Transportation Safety Board of Canada - Departmental Performance Report for the period ending 31 March 2005

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Departmental Performance Report

2.7 Rail Sector

2.7.1 Annual Statistics

A total of 1,129 rail accidents were reported to the TSB in 2004, a 9% increase from last year's total of 1,032 and a 7% increase from the 1999-2003 average of 1,054. Rail activity has been relatively constant over the last six years, averaging 89.7 million train-miles annually. The accident rate increased to 12.5 accidents per million train-miles in 2004, compared to 11.5 in 2003 and the 1999-2003 average rate of 11.8. Rail-related fatalities totalled 100 in 2004, compared to 79 in 2003 and the five-year average of 94. This increase consisted mainly of trespasser fatalities, with 67 in 2004, up from 45 in 2003 and the five-year average of 53.

There was a significant increase in accidents in two areas. First, trespasser accidents showed a 52% increase over 2003, from 65 to 99, and a 27% increase over the five-year average of 78. Second, non-main-track derailments showed a 14% increase over 2003, from 389 to 444, and a 16% increase from the five-year average of 382.

Five main-track collisions occurred in 2004, compared to six in 2003 and the five-year average of eight. In 2004, there were 152 main-track derailments, comparable to the 149 in 2003, but a 21% increase from the five-year average of 126. Non-main-track collisions numbered 114 in 2004, up from 104 in 2003 and the five-year average of 103.

In 2004, crossing accidents decreased to 237 from the 2003 total of 250 and the five-year average of 267. Crossing-related fatalities numbered 25, compared to 28 in 2003 and the five-year average of 37.

In 2004, 210 accidents involved railcars carrying or having recently carried dangerous goods, a 7% decrease from both the 2003 total and the five-year average of 225. Five of these accidents resulted in a release of product.

In 2004, rail incidents reported under TSB mandatory reporting requirements reached a 22-year low of 252, down from 295 in 2003 and from the five-year average of 317. Dangerous goods leakers not related to train accidents annually account for the largest proportion of total incidents. In 2004, dangerous goods leakers decreased to 132 from the 2003 total of 151 and from the five-year average of 173.

Figure 7.

Rail Occurrences and Fatalities[D]f7

One indicator of rail transportation safety in Canada is the Canadian railway main-track accident rate. Although this accident rate has increased slightly from 2.7 accidents per million main-track miles in 2003 to 2.8 in 2004, there has been a notable decrease over the past 10 years. The trend line also indicates a clear downward direction.

Figure 8.

Canadian Railway Main-Track Accident Rates[D]f8

2.7.2 Investigations

Fourteen new rail investigations were started in 2004-2005 and 25 investigations were completed. This represents a significant increase in the number of investigations completed compared to the previous year. The increase is directly linked to the allocation of incremental resources to help address the backlog of work in progress. The average duration of completed investigations dropped to 618 days compared to 894 the year before. This also represents a significant reduction in comparison to the past four years. The reduction is attributable to the concentrated efforts made to complete very old cases. A complete list of all rail investigations started and all rail reports released in 2004-2005 is available on the TSB website.

Table 13: Rail Productivity
	2000- 2001	2001- 2002	2002- 2003	2003- 2004	2004- 2005
Investigations started	20	12	18	14	14
Investigations completed	10	16	22	15	25
Average duration of completed investigations (number of days)	843	708	755	894	618
Recommendations	8	4	5	4	3
Safety advisories	4	7	6	7	6
Safety information letters	2	8	9	11	10
Note: Results can fluctuate significantly from year to year due to a number of factors such as staff turnover, the complexity of investigations and the investigation of major occurrences.

2.7.3 Link to Resources Utilized

Table 14 provides a picture of the net cost to Canadians of rail investigations. The average cost per investigation completed has dropped considerably compared to the previous year, due primarily to the higher output produced with only a marginal increase in resources. The number of investigations started per investigator has remained relatively stable, whereas the number of investigations completed per investigator has increased significantly compared to 2003-2004.

Table 14: Rail Resources
	2003-2004		2004-2005
	FTE	$000	FTE	$000
Actual costs - Rail Branch	21	2,402	22	2,595
Internal professional and communication services costs	16	1,719	16	1,823
Corporate Services costs	10	1,105	11	1,147
Contributions to employee benefit plans		643		701
Services received without charge		568		652
Net cost of Rail investigations	47	6,437	49	6,918


Indicators	2003-2004	2004-2005
Number of Rail investigators	18	19
Average net cost per investigation completed	$429,133	$276,720
Investigations started per investigator	0.78	0.74
Investigations completed per investigator	0.83	1.32

2.7.4 Safety Actions Taken

The TSB issued three rail safety recommendations in 2004-2005. In all three cases, satisfactory intent or fully satisfactory responses have already been received from stakeholders (see section 2.7.4.1 for details).

