TSB deploys an investigator following a fatal accident involving an amateur-built aircraft near Onistagane Lake, Quebec

DORVAL, QC, le 30 Sept. 2022 /CNW/ – The Transportation Safety Board of Canada (TSB) is deploying an investigator following the 23 September 2022 fatal accident involving a Wag-Aero Sportsman amateur built aircraft that took place 126nm North of Alma, Quebec, near Onistagane Lake, Quebec. The TSB is gathering information and assessing the occurrence.

The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

The TSB is online at www.tsb.gc.ca.

Aircraft configuration and illusions caused by steep terrain contributed to 2021 collision with terrain in New Brunswick

Dartmouth, Nova Scotia, 10 August 2022 — In its investigation report (A21A0024) released today, the Transportation Safety Board of Canada (TSB) found that the aircraft configuration and illusions caused by steep terrain contributed to the 2021 collision with terrain of an aerial firefighting aircraft in New Brunswick.

On 11 August 2021, the Air Tractor AT-802 aircraft operated by Forest Protection Limited as Tanker 624 was conducting forest firefighting operations out of Miramichi Airport, New Brunswick, with 1 crew member on board. Following an aborted drop of fire retardant on a forest fire, the aircraft impacted the hillside of a heavily wooded area of northern New Brunswick. The pilot sustained minor injuries. There was no post-impact fire; however, the aircraft was destroyed.

The investigation found that during the aborted drop, the power was increased to 58% of the available power, and the flaps were retracted from 30 degrees to 20 degrees. Due to the pilot’s high workload and divided attention, these settings went unnoticed. The selected power setting, combined with the flap setting, contributed to a reduced airspeed as the aircraft entered a slow climb to avoid rising terrain. As the aircraft approached the rising terrain, the low altitude and tailwind resulted in the pilot perceiving that the airspeed was sufficient, when, in fact, it was decreasing.

The acoustic structures of the stall and over-torque alarms are similar in that they are both continuous tones and do not present variation in rhythm or tempo. As the aircraft approached the stall, the stall warning horn sounded. Because the pilot perceived the aircraft’s speed to be sufficient, the pilot identified this audio tone to be the sound that warns of an over-torque condition, and as a result, he decreased power. As a result of the decreased power, the aircraft decelerated further, stalled and entered an incipient spin at an altitude too low to permit recovery.

The report also highlights the importance of recognizing hazards, such as illusions, involved with low-flying near steep or mountainous terrain. If pilots are not trained on these hazards, there is an increased risk of collision with terrain.

After the occurrence, Forest Protection Limited revised its Fire Suppression Manual, including procedures for an aborted drop. The company also amended its training to include annual mountain flying training and more frequent fire practice missions.

See the investigation page for more information.


The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

TSB – Flight by visual reference in instrument meteorological conditions resulted in a 2019 collision with terrain in Sachigo Lake, Ontario

Winnipeg, Manitoba, 4 August 2022 — The Transportation Safety Board of Canada (TSB) released its investigation report (A19C0145) into the December 2019 collision with terrain of a North Star Air Douglas DC3C Basler Turbo Conversions TP67 (DC3-TP67) aircraft near Sachigo Lake Airport, Ontario. The investigation found that a distorted perception of risk and a results-oriented subculture among some DC3-TP67 pilots within the company contributed to the accident. The report also mentions risk factors related to safety management and regulatory surveillance.

On 3 December 2019, the aircraft was scheduled to conduct a daytime visual flight rules (VFR) cargo flight from Red Lake Airport, Ontario, to Sachigo Lake Airport, Ontario. Weather reports obtained by the captain for the flight route were marginal for VFR, with reports of instrument meteorological conditions (IMC). Shortly after takeoff, the aircraft entered, and climbed above, the cloud layers before reaching the planned cruising altitude.

Before commencing the descent to Sachigo Lake Airport, the pilots obtained the latest weather report, and carried out a visual approach to the runway. A descent was initiated through the cloud layers by reference to the flight instruments. Once the aircraft broke out of cloud at very low level, the aircraft was not in a position to continue with the planned visual approach, yet several attempts were made to land. During the last attempt, the aircraft collided with terrain southwest of the runway and slid along the ground before coming to rest. The two crew members were uninjured, though the aircraft was substantially damaged.

