC/ETC system would also offer a physical fail-safe defence against operating crew errors that are influenced by fatigue, which played a role in this accident.

In the U.S., over the last 50 years, the National Transportation Safety Board (NTSB) has investigated more than 150 PTC-preventable accidents that took the lives of more than 300 people. From these investigations, the NTSB made 51 PTC-related recommendations.

In September 2008, a collision between a Metrolink commuter train and a Union Pacific freight train in Chatsworth, California, prompted the passage of the Rail Safety Improvement Act of 2008 (RSIA) in the U.S. The RSIA mandated that PTC be installed on main rail lines that had specific risks associated with the transportation of dangerous goods (DG) as well as intercity and commuter passenger rail service.

As of 31 December 2020, PTC was fully implemented in the U.S. on all track required by the RSIA legislation, a total of 57 535.7 miles, which accounts for about 41% of the nearly 140 000 route-miles of the U.S. rail network. The total miles of track that have PTC installed includes the U.S. operations of both CN (3107 miles) and Canadian Pacific Railway Company (CP) (2118 miles).

For comparison, the Canadian rail network comprises about 26 000 route-miles of track. Key routes account for a combined total of about 10 940 miles of main track, which represents about 42% of the Canadian rail network. When the key route criteria are compared to the high-hazard route criteria of the U.S. RSIA, it is reasonable to conclude that the hazards and percentages for route-miles of affected track are similar. Although U.S. legislation required that PTC be installed on high-hazard routes, there is no similar requirement to install PTC or ETC on comparable routes in Canada that carry DG.

A review of all TSB rail investigation reports (excluding Class 5 occurrences and including this occurrence) produced since the inception of the TSB in 1990 determined that 80 occurrences may have been prevented had a train control system equivalent to PTC (i.e., ETC) been available.

Furthermore, when TSB Class 5 occurrences are also considered, from 2004 to 2019, there was an annual average of 31 reported occurrences in which a train crew did not respond appropriately to a signal indication displayed in the field, and the yearly number of these occurrences is on the rise. In particular, 2018 (40) and 2019 (38) had the highest number of these occurrences.

In 2000, the TSB issued its first recommendation (R00-04) for implementing additional train control defences following its investigation into the 1998 collision between 2 CP trains near Notch Hill, British Columbia.^{Footnote 10} After determining that backup safety defences for signal indications were inadequate, the Board recommended that

In 2013, the TSB issued another recommendation (R13-01) for implementing additional train control defences following its investigation into the 2012 derailment and collision of VIA Rail Canada Inc. passenger train 92 (VIA 92) near Burlington, Ontario.^{Footnote 11} Following the investigation, the TSB indicated that TC and the industry should move forward with a strategy that would prevent these types of accidents by ensuring that signals, operating speeds, and operating limits are always followed. The Board recommended that

In 2014, in response to the 2 TSB recommendations, a joint TC–industry train control working group (TCWG) was established. The group was chaired by TC Rail Safety, and also included representatives from the railway industry and operating crew unions. After establishing the TCWG, there were a series of ongoing meetings, discussions, and studies related to the development and implementation of ETC systems in Canada with no implementation plan or other tangible results to date. While TC did publish a Notice of Intent in the Canada Gazette, Part I, in February 2022 signalling its intent to require the implementation of ETC in Canada, there is still no implementation plan.

In the time it took TC and industry to strike the TCWG, study the issue, produce the TCWG Final Report, contract a follow-on report from the Canadian Rail Research Laboratory (CaRRL) and study the CaRRL results, PTC had been fully implemented in the U.S. on all of the high-hazard trackage required by the RSIA legislation.

Despite significant investment in PTC technology for the CN and CP locomotive fleets and their U.S. infrastructure, and 2 TSB recommendations to TC related to ETC dating back over 20 years, little has been done to extend the use of PTC into Canada or develop a similar form of ETC in Canada.

In this occurrence, with no backup physical fail-safe defence, such as a PTC/ETC system, there was no automatic intervention available to slow or stop the train. Consequently, the collision occurred after the train 318 LE, who was fatigued, did not respond appropriately to the Clear to Stop signal displayed in the field.

By definition, the CN Rivers Subdivision is a key route and is also an integral part of one of the major rail traffic corridors in Canada. This also means that the cities, towns, and villages along this key route are continually exposed to the risks associated with key trains transporting DG. Any collision or derailment involving a key train presents a risk of a DG release. If a train accident occurs on a key route, a key train or trains may be involved, increasing the risk of a DG release and potential adverse consequences to people, property or the environment.