The TSB has also completed an assessment of responses to rail recommendations issued in 2003-2004. The results of these assessments are contained in Appendix A.

2.7.4.1 Rail Recommendations Issued in 2004-2005

Napodogan Subdivision, New Brunswick - 6 October 2001 Crossing Accident - Canadian National		Report No. R01M0061
RECOMMENDATION	RESPONSE	BOARD ASSESSMENT OF RESPONSE	SAFETY ACTION TAKEN

R04-01
Transport Canada encourage the railway companies to implement technologies and/or methods of train control to assure that in-train forces generated during emergency braking are consistent with safe train operation.	TC accepted the Board's recommendation. TC encouraged the railways to implement new technologies that contribute to safer train operations.	Fully satisfactory	The railway industry is equipping fleets of locomotives and tail-end devices with the new technology.

Rivers Subdivision, Firdale, Manitoba - 2 May 2002 Crossing Accident and Derailment - Canadian National		Report No. R02W0063
RECOMMENDATION	RESPONSE	BOARD ASSESSMENT OF RESPONSE	SAFETY ACTION TAKEN

R04-02
The Department of Transport, in consultation with the provinces and the trucking industry, review and update, as necessary, educational and training material for drivers with respect to the risks associated with a heavy vehicle negotiating a public passive railway crossing.	TC agrees with the Board and raised the need to review this material with the Canadian Council of Motor Transport Administrators Standing Committee on Drivers and Vehicles. Reaction from the provinces has not yet come to fruition.	Satisfactory intent	TC, with the Railway Association of Canada, produced and distributed safety material, including videos, instructors' guides and safety quizzes, concerning safety at crossings for truck, bus and emergency drivers.

R04-03
The Department of Transport, in consultation with other federal, provincial and municipal agencies, implement consistent training requirements that ensure emergency first responders remain competent to respond to rail accidents involving dangerous goods.	TC shares the TSB's concern for the safety of emergency responders. TC sent a letter attaching the TSB report to provincial and territorial representatives requesting review and consideration.	Fully satisfactory	TC has made progress on the issue with the responsible change agents. TC has already started receiving positive feedback to the letter.

2.7.4.2 Other Rail Safety Actions Taken

Subsequent to the derailment of a passenger train due to a broken rail, the TSB issued Rail Safety Advisory 02/04 to the regulator and the industry. The Advisory raised a concern over the use of vintage open hearth rail on main track where passenger trains operate and dangerous goods are carried. Open hearth process has a known propensity to form transverse defects in rail because of impurity inclusions in the steel. The Goderich-Exeter Railway Company advised Transport Canada that it had removed all open hearth rail from the jointed rail portion of the Guelph Subdivision.

Canadian Pacific Railway (CPR) modified its General Operating Instructions in an effort to improve situational awareness for locomotive engineers regarding hot box detectors (HBDs). Section 5, Item 21.2 requires the engineer to set the locomotive distance measuring device as soon as the train reaches the HBD location, and for the crew to verbally confirm with one another any HBD announcements received.

CPR, jointly with Canadian National (CN), has installed a track-side acoustic detector system on CN's Yale Subdivision (directional running zone). This device, the only one its kind in Canada, is being tested to determine whether this technology can identify defective bearings on a predictive basis before they fail or overheat.

CPR has updated its computer system to provide the correct axle count information for Meyler cars in Expressway service.

CPR implemented a bearing temperature trending process on its coal loop in British Columbia. By connecting the HBDs to a central system, CPR performs trending analysis to proactively set out cars with suspect bearings. CPR is reviewing the option of extending this bearing trending process to other locations.

As a result of the potential failure to protect or repair improperly identified track geometry defects, Transport Canada issued a Notice pursuant to section 31 of the Railway Safety Act. CN responded that the previously incorrectly identified defects had been protected or corrected, and that the company had initiated the following additional actions:

All defect settings on the test car were audited to ensure compliance with Railway Track Safety Rules standards.

A daily procedure was developed and implemented that requires test car operators to review and validate defect parameter settings and track class before testing operations.

Since the derailment, two additional test car runs were scheduled over the Bala Subdivision. All defects identified during these tests were properly protected and corrected.

Two additional inspections using contracted track geometry vehicles with gauge restraint technology were scheduled on the Bala Subdivision.

