Today, the Transportation Safety Board of Canada (TSB) released the latest Watchlist, highlighting seven systemic safety issues and one emerging safety issue that continue to put people, property, and the environment at risk across Canada’s air, marine, and rail sectors.
“These are complex and long-standing issues, but they are not unsolvable,” said Yoan Marier, Chair of the TSB. “Real progress requires leadership, accountability, concerted efforts, and sustained action by both industry and regulators.”
Since 2010, the Watchlist has focused national attention on safety issues backed by years of investigation work, compelling data, and TSB recommendations. Despite progress in some areas, serious, and often preventable, occurrences continue to happen.
Watchlist safety issues
Commercial fishing safety: Despite years of attention, unsafe conditions continue to put thousands of Canadian commercial fish harvesters—and the communities that rely on them—at risk. The TSB has issued 55 recommendations on fishing vessel safety; however, progress remains inconsistent across regions and even among fishing communities.
Runway overruns: On average, nine overruns occur each year at Canadian aerodromes. While Transport Canada updated runway-end safety area regulations in 2022, they fall short of international standards. The TSB remains concerned that current mitigations to prevent overruns and reduce damage when they occur are insufficient.
Risk of collisions from runway incursions: Despite new procedures and technologies, runway incursions have risen from 539 in 2018 to 639 in 2024, the largest number on record in 15 years. While the numbers of high-risk incursions are low, the consequences of a collision can be catastrophic.
Not following signal indications: Train crews don’t consistently recognize and follow signal indications. In the absence of mandated physical fail-safe defences that can intervene to slow or stop a train, missed signals continue to create a risk of collisions and derailments. Between 2019 and mid-2025, there were 303 missed-signal occurrences.
Fatigue management: Fatigue continues to affect human performance in air, marine, and rail transportation. Work and rest rules alone are insufficient without effective fatigue management plans, awareness training, and supportive reporting cultures.
Safety management: Many operators are still not required to have formal safety management processes, and where systems exist, effectiveness is not always demonstrated, leaving hazards unidentified and mitigations unvalidated.
Regulatory surveillance: Transport Canada’s surveillance has not always been effective in detecting non-compliance or ensuring timely corrective action. Sustained, risk-based oversight and consistent enforcement are required across the board.
What’s changed
Substance use – this item has been added as an emerging safety issue. Investigations and consultations indicate growing safety risks linked to drug and alcohol impairment in the marine and rail sectors. Inconsistent testing and the absence of reliable data suggest the issue is more widespread than reported and requires close attention.
Unplanned/uncontrolled rail movements – this item has been removed. TC and the rail industry have taken meaningful steps leading to a reduction in these occurrences. Two related TSB recommendations (R20-01, R22-01) were recently closed as Fully Satisfactory. Based on these positive developments, the issue has been removed from the Watchlist.
Going forward, the Watchlist will be kept up-to-date on a continuous basis, allowing the TSB to add new issues as they emerge and remove issues as soon as they are considered mitigated.
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.
Today, the Transportation Safety Board of Canada (TSB) released its final annual statistical summaries for 2024 on transportation occurrences across the air, marine, pipeline, and rail sectors. Tracking occurrence statistics is critical for the TSB to identify trends and emerging safety risks within the different sectors.
In2024, a total of 3,222 occurrences (accidents and incidents) were reported to the TSB. Of these, there were 1,303 accidents, which represents a decrease of 3% from 2023 and 14% compared to the 10-year average of 1507. Compared to the previous year, the number of accidents declined in the marine and rail sectors, while the air sector saw a slight increase.
Air transportation
In2024, the TSB received 1,010 reports of air occurrences (accidents and incidents), a 1% decrease from 1,020 in2023. Of these, 193were accidents – up 7% from the 181 the previous year – resulting in 46fatalities.
Accidents involving commercial operators rose slightly from 76 to 78, while those involving private operations also increased from 103 to 114. The remaining 817reports were aviation incidents, down 2.6% from 839 in2023.
Marine transportation
In2024, the TSB received 951 reports of marine occurrences (accidents and incidents), down 7% from 1,027 in2023. Of these, 213 were accidents that resulted in a total of 12fatalities – a 33% drop from 18fatalities the previous year.