It is clear that the current administrative defences for train operation, such as company procedural guidelines, notices and instructions, as well as the TC–approved Canadian Rail Operating Rules and Work/Rest Rules for Railway Operating Employees, are not always effective. Consequently, incidents and accidents continue to occur.

The first TSB recommendation on this issue is over 20 years old. The 2013 recommendation called for the implementation of physical fail-safe train controls, beginning with Canada’s high-speed rail corridors. (Canada’s primary high-speed rail corridor extends from Québec, Quebec, to Windsor, Ontario.) While the high-speed corridors are generally comprised of key routes, more recent accident history demonstrates that there is also a need for the implementation of fail-safe train control systems on all key routes.

The implementation of physical fail-safe train control technologies such as ETC would provide an extra layer of safety when operated in conjunction with existing administrative defences. However, the Canadian railway industry continues to rely solely on administrative defences, such as company procedural guidelines, the Canadian Rail Operating Rules, and the Work/Rest Rules for Railway Operating Employees, to protect against train crews not responding appropriately to signal indications displayed in the field. If TC and the railway industry do not take action to implement physical fail-safe defences to reduce the consequences of inevitable human errors, the risk of collisions and derailments will persist, with a commensurate increase in risk on key routes in Canada. Therefore, the Board recommends that

Crew resource management training

Railway operations are governed by rules and instructions that place equal responsibility for safe train operations on all crew members. Safe railway operations are predicated on all crew members following all of the rules, all of the time. In the rail industry, operating rules require that crew members verbally acknowledge signal indications displayed in the field to each other. When a train encounters a signal indication displayed in the field, one crew member must communicate the signal indication aloud within the locomotive cab to the other crew member. While the other crew member is required to repeat the message back, there is no requirement for the original sender to confirm that the message was received accurately or understood by the other crew member. As a result, this communication can fail.

The railway rules do not specify a closed-loop communication method, meaning there is no requirement for the original sender of the message to acknowledge, and therefore confirm, that it was received accurately. Moreover, when there is a significant difference in level of experience between operating crew members, an authority gradient may develop in which the less experienced crew member may not always intervene to ensure compliance with all of the rules. In these situations, there is a danger that safety-compromising behaviour will be overlooked because a less experienced employee may be reluctant to question the actions of a more senior employee or intervene in the operation of the train even when it may be critical to do so.

In this occurrence, the investigation determined that communications between the 2 crew members were not always closed-loop. The callouts of signal indications by the conductor were not always acknowledged or repeated back by the LE. The conductor did not confirm that the LE had understood the communication nor was he required to do so. The inexperience of the conductor on the subdivision, and with locomotive operations, also deterred him from trying to intervene and stop the train.

Crew resource management (CRM) is a concept introduced in the aviation and marine industries to limit or eliminate human errors by recognizing the importance of cognitive and interpersonal skills, thereby improving safety. CRM targets a crew’s skills, abilities, attitudes, communication, situational awareness, problem solving, and teamwork. Crew members must successfully interact with each other, their equipment, and their environment to effectively manage threats, errors, and unexpected conditions that may be encountered.

In order to perform in a coordinated, efficient, and safe manner, crew actions need to be based on a common understanding of the current state of the equipment, the intended route to be taken, and any other potential threats. When this understanding is consistent, crews are better able to effectively anticipate and coordinate their actions to achieve their common goal. This common understanding between crew members is referred to as team or shared situational awareness.

Shared situational awareness is developed and maintained by a crew through a number of discrete and continuous behaviours. These behaviours include in-trip briefings, the identification of key points throughout the trip, threat and error management (TEM), callouts to any change in the state of the equipment, the instrument setting or mode, and the communication of any change in plans to ensure that all crew members have a common understanding of activities.

TEM stresses the principles of anticipation, recognition, and recovery when addressing threats, errors, and undesirable equipment states, and is based on the proactive detection of threats that could reduce safety margins. Effective error management is associated with specific behaviours by the crew, the most common being vigilance, a propensity to ask questions or provide feedback, and assertiveness.

A 2015 study entitled Human Factors Analysis of “Missed Signals” in Railway Operations,^{Footnote 12} when addressing team training, indicated that CRM training

emphasizes non-technical skills such as communication, briefing, backing up behaviour,^{Footnote 13} mutual performance monitoring, team leadership, decision making, task-related assertiveness (e.g., a junior operator speaking up to a dominant colleague), and team adaptability.