The investigation found that the decision to depart on, and continue, a VFR flight in IMC was influenced by a distorted perception of risk resulting from successful past experience in similar situations. The results-oriented subculture of some of North Star Air’s DC3-TP67 pilots, which emphasize mission completion over regulatory compliance, resulted in VFR flights, such as the occurrence flight, being conducted in IMC.

The report includes findings related to safety management and regulatory surveillance, two issues on the TSB Watchlist 2020. North Star Air’s safety management system did not identify the underlying factors that led to the reported instances of company aircraft operating VFR flights into IMC, nor were any additional measures taken to monitor its DC3-TP67 operation to ensure flights were being conducted in accordance with regulations. As a result, previously identified unsafe practices persisted, and played a direct role in this occurrence.

In 2017, Transport Canada (TC) had provided information to the company of allegations regarding VFR flights in IMC for its internal investigation. A 2018 TC inspection of company operations did not include information about these allegations, about corrective action, or that the company investigation into these allegations was still open after almost two years. As seen in this occurrence, the unsafe practice of operating under VFR in IMC persisted unbeknownst to the regulator. If TC relies on operators to investigate allegations of regulatory non-compliance without monitoring them, there is an increased risk that the unsafe practices that are being investigated will persist.

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

See the investigation page for more information.


The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

TSB Investigation report: January 2022 loss of control and collision with terrain in Camrose, Alberta

Edmonton, Alberta, 3 August 2022 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A22W0005) into the 23 January 2022 loss of control and collision with terrain involving a Bell Textron Inc. 206B JetRanger II helicopter in Camrose, Alberta.

The TSB conducted a limited-scope, class 4 investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues. See the Policy on Occurrence Classification for more information.


The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

Severe turbulence led to helicopter collision with terrain on Bowen Island, British Columbia

Richmond, British Columbia, 28 July 2022 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A21P0018) into the Airspan Helicopters Ltd.’s Bell 212 loss of control and collision with terrain that occurred on Bowen Island, British Columbia (BC) in March 2021. The investigation found that environmental conditions and the helicopter’s system limitations led to the occurrence.

On 05 March 2021, the Bell 212 helicopter, with two pilots on board, was travelling from Sechelt, BC, to Cypress Provincial Park, BC. During the cruise portion of the flight, the helicopter entered wind shear and experienced a sudden loss of control. After the crew regained control of the helicopter, the number 2 engine experienced an uncommanded in-flight shutdown and the flight controls became very hard to manipulate. A location on nearby Bowen Island, BC, was selected for an emergency landing. During the descent, the helicopter began a rapid rotation to the right, which the pilots were unable to arrest. After several rotations, the helicopter collided with trees and came to rest on a rocky ridge on the northwest corner of Bowen Island. Both occupants received serious injuries. The helicopter was substantially damaged.

The investigation found that at the time of the occurrence, the environmental conditions were conducive to severe mechanical turbulence, lee waves, and low-level wind shear along the helicopter’s flight path in the vicinity of Bowen Island. The pilots were aware of the forecasted weather, low-level wind shear, and mechanical turbulence, but decided to continue with the day’s planned flights based on improving weather forecast later in the day, the desire to complete the operational flight, and the observation that other aircraft were operating around the Sechelt Aerodrome.

The helicopter entered an area of severe turbulence that led to a loss of control, that resulted in excessive flapping of the main rotor blades. As a result, the main rotor blades contacted and severed the tail rotor driveshaft, causing a loss of tail rotor thrust and yaw control. The helicopter’s extreme attitude during the initial loss of control likely caused the hydraulic system to malfunction, the number 2 engine to shut down in flight, and the number 1 engine to reduce fuel flow (resulting in less power), which subsequently reduced the main rotor speed. As the helicopter slowed for the emergency landing, yaw control was lost due to the absence of tail rotor thrust, and the helicopter collided with the terrain.

Following the occurrence, Airspan Helicopters Ltd. temporarily suspended all operations, completed an internal safety investigation, and took several actions to mitigate future occurrences.

For additional information, please see the investigation report.


The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

TSB reassessment of outstanding safety recommendations: slow progress, continued action needed

Gatineau, Quebec, 27 June 2022 — Today, the Transportation Safety Board of Canada (TSB) released its annual reassessment of responses to 53 of its outstanding safety recommendations in the air, marine, and rail transportation sectors. There are currently no outstanding recommendations in the pipeline transportation sector.