A derailment occurred (TSB Report No. R03Q0022) when the car body on the E platform of loaded container car CN 677048 collapsed onto the main track due to fatigue at a high-stress location where a missing weld had gone undetected during inspection and repair practices. The TSB sent Rail Safety Advisory 03/03, Inspection of CN 677 series Doublestack Intermodal Rail Cars, to Transport Canada. CN issued instructions to all its field inspection forces to visually inspect all cars in the CN 677 series.

Subsequent to a derailment (TSB Report No. R03D0042) of a freight train proceeding at 26 mph in a 10 mph zone, the St. Lawrence & Atlantic Railroad reduced train speeds to 10 mph in all urban areas it serves. The frequency of ongoing inspections by the internal rail defect detection cars and of track geometry testing has been increased to twice annually. Transport Canada conducted an audit of methods and evaluated the track condition in the Sherbrooke Subdivision. TC also conducted train speed checks using radar in areas where speed limits are in effect.

Subsequent to TSB Occurrence No. R03T0080, CPR modified the software on all wayside detectors such that, while passing the detector, the alarm tone is immediately followed by a radio announcement identifying the nature of the defect (e.g. dragging equipment, hot box or hot wheel). CPR's General Operating Instructions involving train inspections and hot box detectors have been revised.

CPR completed a tie replacement program on the Belleville Subdivision.

2.8 Air Sector

2.8.1 Annual Statistics

Canadian-registered aircraft, other than ultralights, were involved in 252 reported accidents in 2004, a 15% decrease from the 2003 figure of 295 and a 17% decrease from the 1999-2003 average of 305. The estimate of 2004 flying activity is 3,809,000 hours, yielding an accident rate of 6.6 accidents per 100,000 flying hours, down from the 2003 rate of 7.8 and the five-year rate of 7.9. Canadian-registered aircraft, other than ultralights, were involved in 24 fatal occurrences with 37 fatalities in 2004, fewer than the five-year average of 33 fatal occurrences with 60 fatalities. More than half of the fatal occurrences involved privately operated aircraft, and 4 of the remaining 9 fatal occurrences involved helicopters.

The number of accidents involving ultralights decreased to 36 in 2004 from 46 in 2003, and the number of fatal accidents decreased slightly to 6 in 2004 from 7 in 2003.

The number of foreign-registered aircraft involved in accidents in Canada decreased to 20 in 2004 from 30 in 2003. Fatal accidents also decreased to 3 with 10 fatalities in 2004 from 6 with 8 fatalities in 2003.

In 2004, a total of 907 incidents were reported in accordance with TSB mandatory reporting requirements. This represents a 9% increase from the 2003 total of 834 and a 14% increase from the 1999-2003 average of 795.

Figure 9.

Air Occurrences and Fatalities[D]f9

One indicator of air transportation safety in Canada is the accident rate for Canadian-registered aircraft. This rate has decreased from 7.5 accidents per 100,000 hours in 2003 to 6.5 in 2004. A similar decrease is also observed compared to the five-year average. The overall general trend line also indicates a clear downward direction over the past 10 years.

Figure 10.

Canadian-Registered Aircraft Accident Rates[D]f10

2.8.2 Investigations

A total of 44 new air investigations were started in 2004-2005 and 67 investigations were completed. This represents a significant increase in the number of investigations completed compared to the previous year, and an all-time low with respect to new investigations started. The increase in investigations completed is directly linked to the allocation of incremental resources to help address the backlog of work in progress. The average duration of completed investigations has increased to 524 days, compared to 485 the year before. This is attributable to the concentrated efforts made to complete older cases. A complete list of all air investigations started and all air reports released in 2004-2005 is available on the TSB website.

Table 15: Air Productivity
	2000- 2001	2001- 2002	2002- 2003	2003- 2004	2004- 2005
Investigations started	69	65	56	47	44
Investigations completed	49	74	70	40	67
Average duration of completed investigations (number of days)	522	505	494	485	524
Recommendations	12	7	17	0	4
Safety advisories	11	14	13	9	9
Safety information letters	9	8	6	8	6
Note: Results can fluctuate significantly from year to year due to a number of factors such as staff turnover, the complexity of investigations and the investigation of major occurrences.