The report went on to state that CRM training includes aspects of team situational awareness such as “perception” and “information sharing, coordination and crosschecking information” and instructed crews to “become vigilant for losses of [situational awareness]; both one’s own and by others.”

CRM focuses on providing crews with the interpersonal skills required to carry out their tasks safely: “CRM training typically consists of an ongoing training and monitoring process through which personnel are trained to approach their activities from a team perspective rather than from an individual perspective.”^{Footnote 14}

Significant safety benefits were experienced in the aviation and marine industries with the introduction of CRM. Given the prevalence of human factors issues in rail accident statistics, this type of training could yield significant safety benefits in the rail industry.^{Footnote 15}

Since 2017, CN has delivered a course called “Looking out for each other” as part of its operating crew requalification programs delivered every 3 years. While the CN training is insightful, it is broadly focused and does not specifically deal with train crew interaction within a locomotive cab or the authority gradients that may exist in that environment. While CP provides CRM training to its new operating employees, it does not provide formal dedicated recurrent CRM training.

The Railway Employee Qualification Standards Regulations have no requirement for operating crews to complete a separate module on CRM when they qualify or re-qualify. Consequently, the adoption of CRM training in the rail industry has been sporadic and the approach differs between railways. Although railway training touches on CRM principles, neither CP nor CN provide dedicated, recurrent CRM training that explores all aspects of CRM. Recurrent CRM training would seek to improve non-technical skills that deal with in-cab communication, job briefings, backing-up behaviour, mutual performance monitoring, team leadership, decision making, task-related assertiveness (e.g., a junior operator speaking up to a dominant colleague), team adaptability, as well as concepts of TEM and team situational awareness.

The TSB has investigated 8 other rail occurrences, dating back as far as 1996, in which ineffective CRM practices were identified as a factor that contributed to the accidents.^{Footnote 16}

If operating crew members do not receive enhanced initial and recurrent CRM training to develop skills in crew communication, the coordination of decision making and activities, and dealing with authority gradients that may exist within a locomotive cab environment, there is an increased risk that inadequate crew communication will lead to unsafe operations. Therefore, the Board recommends that

Following this accident and 2 additional serious Canadian Pacific Railway Company crude oil unit train derailments near Guernsey, Saskatchewan, on 09 December 2019 (TSB Occurrence R19W0320) and 06 February 2020 (TSB Occurrence R20W0025), on 04 March 2020 the TSB issued rail safety advisories (RSA) 02/20 and 03/20 to TC.

The RSAs noted that, since 2015, including this accident, the TSB had deployed to 7 train derailments involving tank cars that were transporting crude oil, 6 of which resulted in a significant release of product. A review of the 7 accidents revealed the following:

• All 7 derailments occurred on a key route on which the track was maintained in accordance with the Rules Respecting Track Safety, also known as the Track Safety Rules (TSR), Class 3 or 4 standard.
• All 7 derailments occurred as a result of a broken rail, broken joint bars or other track infrastructure condition.
• For 6 of the 7 cases
• train speed ranged from 38 mph to 49 mph;
• between 29 and 39 tank cars loaded with petroleum crude oil derailed;
• a total of 8.43 million litres of petroleum crude oil was released; and
• the derailment occurred during the winter months.

In RSA 02/20, the TSB indicated that train speed is one of the primary factors that contributes to the severity of a derailment. However, other factors such as train length, train weight, the position of the first car(s) derailed, the position of the cars in the train, and tank car design also play a role. The RSA suggested that, to reduce the frequency of these accidents and the commensurate risk to the public, property and the environment, TC should further review and modify key train speeds, as appropriate, based on various train risk profiles while also considering other factors that influence the severity of a derailment.

In RSA 03/20, the TSB noted that, as train operations have evolved, the TSR have not kept pace. The current TSR came into force on 25 May 2012, almost 4 years before the TC-approved Rules Respecting Key Trains and Key Routes came into force in February 2016. While the TSR establish minimum standards for track infrastructure, there are no provisions in the TSR to address the need for enhanced track standards for key routes despite sometimes significant increases in dangerous goods traffic volumes on these routes.

To reduce the frequency and mitigate the risks associated with accidents involving key trains on key routes, it is imperative that the track infrastructure be adequately maintained. Considering that the underlying causes of the 7 accidents identified were all related to failures of track infrastructure, TC was advised that the current TSR do not address the increased risks associated with the operation of key trains. The TSB suggested that TC consider revising the Rules Respecting Track Safety to include enhanced track standards for key routes.