As seen in past years, most fatalities (10 of the 12) were linked to commercial fishing safety, which continues to be a key safety concern on the TSB’s Watchlist. The remaining 738reported occurrences were marine incidents, also down 7% from the 797 in2023.
Pipeline transportation
In2024, a total of 63 pipeline occurrences were reported to the TSB – 62incidents and one accident – down from 68 in both 2022 and 2023 and well below the 10-year average of 94.5. Thirteen involved a product release, the lowest number ever reported, and a 24% drop from 2023. As in previous years, there were no serious injuries or fatalities arising directly from the operation of a federally regulated pipelines.
Rail transportation
In2024, the TSB received 1,198 reports of rail occurrences, a 3% decrease from 1,241 in 2023. Of these, 896 were accidents – down from 918 the previous year and 12% below the 10-year average.
A total of 87rail accidents involved dangerous goods, unchanged from 2023 and below the 10-year average of 115. Three resulted in a release of dangerous goods, down from seven in2023.
There were 69fatalities in2024, up from 67 last year and above the 10-year average of 62. Trespassing accidents remain the leading cause, accounting for 81% of all rail-related fatalities (56), followed by crossing fatalities (12).
Uncontrolled movements of rolling stock were involved in 43occurrences (31 accidents and 12 incidents), up from 37 in2023. Four of these were linked to vandalism, compared to three from the previous year.
The remaining 302reports were incidents, a 7% decrease from 323 in2023.
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.
Since the late evening of February 17, investigators from the Transportation Safety Board have been on-site at Toronto/Lester B. Pearson International Airport following the impact upon landing of an Endeavor Air CRJ-900 aircraft manufactured by Bombardier.
Since then, the TSB has been coordinating with officials from the U.S. National Transportation Safety Board, the Federal Aviation Administration, the manufacturer of the aircraft, the airline, and countless other organizations to find out what happened and why.
Much work has been conducted, and much work remains. The investigation is still in the field phase and investigators are working tirelessly to complete work at the site. Efforts have begun to remove the aircraft from the runway, and it will be moved to a hangar where it will undergo further examination. The site will be released following further examination and clean-up.
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 releases investigation report into 2022 runway overrun of Boeing 737 in Kitchener, Ontario
Richmond Hill, Ontario, —
The Transportation Safety Board of Canada (TSB) has released its investigation report (A22O0161) on the 2022 runway overrun of a Flair Airlines Boeing 737-800 at the Region of Waterloo International Airport in Ontario. There were no injuries.
The captain held both thrust levers at idle during the landing flare. After touchdown, the captain removed his hand from the left thrust lever to activate the right engine thrust reverser. With the aircraft still in go-around mode, the right engine was producing reverse thrust and the left engine began advancing towards maximum thrust, deactivating the automatic systems that help stop the aircraft and causing control difficulties. The captain managed to stay on the runway and used manual braking to slow down; however, there was insufficient runway remaining on which to stop, and the aircraft overran the runway by approximately 500 feet.
The investigation found that there were several factors which contributed to the inadvertent press of the TO/GA switch and the undetected flight mode change. These include pilot fatigue, the attention of both pilots focused outside the aircraft during the flare and landing, and that the aircraft systems did not provide visual and aural cues that were noticeable enough by the flight crew to indicate the inadvertent mode change during that phase of flight.
A defect with the aircraft’s left thrust reverser was first reported in May 2022, over six months before the occurrence, and 22 subsequent reports provided an opportunity to troubleshoot the problem. Despite this, the defect did not meet the regulatory definition of a recurring defect, thus, Flair’s maintenance control software did not identify it as such. If the underlying issue behind a persistent maintenance defect is not addressed in a timely manner, there is a risk that it may compound, resulting in a serious consequence.
Following the occurrence, Flair Airlines modified its operating procedures to better support the existing requirement to disengage both the autopilot and autothrottle at the same time.
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.
Dorval, Quebec, — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A21Q0131) into the 2021 lateral runway excursion involving a Beechcraft King Air B200 in Sanikiluaq, Nunavut.