These reassessments show some progress across Canada’s transportation system with responses to two recommendations receiving the highest rating of Fully Satisfactory: one in the air transportation sector and the other in the marine transportation sector. However, there has been minimal movement on some key safety issues across all three sectors, which continues to raise concerns from the Board.

The TSB issues safety recommendations as a call to industry and regulators to address systemic problems that pose a serious safety risk to Canada’s transportation system. Each year, the TSB reassesses outstanding recommendations as part of its ongoing efforts to urge the regulators or industry to act on the safety issues identified in investigations.

This brings the total of TSB recommendations assessed as Fully Satisfactory to 84.1%, a slight decrease of 0.4% over 2021 (84.5%). As of March 31, 2022, 84 recommendations still remain outstanding, roughly half of which date back almost 10 years.

Air transportation sector

In the air transportation sector, the Board closed two recommendations among the 26 reassessed. Recommendation A19-01 was closed as Fully Satisfactory following Transport Canada’s amendments to the Canadian Aviation Regulations (CARs) to eliminate the ambiguity associated with the use of safety belts on board aircraft. Recommendation A18-06 was closed after receiving a rating of Unsatisfactory, with no further actions planned by the United States Federal Aviation Administration.

Two recommendations issued to Transport Canada in 2018, during an investigation into a loss of control and collision with terrain of a West Wind Aviation ATR 42-320 in Fond-du-Lac, Manitoba (A17C0146), were assessed by the Board this year. Both received a rating of Satisfactory Intent (A18-02 and A18-03), as a result of progress being made to ensure locations with inadequate de-icing and anti-icing equipment are being identified and action is being taken to ensure that the proper equipment is available, and to increase compliance with relevant sections of the CARs and reduce the likelihood of aircraft taking off with contaminated critical surfaces.

Marine transportation sector

In Canada’s marine transportation sector, 18 marine recommendations were reassessed, Recommendation M94-06 was closed as Fully Satisfactory. The Large Fishing Vessel Inspection Regulations now require that large fishing vessels be fitted with water level detectors in all watertight compartments below the waterline that are not intended to carry liquids. The changes contained in these new regulations are expected to mitigate the risk associated with this safety deficiency.

However, in response to Recommendation M16-03 which calls for stability assessments for small fishing vessels, Transport Canada will not be taking further regulatory action. The department has indicated that the inspection of fishing vessels below 15 gross tonnage is risk-based, in order to focus on areas of higher risk. Transport Canada noted that regulatory compliance is the responsibility of the vessel’s authorized representative, and that authorized representatives should be aware of regulations and safety publications.

The Board is concerned about Transport Canada’s proposed approach to addressing the underlying safety deficiencies associated with M16-03 and, in general, the verification of compliance with regulatory requirements within the fishing industry. As TSB statistics have demonstrated, fish harvesting continues to be a hazardous occupation, and the fishing industry continues to represent a high-risk sector in the transportation system. As in previous years, the majority of the fatalities (8 of the 11) were related to commercial fishing (Canadian-flag vessels in Canadian waters). Commercial Fishing Safety has been an issue on the TSB Watchlist since its inception in 2010.

Rail transportation sector

As for the rail transportation sector, none of the nine responses to rail transportation safety recommendations the Board reassessed in 2021–22 were closed as Fully Satisfactory. The nine responses obtained Satisfactory Intent (4) and Satisfactory in Part (5).

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

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

Regarding Recommendation R13-01 on physical fail-safe train controls, the Board considers the responses from the Railway Association of Canada and Transport Canada to be Satisfactory in Part and strongly encourages both organizations to accelerate the pace of enhanced train control implementation.


The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

Transportation Safety Board of Canada releases 2021 transportation occurrence statistics

Gatineau, Quebec, 17 June 2022 — Building on the preliminary statistics published in February 2022, the Transportation Safety Board of Canada (TSB) today released its 2021 final annual statistical summaries on transportation occurrences in the airmarinepipeline, and rail transportation sectors.

2021 Transportation accidents reported to the TSB
Figure 1. 2021 Transportation accidents reported to the TSB

Air transportation sector

Air transportation in Canada continued to be affected by the pandemic during the first half of 2021. During the second half of the year, as vaccination rates increased and travel restrictions began to ease in both Canada and abroad, total aircraft movements resumed to 73.2% of pre-pandemic levels. Overall, aircraft movements at the 90 airports serviced by NAV CANADA reached 4.29 million in 2021, up 11.8% from 3.84 million in 2020. The above figure is indicative of a partial recovery of activity in the commercial sectors responsible for air travel, air cargo, aerial work, and flight training. The numbers presented above also include recreational aviation activity at major airports.