This year, the TSB undertook a major investigation into the crash of an MK Airlines Boeing 747-244BC during takeoff from Runway 24 at Halifax, Nova Scotia. Considerable resources were required for this investigation, and the TSB sought incremental funding from Parliament through Supplementary Estimates. To date, more than $700,000 has been spent on this investigation. The initial phase of the investigation raised a concern about the accuracy of published runway slope information. The aerodrome information for Halifax was reviewed as part of the accident investigation, and it was discovered that the slope information for Runway 24 published in Canadian flight information publications is incorrect. Transport Canada subsequently issued a Notice of Proposed Amendment to the Canadian Aviation Regulation Advisory Council to strengthen and streamline the aerodrome data verification process as a result of advice contained in TSB Safety Advisory A040059.

2.8.3 Link to Resources Utilized

Table 16 provides a picture of the net cost to Canadians of air investigations. The average cost per investigation completed has dropped considerably compared to the previous year, due primarily to the higher output produced with virtually the same resource level. The number of investigations started per investigator has also dropped slightly, whereas the number of investigations completed per investigator has increased significantly compared to 2003-2004.

Table 16: Air Resources
	2003-2004		2004-2005
	FTE	$000	FTE	$000
Actual costs - Air Branch	57	7,612	59	7,567
Internal professional and communication services costs	45	5,448	42	5,316
Corporate Services costs	27	3,501	30	3,345
Contributions to employee benefit plans		2,037		2,043
Services received without charge		1,801		1,902
Net cost of Air investigations	129	20,399	131	20,173


Indicators	2003-2004	2004-2005
Number of Air investigators	53	54
Average net cost per investigation completed	$509,975	$301,090
Investigations started per investigator	0.89	0.81
Investigations completed per investigator	0.75	1.24

2.8.4 Safety Actions Taken

Four new air safety recommendations were issued in 2004-2005. To date, safety actions have been undertaken on two of these recommendations and responses are pending on the other two.

2.8.4.1 Air Recommendations Issued in 2004-2005

Pelee Island, Ontario - 17 January 2004 Collision with terrain, Georgian Express		Occurrence No. A04H0001
RECOMMENDATION	RESPONSE	BOARD ASSESSMENT OF RESPONSE	SAFETY ACTION TAKEN

A04-01
The Department of Transport require that actual passenger weights be used for aircraft involved in commercial or air taxi operations with a capacity of nine passengers or fewer.	TC's response stated that current regulations make it clear that air operators are to ensure that their aircraft are flown within the limits of the weight and balance envelope and that the standards provide options that may be used but do not override the regulatory requirement to remain within the weight limits of the aircraft. TC continues to review the standards. One option that is under consideration is the use of actual weights for all operations conducted under subpart 3 (Air Taxi Operations) of Part VII (Commercial Air Services) in the Canadian Air Regulations. Once our review, including a risk assessment, is complete, a Notice of Proposed Amendments (if required) will be developed and submitted to the Canadian Aviation Regulation Advisory Council for consultation.	Satisfactory intent	None

A04-02
The Department of Transport re-evaluate the standard weights for passengers and carry-on baggage and adjust them for all aircraft to reflect the current realities.	TC re-evaluated the standard weights for passengers and carry-on baggage and adjusted them for all aircraft to reflect the current realities. A Commercial & Business Aviation Advisory Circular (CBAAC 0235) and Policy Letter were issued in October 2004 and the Aeronautical Information Publication (A.I.P. Canada) published weights will be amended on 20 January 2005. Operators whose approved weight and balance control program is based on the AIP weights will need to amend their programs to reflect these new weights.	Fully satisfactory	A Commercial & Business Aviation Advisory Circular (CBAAC 0235) and Policy Letter were issued in October, and the AIP Canada published weights were amended on 20 January 2005.

Timmins, Ontario 40 nm W - 20 October 2002 Engine Power Loss in Flight - Cathay Pacific Airways Airbus A340-300		Report No. A02P0261
RECOMMENDATION	RESPONSE	BOARD ASSESSMENT OF RESPONSE	SAFETY ACTION TAKEN

A04-03
The Direction Générale de l'Aviation Civile (DGAC) and the Federal Aviation Administration (FAA) issue airworthiness directives to require the implementation of all CFM56-5 series jet engine service bulletins whose purpose is to incorporate software updates designed to ensure that, in the event of a permanent magnet alternator failure, the electronic control unit will revert to aircraft power.	In a letter received on 2 March 2005, the Federal Aviation Administration aknowledged receipt of the recommendation and advised that it had been forwarded to the appropriate office for staffing. The letter advised that the TSB would be informed of the resolution of the TSB recommendation. The Direction Générale de l'Aviation Civile has not yet responded.	Pending