On December 17, 2021, the aircraft, operated by Keewatin Air LP, was on a medical evacuation flight from Winnipeg, Manitoba to Sanikiluaq, Nunavut, with two flight crew members and two medical staff on board. During the landing, the aircraft started to drift to the left. The pilot attempted to keep it on a straight path but was unsuccessful. A go-around was initiated to take off again, but the aircraft ended up exiting the runway and coming to rest on the south side. The four occupants were able to exit safely; however, the aircraft was substantially damaged.
The investigation found that, in the absence of precise data on the aircraft’s performance limitations, the flight crew decided to proceed with an approach in strong crosswind conditions, relying on previous successful landings in similar conditions and a plan for a go-around if control issues arose. As the aircraft crossed the runway threshold, no deviations were observed, and the approach remained stable, so the crew chose to land. However, the strong crosswind and limited tire traction caused the aircraft to drift left. Despite the pilot-in-command’s attempt to execute a go-around, the aircraft exited the runway surface shortly after.
Additionally, two findings as to risk were identified during the investigation. If air operators have little information on runway conditions and associated aircraft performance, there is a risk that flights will be authorized in conditions beyond the aircraft’s landing performance capabilities. Furthermore, if an uncontrolled lateral drift of the aircraft occurs after landing and a go-around is initiated while the aircraft is in a low-energy state, there is a risk that if a runway excursion occurs, it will be exacerbated, or if the aircraft takes off in this state, that a loss of control or controlled flight into terrain will occur.
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.
Richmond, British Columbia, 22 July 2024 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A23P0091) into a 2023 collision with terrain involving a float-equipped De Havilland DHC-2 Mk. I (Beaver) aircraft, operated by Air Nootka Ltd., which occurred at Gold River Water Aerodrome, British Columbia.
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.
Gatineau, Quebec, 13 June 2024 — Building on the preliminary statistics published in February 2024, the Transportation Safety Board of Canada (TSB) released today its final annual statistical summaries from 2023 on transportation occurrences in the air, marine, pipeline, and rail transportation sectors.
Air transportation
In 2023, a total of 1020 air transportation occurrences (accidents and incidents) were reported to the TSB, an increase of 14% over the previous year (894).
Of these occurrences, a total of 182were accidents, a 10% increase from 2022 (166). Nineteen of these were fatal, resulting in 33 fatalities, which is down slightly from the 24 fatal accidents and 34 fatalities in 2022. Overall, the number of air transportation accidents has been decreasing in the last decade.
Accidents involving commercial operators increased 38% from 2022 (56) to 2023 (77), while those involving private operations decreased from 108 to 103.
Of the total occurrences, 838wereaviation incidents, which is an increase from the previous year (728).
Executive summary
The TSB received 1020 reports of air occurrences in 2023 (182 accidents and 838 incidents), including 33 fatalities.
A total of 182 accidents were reported in 2023. This number is 10% higher than the previous year and 17% below the yearly average of 220 accidents reported in the prior 10 years, 2013 to 2022. Most (169) of the accidents in 2023 took place in Canada and involved Canadian-registered aircraft. In general, the number of air transportation accidents has decreased in the last decade.
The TSB recorded 19 fatal air transportation accidents involving 33 fatalities in 2023. This is down slightly from 2022 and is 24% below the average of 25 fatal accidents involving 40 fatalities over the ten years 2013 to 2022. Thirteen of the 33 air transportation fatalities in 2023 involved commercial operations. There were no fatalities involving airliner operations (CARs 705), or commuter operations (CARs 704) in 2023. The remaining 20 (of 33) fatalities in 2023 were linked to privately registered aircraft and involved recreational operators. Two accidents in 2023 involved a release of dangerous goods.
The 2023 overall air transportation accident rate of 2.8 per 100 000 aircraft movements is among the lowest recorded by the TSB since it began measuring accident rate by movements in 2004. This accident rate was calculated based on the 156 accidents (12% more than in 2022) in Canada involving Canadian-registered and foreign airplanes and helicopters (ultralights and other aircraft types are excluded), and the estimated 5 502 000 aircraft movements at Canadian airports (6% more than in 2022).
Air transportation occurrences in 2023
The Transportation Safety Board of Canada (TSB) gathers and uses transportation occurrence data during the course of its investigations to analyze safety deficiencies and identify risks in the Canadian air transportation system.