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

The TSB recorded 22 fatal air transportation accidents resulting in 32 fatalities in 2021. This in a considerable increase over the 12 fatal accidents and 16 fatalities in 2020, but is still 21% below the annual average of 27.7 fatal accidents and 31% below the annual average of 47 fatalities over the 10 years from 2011 to 2020.

Marine transportation sector

In 2021, 220 marine accidents (accidents resulting directly from the operation of a ship other than a pleasure craft) were reported to the TSB, a decrease from the 2020 total of 264 and below the 10-year (2011–2020) average of 284. In 2021 the proportion of shipping accidents (as opposed to accidents aboard ship) was 80% of marine accidents, comparable to the previous 10-year average of 82%.

In 2021, 11 marine fatalities were reported, down from the 18 fatalities reported in 2020, and below the annual average of 15.6 in the 2011–2020 time period. Of the 11 fatalities in 2021, nine were the result of four shipping accidents, while the remaining two fatalities resulted from accidents aboard ship.

Of note, six of the nine shipping accident fatalities in 2021 involved commercial fishing vessels, and both of the fatalities that ensued from accidents aboard ship occurred aboard commercial fishing vessels. These data indicate that more still needs to be done to improve safety in the commercial fishing industry, an outstanding issue on the TSB Watchlist.

Pipeline transportation sector

In 2021, 115 pipeline transportation occurrences were reported to the TSB, an increase from the 2020 total of 81, but similar to the average number of occurrences for the previous 10 years (117 occurrences). Among all occurrences in 2021, two were accidents. These were the first accidents since 2018 and are less than the previous 10-year (2011 to 2020) average of three accidents per year. Of the 115 occurrences in 2021, 23 involved a release of product, lower than the average of 77 per year over the previous 10 years.

There were no serious injuries or fatalities arising directly from the operation of a federally regulated pipeline in 2021. Indeed, there have been no fatal accidents on a federally regulated pipeline system directly resulting from the operation of a pipeline since the inception of the TSB in 1990.

Rail transportation sector

In 2021, 1038 rail accidents were reported to the TSB, an increase from the 2020 total of 988, but a 3% decrease from the previous 10-year (2011–2020) average of 1071. Of 1038 reported accidents in 2021, 189 (18%) involved fires on railway right-of-way or on rolling stock, which is an increase from 79 such events in 2020 and an average of 40 per year from 2011 to 2020.

Freight trains accounted for 38% of all trains involved in rail accidents in 2021. Four percent (42 in total) were passenger trains, with the remaining 58% comprising mainly single cars/cuts of cars, locomotives, and track units.

Rail fatalities totaled 60 in 2021, unchanged from 2020 but below the previous 10-year average of 71.

In 2021, 86 accidents involved dangerous goods, up from 82 in 2020 but below the 10-year average of 125. Two accidents resulted in a dangerous goods release in 2021, compared with three in 2020, and the 10-year average of four.


The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

Inaccurate transponder information identified as a factor in March 2020 runway incursion and risk of collision at Toronto/Lester B. Pearson International Airport

Richmond Hill, Ontario, 14 June 2022 — The Transportation Safety Board of Canada (TSB) today released its investigation report (A20O0029) into the March 2020 runway incursion and risk of collision between two aircraft at the Toronto/Lester B. Pearson International Airport, Ontario. There were no injuries.

Figure 1. Screen shot of the display monitor at the controller working position showing information from the advanced surface movement guidance and control system (Source: NAV CANADA, with TSB annotations)
Figure 2. Screen shot magnification, taken at 0948:27, showing the track labels of a de Havilland DHC-8 (JZA28) travelling at 7 knots (007), the Boeing 777 (ACA606) travelling at 10 knots (010), and the Embraer 190 (ACA1037) travelling at 37 knots (037) (Source: NAV CANADA)

On 07 March 2020, at 0948 local time, an Air Canada Embraer 190 was conducting a takeoff from Runway 06L at Toronto/Lester B. Pearson International Airport, Ontario. Shortly after the Embraer 190 had begun its take-off roll, an Air Canada Boeing 777 was instructed to line up on Runway 06L. As the Embraer 190 was accelerating on its take-off roll, it struck a bird. The flight crew initiated a rejected takeoff and made a radio call to report that they were rejecting the takeoff. Neither air traffic control nor the Boeing 777 flight crew heard this radio call because the Boeing 777 flight crew was reading back their take-off clearance on the same frequency. As the Boeing 777 was accelerating on its take-off roll, the flight crew observed that the Embraer 190 was still on the runway and initiated a rejected takeoff. Both aircraft eventually exited the runway and returned to the terminal. There were no injuries nor damage to either aircraft.