On 01 April 2020, TC issued Ministerial Order (MO) 20-05 which indicated that, pursuant to the provisions of section 32.01 of the Railway Safety Act, federally regulated railway companies were ordered to implement additional safety measures for key trains.

The MO identified that there were a number of recent derailments of trains transporting dangerous goods that resulted in the breach of tank cars and the release of dangerous goods, including the St-Lazare derailment in Manitoba in 2019, the Guernsey derailment in Saskatchewan in 2019 and the second Guernsey derailment in Saskatchewan in 2020.

Federally regulated railways were ordered to implement an additional definition for a higher-risk key train, which was defined as an engine with cars that include loaded tank cars carrying crude oil or liquefied petroleum gases, as defined in the Transportation of Dangerous Goods Act, 1992, in a continuous block of 20 or more tank cars, or 35 or more tank cars dispersed through a train.

The MO also included additional speed restrictions, requirements for continuous welded rail (CWR) joint management, and requirements for installing replacement (plug) rail.

MO 20-05 was effective immediately, with the exception of the requirements for CWR joint management and installing replacement (plug) rails, which were planned to come into effect on 01 September 2020. This MO will remain in effect until the Minister approves revised Rules Respecting Key Trains and Key Routes that incorporate the above measures on a permanent basis.

On 01 April 2020, TC issued Ministerial Order MO 20-06 pursuant to the provisions of paragraph 19(1)(a) of the Railway Safety Act. The MO ordered federally regulated railway companies to revise the Rules Respecting Key Trains and Key Routes.

The MO required that revised rules be based on an assessment of safety risk and, at a minimum, incorporate new definitions, including of “higher-risk key trains,” which is to be defined as “an engine with cars that include loaded tank cars carrying crude oil or liquefied petroleum gases, as defined in the Transportation of Dangerous Goods Act, 1992, in a continuous block of 20 or more tank cars, or 35 or more tank cars dispersed through a train;” additional speed restrictions; requirements for CWR joint management; and requirements for installing replacement (plug) rail.

The MO required that railways file the revised Rules Respecting Key Trains and Key Routes with the Minister of Transport for approval within 210 days of the date that the MO was issued.

On 06 November 2020, TC issued Ministerial Order MO 20-10 pursuant to the provisions of section 32.01 of the Railway Safety Act. With the issuance of MO 20-10, MO 20-05 was repealed, and federally regulated railway companies were ordered to implement additional safety measures for key trains including the following:

• Part I: Additional key train speed restrictions when a winter operation risk mitigation plan is not in place
• Part II: Requirement for continuous welded rail (CWR) joint management
• Part III: Requirement for installation of replacement (plug) rail
• Part IV: Key train speed restrictions with a winter operation risk mitigation plan in place
• Part V: Requirements for winter operation risk mitigation
• Part VI: Requirements for rail break detection technology

This order was effective immediately and will remain in effect until the Minister approves revised Rules Respecting Key Trains and Key Routes that incorporate the above measures on a permanent basis.

On 22 February 2021, TC approved the revised Rules Respecting Key Trains and Key Routes submitted by the industry. The revised rules came into effect on 22 August 2021.^{Footnote 17} The revised rules are as follows:

• Require companies to develop and adhere to a maintenance and inspection plan for permanent rail joints and temporary rail joints in CWR.
• The inspection plan is to include time limits for the retention of temporary rail joints until permanently repaired, as well as the requirement for records detailing the location, installation, inspection, and maintenance dates for temporary rail joints.
• Restrict the maximum operating speed of key trains in census metropolitan areas (CMAs).
• Define higher-risk key trains as those trains that include loaded tank cars carrying crude oil or liquefied petroleum gases in a continuous block of 20 or more tank cars or 35 or more tank cars dispersed through a train, and
• further restrict the maximum operating speed of higher-risk key trains, when compared to key trains operating both within and outside of CMAs.
• Contain new requirements for winter operation risk mitigation plans.

On 01 April 2020, TC issued Ministerial Order MO 20-07, which indicated that, pursuant to the provisions of paragraph 19(1)(a) of the Railway Safety Act, federally regulated railway companies were ordered to revise the TSR.

The revised TSR should be based on an assessment of safety risks, track-related derailment causes, evolving technology, current railway internal standards and industry best practices, and shall, at a minimum, address the following elements in 3 phases:

Phase 1 elements

• Training, qualification, and quality assurance
• CWR management
• Track geometry
• Rail wear management
• Rail surface management

Phase 2 elements

• Track inspection frequency
• Automated track inspection technology

Phase 3 - Structures / Other elements

• Requirement for concrete ties
• Requirement for inspection of yard tracks over which passenger equipment carrying passengers operates
• Requirements to develop and report on key track performance indicators
• Requirement to file with TC the most recent version of company track standards

The dates for filing the revised TSR with the Minister are 01 April 2021 (Phase 1), 02 October 2021 (Phase 2) and 02 April 2022 (Phase 3).