This statistical summary serves to describe the accident, incident, and injury counts that are presented in the included Tables. It provides limited discussion and some context but is not intended to be an in-depth analysis of the data.
It should be noted that certain characteristics of the data constrain statistical analysis and the identification of emerging trends. These include the small totals of accidents and incidents, the large variability in the data from year to year, and changes to regulations and definitions. The reader is cautioned to keep these limitations in mind when reading this summary to avoid drawing conclusions that cannot be supported by statistical analysis.
Throughout this document, there are instances where categories of occurrences sum to more than the total number of occurrences. For example, if a single occurrence involves an airplane and a glider, the occurrence count will increase by one in each aircraft category but the occurrence itself will be counted only once in the total of occurrences.
The 2023 data were collected according to the reporting requirements described in the Transportation Safety Board Regulations in force during that calendar year.
The statistics presented here reflect the TSB Aviation Safety Information System (ASIS) database at 12 March 2024. Since the occurrence data are constantly being updated in the live database, the statistics may change slightly over time.
Also, as many occurrences are limited to data gathering, information recorded on some occurrences may not have been verified.
The following discussion refers to data tables contained in this document.
COVID-19 impacts on civil aviation in Canada
Air transportation in Canada continued to rebound in 2023, after 3 years of significant disruption. Year-over-year demand for business and vacation travel increased and cargo activity remained high. Information collected by Statistics Canada indicates that total aircraft movements (take-offs and landings) at Canada’s major and selected small airports numbered 5.5 million, which was 5.5% higher than in 2022 and represented 89.6% of the pre-pandemic movements in 2019. While activity at Canada’s major and selected small airports is documented, it is difficult to estimate the amount of activity—commercial or private—at many small airports in Canada or off-airport entirely. Therefore, a full picture of activity in the aviation industry is lacking. Nonetheless, the activity patterns discussed here are indicative, and give partial context to the accident statistics presented in this document.
Figure 1. Total aircraft movements at major and selected small airports, by class (Source: Statistics Canada)Footnote3
Overview of accidents and fatalities
Accident counts
Air transportation occurrences (both accidents and incidents) are reportable to the TSB if they occur in Canada. Occurrences that take place outside of Canada are also reportable if they involve Canadian-registered aircraft, and meet the criteria laid out in the TSB Regulations.
In 2023, a total of 182 air transportation accidents were reported to the TSB (Table 1 and Figure 2). This number is 10% higher than the previous year’s total of 166 accidents and 17% below the yearly average of 220 accidents reported in the prior 10 years, 2013 to 2022. Most (169) of the accidents in 2023 took place in Canada and involved Canadian-registered aircraft. Seven accidents involving Canadian-registered aircraft took place outside Canada, and 6 accidents in Canada involved a foreign-registered aircraft. In general, the number of air transportation accidents has been decreasing in the last decade.
Figure 2. Reported air transportation accidents, 2013 to 2023.
There were 159 accidents involving Canadian-registered aircraft (excluding ultralights) in 2023 (Table 2). This is 9% above the 2022 count of 146 accidents, but 34% below the average of 193 accidents in the preceding 10 years (2013 to 2022). If the 17 accidents involving ultralights are included in the count, there were 176 accidents involving Canadian-registered aircraft in 2023.
Aircraft type
Of the 182 air transportation accidents reported to the TSB in 2023, 131 (72%) involved fixed-wing, powered airplanes (other than ultralights) (Table 1), 32 (18%) involved helicopters, 17 (9%) involved ultralights, and 2 accidents (1%) involved all other types of aircraft, such as balloons, gyroplanes, gliders, airships, hang gliders, or Unmanned Aerial Vehicles (UAVs). In the 10 years from 2013 to 2022, the average proportion of accidents involving each of these four categories of aircraft has remained constant: in each year, airplanes have been involved in roughly 75% of reportable accidents, helicopters in about 12%, ultralights in about 9%, and other aircraft in about 3%.
Operator type
There were 77 accidents that involved commercially operated aircraft of all types in 2023 (Table 1). This is 38% more than the 56 such accidents recorded in 2022, and 6% above the average of 72 accidents recorded in the 10 years from 2013 to 2022.