A04-04
The Department of Transport ensure the continued airworthiness of Canadian-registered aircraft fitted with the CFM56-5 series engine by developing an appropriate safety assurance strategy to make certain that, in the event of a permanent magnet alternator failure, the electronic control unit will revert to aircraft power.	TC's response stated that it confirmed, through communication with the Canadian aviation industry, that all Canadian aircraft presently affected by CFM Service Bulletin 73-0126 will have their ECU software upgraded to version C.3.J by March 2005. Therefore, TC is not planning on taking any further action.	Pending

2.8.4.2 Other Air Safety Actions Taken

Calgary Airport Authority has responded to Safety Information Letter A040061-1 by requesting that NAV CANADA file a Notice to Airmen outlining revised Landing Distances Available for Land and Hold Short Operations. The Canada Flight Supplement and the Canada Air Pilot documents will follow at the next amendment cycle.

Transport Canada published an article in their Aviation Safety Letter, Issue 1/2005, highlighting the details of an occurrence reported to them concerning the throttle arrangement of Beech 90s.

Transport Canada included an article in the Aviation Safety Maintainer on the topic of scheduled lubrication intervals after being advised by the TSB of an occurrence involving a Beech 1900D.

Transport Canada took action to advise the Type Certificate Holder for the Piper PA-18-150 that certain weight and balance information available to Piper PA-18 owners and operators in Canada may be in error.

Transport Canada issued a Notice of Proposed Amendment to the Canadian Aviation Regulation Advisory Council to strengthen and streamline the aerodrome data verification process as a result of advice from the TSB in Safety Advisory A040059 concerning information discovered during the investigation into the MK 747 accident in Halifax.

Air Canada initiated an internal awareness campaign concerning visual approach guidance and published a description of the TSB investigation into an approach to the wrong airport. Enhancements were made to the Flight Operations Manual with respect to visual approach guidance.

The RCMP Air Services made arrangements for all pilots who did not have a current proficiency check ride to have one done. The operations manual has been amended to reflect a requirement for their helicopter pilots to have a proficiency check ride every two years and a route check on alternate years.

The Transport Canada Civil Aviation Medicine Branch has initiated a project with the TSB to re-examine accidents involving known or suspected cardiac incapacitation during the past 10 years. Following this review, more frequent or extensive testing may be proposed.

Robinson Helicopter Company issued an updated service bulletin (SB-78A) that included background information regarding a recent accident and the risk of excessive teetering of the main rotor, should the brackets fail. That service bulletin requested that owners, operators and service centres determine if SB-78A was complied with and, if not, to proceed with the instructions for SB-78A. The U.S. Federal Aviation Administration plans to issue a Notice of Proposed Rulemaking Airworthiness Directive to mandate the installation of the manufacturer's higher-strength teeter stop brackets.

NAV CANADA increased the ability of Calgary Tower and Edmonton Flight Information Centre personnel to search computer records for positive information on aircraft arrival and departure, with options for search by registration or time frame. In addition, the Edmonton Area Control Centre shift managers and the Edmonton air traffic operations specialist now have access to the same computer records for search capabilities. A similar system is being beta-tested in two centres and will be considered for national deployment.

As a result of a loss of separation occurrence, NAV CANADA has added one controller on the day shift to avoid the situation in which one controller works more than one data board. Toronto Area Control Centre and Cleveland Air Route Traffic Control Center held discussions that resulted in the staffing of additional full-time day and evening data controllers in both units to manually pass hand-off data.

As a result of a water bombing occurrence, and commencing with its 2004 annual pilot training course, Air Spray Ltd. has placed additional emphasis on human factors and emergency manoeuvring in mountainous areas. Particular attention has been given to the deceptive nature of mountainous terrain at high sun angles, and the deceptive illusionary nature of mountain flying continues to be stressed in its training programs.

Following a low fuel situation over the Pacific Ocean, Kelowna Flightcraft Air Charter Ltd. has purchased up-to-date North American data cards from Garmin for all Apollo 820 GPSs installed in its Convair 580 aircraft.

Following a collision with terrain occurrence, Transport Canada produced a Service Difficulty Alert (AL-2003-07, dated 2003-07-17) indicating that the installation procedures for the horizontal stabilizer actuator in the King Air maintenance manual are being reassessed.

As a result of an in-flight fire and precautionary landing, Boeing has undertaken a program to redesign the window terminal block to eliminate the screw connection. All Boeing 747, 757, 767 and 777 windows delivered thereafter, either on new aircraft or as spares, will have the new terminals installed. The intent is to eliminate concerns with arcing at the window power terminals.

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Updated: 2005-11-01		Important Notices