On 31 May 2021, TC approved the Phase 1 revisions to the TSR. The revised TSR Part I, Section 9, items b) through f) include quality assurance requirements for safety-critical maintenance and repair activities.^{Footnote 18} These quality assurance requirements are expected to decrease the likelihood of derailments resulting from repair and maintenance activities that are inconsistent with the railway company’s standards and procedures.

Part II, Subpart D, Section IX of the revised TSR includes requirements for CWR Management Plans that include comprehensive installation, inspection, and maintenance requirements.^{Footnote 19}

The revised TSR also include requirements for railway companies to prepare and adhere to Track Geometry Management Plans, Rail Surface Management Plans, and Rail Wear Management Plans.

CN provided the following information with regards to safety action taken:

CN now requires the outside surface of all compromise joint bars, which is the side of a joint bar that is exposed when installed in track, to be spray-painted royal blue by the supplier. This change allows for compromise joint bars to be more easily differentiated from standard joint bars.

The occurrence joint bars and rail were returned to CN for use in its training program for Engineering personnel.

For training purposes, CN is also developing multiple rail track and joint bar kits made of lightweight composite material. Because rail track and joint bar kits could weigh up to 400 pounds, light weight kits are better suited for transport and practical, hands-on training.

The following items were part of CN’s ongoing track maintenance initiatives for the Rivers Subdivision between 01 March 2019 and 31 December 2019:

• A total of 1019 temporary plug rails, and the associated 2038 rail joints, were eliminated from the Rivers Subdivision (main track and sidings included).
• A total of 192 867 feet of CWR rail was installed/replaced on the Rivers Subdivision as part of CN’s capital programs.

Following the occurrence, TC’s Regional Enforcement Unit conducted a regulatory investigation. The TC investigation determined that the Canadian National Railway Company (CN) employee’s actions were not in accordance with the Canadian Rail Operating Rules (CROR) Rule 803, which governs track unit and track work authorization. Subsequently, TC issued an Administrative Monetary Penalty to CN for the CROR Rule 803 contravention.

Since the occurrence, CN has developed a software application (Electronic Track Authority Verification [ETAV]) for maintenance-of-way (MOW) employees that uses the track unit’s GPS location to provide audible alerts within the cab of the track unit as it approaches its limits of authority. The ETAV application obtains the limits of authority either by interacting with the electronic track occupancy permit program or by having the MOW employees manually input them. As of May 2022, CN has equipped 68% of a total of 1896 track units with the hardware necessary to support ETAV. The GPS locations that are used to delineate limits of authority have been mapped for ETAV use on 100% of CN’s main east-west corridor subdivisions, including the Caramat Subdivision, and on 44% of CN’s secondary corridor subdivisions.

Canadian Pacific Railway Company (CP) constructed a toe berm on the north side of the track to balance the existing former track embankment on the south side, and completed rehabilitation and stabilization work on the south side of the track after the derailment. The toe berm helps to evenly distribute loading of the subgrade and to counter differential settlement through the derailment area.

CP conducted simulations and modified the distributed power configuration for grain trains of 224 cars. Such trains are now operated with a tail-end remote locomotive (distributed power train configuration 2-1-1) instead of a sense and braking unit (distributed power train configuration 2-1-0, the configuration of the occurrence train). Trains with 112 or 168 cars are still permitted to operate with a sense and braking unit instead of a tail-end remote locomotive.

In response to this occurrence and other recent occurrences involving fires on a railway right-of-way, TC approved the new Railway Extreme Heat and Fire Risk Mitigation Rules, which came into effect on 15 June 2022. The new rules stipulate requirements to address track integrity during periods of extreme heat, for inspection of the exhaust system, and for a fire risk mitigation plan for the prevention of fires on railway rights-of-way.

Following the occurrence, TC conducted a regulatory inspection of the crossing. The crossing met regulatory requirements with regard to visibility, sightlines, and crossing warning time.

Following the derailment, Canadian National Railway Company issued Operating Bulletin No. 618. This bulletin instructed train crews to avoid excessive braking and limit the dynamic brakes to position 5 or less from Mile 17.0 to Mile 21.2 of the Napadogan Subdivision.