Commercially operated Canadian-registered airplanes were involved in 50 accidents in 2023 (Table 2 and Figure 3). Of those, 6 involved operations under Canadian Aviation Regulations (CARs) Subpart 705 (airliners). This is greater than the 4 accidents involving Canadian-registered airliners in 2022, and the same as the average of 6 accidents per year recorded from 2013 to 2022.
Figure 3. Accidents involving Canadian-registered aircraft, excluding ultralights, by aircraft type and operation type in 2023, compared with the 2013 to 2022 average.
Figure 3. Accidents involving Canadian-registered aircraft, excluding ultralights, by aircraft type and operation type in 2023, compared with the 2013 to 2022 average.
In 2023, there were 2 accidents involving a Canadian-registered commuter airplane operating under CARs Subpart 704 (Table 2), as well as 25 accidents involving air taxi operations (CARs Subpart 703)—13 involving airplanes and 12 involving helicopters. The 25 air taxi accidents are more than double those reported in 2022 (12) and are slightly above the average of 24 accidents per year occurring between 2013 and 2022. Flight training units operating under CARs Subpart 406 were involved in 25 accidents in 2023, of which 23 involved airplanes and 2 involved a helicopter. On average for the period 2013 to 2022, flight training units were involved in about 19 airplane and 1 helicopter accidents per year.
Overall, in 2023, 103 air transportation accidents involved non-commercial (i.e., private aircraft) operations (Table 1), compared to 108 in the preceding year. The 2023 total is 29% below the annual average of 144 accidents from 2013 to 2022. Of the 103 total accidents in the non-commercial (private aircraft) operations category, 76 involved Canadian-registered airplanes (Table 2), with 5 of these involving an airplane operating under CARs Subpart 604 having a Private Operator Registration Document (PORD).
Most operators of non-commercial (private) Canadian-registered aircraft are classified as recreational. Recreational operators are responsible for a significant amount of flying activity and tend to be involved in many accidents each year. In 2023, 92 accidents involved recreational operators of Canadian-registered aircraft—69 of them in fixed-wing airplanes (Table 2), 4 in helicopters, and 19 in other aircraft. These 92 accidents are 8% fewer than in the preceding year, and 31% fewer than the 10-year average number of accidents involving recreational Canadian-registered aircraft (134).
In addition to commercial and private operations, 2 accidents in 2023 involved State operators, and 1 accident was categorized as having another or unknown operation type (Table 1).
Province or territory
Ontario and British Columbia had the largest number of reported accidents in 2023, with 44 reported accidents in each province (all aircraft types, including ultralights), surpassing Quebec with 32 accidents (Table 7). Ontario averaged more accidents per year (54) in the 2013–2023 period than any other province or territory, with Quebec having the second-largest average accident count (44).
Altogether, 7 accidents that were reportable under TSB Regulations occurred outside Canada in 2023. These all involved fixed-wing airplanes: 2 were operating commercially and 5 privately (data not presented). While these 7 accidents equal the number from 2022, they are fewer than the average of 8 per year seen over the previous ten years.
When ultralights are excluded from the counts, many provinces and territories saw fewer accidents reported in 2023 than the average of the previous 10 years (Table 8 and Figure 4). Only British Columbia, Northwest Territories, and Nunavut had more than the average number of accidents.
Figure 4. Air transportation accidents involving Canadian-registered aircraft, excluding ultralights, in 2023 compared with the 2013–2022 average, by province or territory.
Fatal accidents, fatalities, and serious injuries
The TSB recorded 19 fatal air transportation accidents resulting in 33 fatalities in 2023 (tables 1 and 4, and Figure 5). This is fewer than the 24 fatal accidents in 2022 and is 24% below the average of 25 fatal accidents over the ten years from 2013 to 2022. Of the 19 fatal accidents in 2023, 11 involved fixed-wing, powered airplanes, 4 involved helicopters, and 4 involved ultralight aircraft. All 19 of these occurrences involved Canadian-registered aircraft, with 18 occurring in Canadian airspace and one occurring in the United States (Table 7).
Figure 5. Fatal accidents and fatalities involving Canadian-registered aircraft, 2013 to 2023.