Figure 3. Screen shot magnification, taken at 0948:30, showing the change in status of the Embraer 190 (ACA1037) to in air at an altitude of 500 feet ASL (A005) and travelling at 50 knots (050) and the Boeing 777 (ACA606) travelling at 9 knots (009) (Source: NAV CANADA)

The investigation found that the Embraer 190’s transponder transmitted that the aircraft was in air after the aircraft accelerated past 50 knots. As a result, although compliant with current standards, an inaccurate in-air status was transmitted while the aircraft remained on the ground during its take-off roll and rejected takeoff. The use of this data by NAV CANADA’s runway incursion monitoring and conflict alert sub-system (RIMCAS) led to the inaccurate identification of the Embraer 190 and the Boeing 777 as in air while these two aircraft were still on the ground. This resulted in late and inaccurate RIMCAS alerts and delayed the air traffic controller’s response to the risk of collision. The risk was mitigated once the Boeing 777 flight crew rejected their takeoff after recognizing that the Embraer 190 was still on the runway ahead of them.

The risk of collisions from runway incursions has been on the TSB Watchlist since its inception in 2010 and calls for effective defences tailored to address identified hazards at airports and in aircraft, vehicles, and air traffic service facilities across Canada.

Following the occurrence, 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 systems to ensure maximum safety benefit.

As a result, NAV CANADA published Urgent ATCI – ATC Information Bulletin 2020-003 for all Toronto Tower personnel. The bulletin cautioned controllers that RIMCAS Stage 1 and Stage 2 alerts may not be generated when certain aircraft are departing, and reminded controllers to monitor these situations closely.

See the investigation page for more information.


The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability

Pilot decision making, deteriorating weather and spatial disorientation led to the January 2021 fatal helicopter accident near Grande Prairie, Alberta

Edmonton, Alberta, 11 May 2022 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A21W0001) into the fatal January 2021 accident involving a privately registered Robinson R44 Raven II helicopter 39 nautical miles northeast of Grande Prairie, Alberta. The investigation found that the decision to depart into weather below night visual flight rules (VFR) limits, deteriorating weather, and spatial disorientation led to the accident.

On 01 January 2021, the privately registered Robinson Helicopter Company R44 Raven II helicopter departed a farm near Eaglesham, Alberta, on a night VFR flight to DeBolt, Alberta, with a pilot and three passengers on board. During the flight, control of the helicopter was lost and it collided with terrain. The four occupants were fatally injured. The helicopter was destroyed and there was a post-impact fire. An emergency locator transmitter signal was received by the search and rescue satellite system.

The investigation found that an inaccurate assessment of the enroute weather led to the pilot’s decision to depart when the weather conditions for the intended flight were below the limits required for a night VFR flight. It is likely that, shortly after departure, the pilot encountered deteriorating weather and poor visibility. As a result of the limited external visual cues, the pilot became spatially disoriented and lost control of the helicopter shortly before the collision with the ground.

Thorough flight planning allows for informed decisions on the ground to avoid the need for potentially more difficult in-flight decisions. If pilots do not access all available weather information, such as weather briefings from NAV CANADA flight service specialists, there is an increased risk that they will fly into hazardous weather conditions.

Since 2013, the TSB has investigated seven other fatal accidents involving private aircraft on night VFR flights, each time highlighting the lack of clarity in the regulations regarding visual references. In 2016, the Board issued a recommendation (A16-08) for Transport Canada to clearly define the visual references required to reduce the risks associated with night VFR flights. If the Canadian Aviation Regulations do not clearly define what is meant by “visual reference to the surface,” night VFR flights may be conducted with inadequate visual references, which increases the risk of an accident as a result of controlled-flight-into-terrain and loss-of-control accidents.

See the investigation page for more information.


The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.