Thirteen of the 33 air transportation fatalities in 2023 involved commercial operations (Table 4): 4 of them under air taxi regulations (CARs 703), 4 under aerial work regulations (CARs 702), and 5 under flight training unit regulations (CARs 406). There were no fatalities involving airliner operations (CARs 705), or commuter operations (CARs 704). The remaining 20 fatalities were linked to privately registered aircraft and involved recreational operators. None of these involved an operator holding a Private Operator Registration Document (PORD) (CARs 604).
With regards to type of aircraft, 24 of 33 fatalities in 2023 resulted from accidents in fixed-wing powered airplanes, 5 from helicopter accidents, and 4 from ultralights (Table 4). Of the 33 total fatalities, 19 were pilots or crew members, 12 were aircraft passengers, and 2 were among persons on the ground.
Overall, 22 persons were seriously injured in aircraft accidents in 2023 (Table 5), which is 37% fewer than in 2022, and 25% below the average for the period 2013 to 2022. Seven persons were seriously injured in accidents involving commercial operations in 2023: none in airliners (CARs 705), 1 in a commuter aircraft (CARs 704), 3 in the air taxi sector (CARs 703), 2 in aerial work operations (CARs 702), and 1 with a flight-training unit (CARs 406). Also, during 2023, 13 persons incurred serious injuries in recreational operations. Two more people were injured in other operation types, including State-operated aircraft.
Richmond, British Columbia, 1 May 2024 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A22P0067) into an emergency forced landing of an Air Tractor AT-802A aircraft, operated by Conair Group Inc., south of Cranbrook, British Columbia (BC).
On August 2, 2022, the firefighting aircraft, equipped with amphibious floats, was conducting aerial operations in the area of Connell Ridge, the site of multiple wildfires, when it sustained a loss of engine power. Unable to restore power, the pilot selected a reforested area and completed an emergency landing in the trees, coming to rest approximately 200 m from the edge of the forest fire. The aircraft was substantially damaged by impact forces. The pilot, who was the sole occupant on board, sustained minor injuries.
Firefighting aircraft must operate at low altitudes to fight forest fires effectively. At such low levels, recovery from an aircraft malfunction becomes extremely challenging. In such a situation, a pilot’s decision making and reaction time are critical for a successful outcome.
In this occurrence, 40 seconds passed from the time the aircraft suffered the engine power loss to when it struck the trees. Although the cause could not be determined, the investigation found that it occurred at approximately 350 feet above ground level, leaving insufficient time for the pilot to complete the checklists, determine the cause, and attempt to restore power. His focus was on successfully performing an emergency landing and carefully managing the aircraft’s speed and rate of descent to ensure he would reach the selected landing site.
The investigation also determined that the pilot’s decision making, experience, and recent training assisted in a successful outcome. Additionally, the pilot’s use of a flight helmet, the 5-point harness, windscreen design, and slow impact speed all reduced his injuries.
As a result of the accident, Conair Group Inc. provided all its AT-802 pilots with low-level engine failure simulator training and introduced a flight operation briefing on engine failures to initial and recurrent pilot training.
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.
Dorval, Quebec, 30 April 2024 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A23Q0069) into a mid-air collision between two Cessna 150M aircraft, both operated by Richcopter Inc., that occurred during a night flight training session at Ottawa/Gatineau Airport, Quebec, on 20 June 2023.
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.
Richmond Hill, Ontario, 28 March 2024 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A23O0108) into the 20 August 2023 fatal accident of a ground crew member during external loading operations involving an AS350 BA helicopter, near Wawa, Ontario.
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.
Air transportation safety investigation report A23O0108
Ground personnel entanglement with external load G4 Drilling Canada Ltd. and Expedition Helicopters Inc. Airbus Helicopters AS350 BA, C-FHAU Wawa, Ontario, 25 NM W 20 August 2023
History of the flight
On 20 August 2023, the Expedition Helicopters Inc. Airbus Helicopters AS350 BA helicopter (registration C-FHAU, serial number 2778) was conducting external load operations, moving drilling equipment, in support of Angus Gold Inc. mining exploration activities being conducted by G4 Drilling Canada Ltd. (G4) approximately 25 nautical miles (NM) west of Wawa, Ontario. The pilot was alone on board and occupied the right seat. The single-engine helicopter was equipped and configured to conduct external load operations—the pilot door was removed, a vertical reference window was installed, and a 100-foot longline was being used. There were no overdue maintenance items or reported defects before the occurrence. The weather was suitable for the day visual flight rules flight. The winds at Wawa were reported as being from the north at 10 knots, variable from 320° to 050° true.
The pilot’s task consisted of transferring surface drilling equipment by longline from an old drill site on an island to a new drill site on a nearby peninsula, approximately 900 feet away (Figure 1). The G4 ground crew consisted of a foreman, an assistant foreman, a driller, and a helper.
Figure 1. Map showing the accident site, with the locations of the old and new drill sites in inset (Source of main image: Google Earth, with TSB annotations. Source of inset image: Angus Gold Inc., with TSB annotations)
The pilot started his duty day at approximately 0615 and flew various short flights for about 2.5 hours. He was then off duty until the first drilling equipment transfer flight, which started at approximately 1520.
The foreman and the assistant foreman were stationed at the old site, preparing and attaching the drilling equipment to the longline, while the driller and helper were at the new site receiving, positioning, and detaching the drilling equipment from the longline. By approximately 1630, only the drill shack cage remained to be moved (Figure 2). This cage was to be placed over the drill and equipment on the drilling platform at the new site.
Figure 2. Drill shack cage with tag line (inset) (Source of main image: Ministry of Labour, Immigration, Training and Skills Development, with TSB annotations. Source of inset image: Ontario Provincial Police)
When the cage is carried by longline, the pilot cannot control the rotation of the cage during the transfer or during the descent into position, so the ground crew uses tag lines (Figure 2, inset) to help guide and position the cage down onto the platform.
When the helicopter reached the new site with the cage, the pilot, the driller, and the helper had difficulties positioning the cage. After several unsuccessful attempts, the pilot decided to bring the assistant foreman to the new site to help. The pilot flew back to the old site, released the cage, picked up the assistant foreman and took him to the new site. The pilot then returned to the old site, the cage was reattached to the helicopter, and the pilot flew back to the new site with the cage.
At approximately 1700, the pilot positioned the helicopter into the wind and lowered the cage over the drill. The driller and helper each held 1 tag line and the assistant foreman held 2 tag lines (Figures 3 and 4). When the pilot looked down through the vertical reference window, he could see the driller and the helper only, because a piece of plywood on top of the cage was blocking his view of the assistant foreman.
Figure 3. Photo of the new site, with approximate positions of the ground crew members (Source: Ontario Provincial Police, with TSB annotations)Figure 4. Diagram showing the cage, the helicopter (as it would have been oriented 100 to 150 feet overhead), and the tag lines held by the ground crew members (Source: TSB)
After some time still being unsuccessful in positioning the cage, the pilot transmitted over the radio to the driller, who was the only one who had a portable handheld radio, that he had to go refuel the helicopter. This radio communication went unheard by the driller. The investigation could not determine why it went unheard.
The pilot began to climb and lifted the cage slowly while paying attention to the cage and any hand signals from the ground crew. As he continued to lift the cage, he did not see any hand signals from the driller or helper, and assumed that he was clear and continued to lift. As the cage lifted, the assistant foreman became entangled in his 2 tag lines. The driller and helper were concentrating on their own tag lines and did not see the assistant foreman become entangled. As the helicopter climbed and departed, the assistant foreman was carried aloft. When the driller and helper realized that the assistant foreman was being carried away, the driller called the pilot on the radio to inform him. However, the radio call was made in French, and given that the pilot did not understand French, he could not understand what was being said. The pilot departed the area and climbed to approximately 200 to 300 feet above ground level over the nearby lake.
A few moments later, the driller and helper saw the assistant foreman fall. At 1722, the driller texted the project lead at the base camp to report the accident.
The pilot was still unaware of the accident but, hearing the tone in the driller’s voice over the radio, felt that something had gone wrong. He proceeded to the old site, dropped off the cage and asked the foreman to accompany him back to the new site. After landing at the new site, the pilot and foreman were made aware of the accident. The pilot returned to the base camp, refuelled, and returned with 2 passengers to search for the assistant foreman. He was found on land, in a forested area across the lake from the new site, and had been fatally injured.
