1993 TSB Recommendations & TC Responses
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Stand Alone Recommendations, Regarding Rail Testing for Internal Defects (R93-01)(R93-02)
TSB Recommendation R93-01
Adequacy of current procedures for main track rail testing
The Department of Transport reassess the adequacy of current Canadian railway procedures and equipment for main track rail testing for:
- identifying rail defects on curved track; and
- identifying vertical split head defects. (R93-01)
TSB Recommendation R93-02
Adequacy of training of operators of rail testing vehicles
The Department of Transport reassess the adequacy of the training and suitability of the working conditions of the operators of rail testing vehicles. R93-02
Transport Canada's Response (R93-01 and R93-02)
(signed by the Minister on July 28, 1993)
As noted in the response to Recommendations 92-23/24, we are pursing the issue of the efficiency of rail testing, whether in main, secondary main or branch lines and in tangent or curved track. In addition, Railway Safety Inspectors have also reviewed the detection of rail defects in crossings and turnouts with the railways and steps are being taken to improve surveillance of these areas.
While a disproportionate number of defects are expected to occur in curved track because of the more critical loading of rail in curves, it is clear that the detection is to some degree dependent on the surface condition of the rail, including the effect of rail lubrication. In addition, as the Board has stated, detection of flaws is also dependent on the proficiency of the detector operator.
The railways have taken action to evaluate the performance of their contractors and have shortened rail testing intervals if operating circumstances change or the number of detected defects increase. Testing output tapes are being reviewed to determine if operator errors exist and software development is underway to alert operators to anomalies which require further inspection. In addition, more stringent rail inspection procedures are being introduced to detect potential rail problems in grade crossings.
The department is working with the railways to determine what improvements can be made and what benefits will follow in terms of higher rates of identification of defects. As noted previously, the department is receiving computerized rail defect summaries form the railways to aid in determining the seriousness of the problem.
The Board's Report refers to 19 main line derailment between 1982 and 1991 which have occurred within 100 days of testing by rail testing vehicles. Recognizing that rail testing technology and procedures have been improved since many of these accidents occurred, the department will examine the degree to which these changes might have enabled early identification of the rail flaws and, thereby, have prevented the accidents. The need for further remedial measures will be determined from this analysis. The Surface Group will be contacting Board staff in this connection and will advise you of results.
R90C0092 – Derailment, Mile 77.92 on CP Rail's Maple Creek Subdivision, Near Cardell, Saskatchewan - June 26, 1990 (R93-03)
TSB Recommendation R93-03
The Department of Transport ensure that federally regulated railways are correctly applying appropriate standards for destressing continuous welded rail. R93-03
Transport Canada's Response (R93-03)
(signed by the Minister on August 16, 1993)
Transport Canada's Surface Group is currently examining railway policies concerning the handling of continuous welded rail, as well as railway employee knowledge of, and compliance with, these policies. On completion of this review, the Board will be advised of conclusions reached and any action taken.
R92T0183 – Derailment, CN freight train, Mile 113.5 of CN's Caramat Subdivision, Nakina, Ontario - July 19, 1992 (R93-04)(R93-05)(R93-06)(R93-07)
TSB Recommendation R93-04
Track Failure and Adjacent Waters
The Department of Transport, in collaboration with the Department of Energy, Mines and Resources and the railways, institute a program to identify other locations of incipient failure where main track has been laid over weak sediments or where waters adjacent to main track may be subject to rapid draw down. R93-04
TSB Recommendation R93-05
The Department of Transport impose restricted speeds for trains traversing those sites identified as most vulnerable to failure caused by draw down of adjacent waters. R93-05
TSB Recommendation R93-06
Measures to Increase Soil Stability
The Department of Transport, in consultation with the railway industry, identify and implement corrective measures to increase soil stability with an acceptable factor of safety at those locations identified as being vulnerable to terrain slump. R93-06
TSB Recommendation R93-07
Adequacy of current roadbed design criteria
The Department of Transport review the adequacy of current roadbed design criteria for laying roadbed over peat, silt or other weak sediments. R93-07
Transport Canada's Response to all recommendations (R93-04 to R93-07)
(signed by the Minister on September 21, 1993)
This tragic accident was reviewed in detail by Transport Canada's Railway Safety Officers immediately after the occurrence, the rail line was inspected for similar situations and the issue was taken up with senior officers of CN Rail. In addition, the occurrence was also discussed with senior officers of CP Rail to alert them to the potential hazard posed by severe water conditions in Northern Ontario. Furthermore, CP has subsequently strengthened its efforts in this field.
The department determined that CN Rail was taking satisfactory action by undertaking aerial surveys of beaver dam locations along the railway right of way and employing trappers to remove beaver at strategic points. Furthermore, during on-going monitoring programs, Railway Safety Officers are verifying that track is being inspected by the railways in accordance with the approved Track Safety Rules.
The department has requested the railway to carry out a geotechnical analysis to determine if there are other locations which are susceptible to collapse under similar conditions. In line with the recommendation of the TSB, the railway is requested either to take suitable measures to stabilize embankments where there is a potential risk of collapse or to develop an early warning system to prevent similar accidents from occurring.
The primary area of concern with respect to repetition of this accident is the possibility of rapid draw down of water levels. In discussions with senior officers of CN Rail, the company advised that it is expanding beaver control programs to include potentially dangerous dams on the downstream side of tracks. Training programs for track maintenance forces are being revised to alert employees to the hazards posed by rapid draw down.
Speed restrictions are normally applied to tracks potentially subject to disturbance. With heightened awareness of the threat posed by rapid draw down, railways, who have the responsibility to control track speed, are expected to react with appropriate restrictions. Railway Safety Officers are aware of the potential hazard and will be observing railway performance with respect to interim measures at these locations.
Regarding the design criteria for construction, it should be recognized that the line where the accident occurred was constructed over 80 years ago and that construction standards have undergone radical changes since that time. While no railway line construction projects are under consideration at this time, should such a proposal be forthcoming, design and construction would be carried out in accordance with the applicable engineering standards.
A copy of this letter is being sent to the Railway Association of Canada to bring the circumstances surrounding this accident to the attention of all member railway companies.
R91D0045 – Derailment, CN freight train, Mile 41.59 of CN's Kingston Subdivision, Côteau, Quebec - March 21, 1991 (R93-08)(R93-09)
TSB Recommendation R93-08
Truck Hunting and Speed
The Department of Transport ensure that appropriate speed restrictions are in effect for all empty bulkhead flatcars and long gondola cars which are not equipped with constant contact side bearings. R93-08
Transport Canada's Response (R93-08)
(signed by the Minister on November 22, 1993)
A speed restriction of 50 miles per hour was in effect for empty bulkhead flatcars and long gondola cars not equipped with constant contact side bearings. This applies to Canadian and foreign cars operating on federally regulated railways. Cars subject to this restriction are normally identified on train journals, as well as transfer and switch lists. The error which allowed this car to move without proper notification has been brought to the attention of the railway for correction.
TSB Recommendation R93-09
Speed restriction on cars
The Department of Transport assess the requirement for speed restrictions on other rail car types to reduce the likelihood of derailments related to truck hunting. R93-09
Transport Canada's Response (R93-09)
(signed by the Minister on November 22, 1993)
The department monitors accident reports to identify safety deficiencies in railway performance. This includes any indication of specific safety problems associated with types of freight cars. The Surface Group will continue to analyze these reports and is also in communication with the industry on results of testing to determine susceptibility of car designs to truck hunting at various speeds.
R90E0198 – Collision, Between CN track units, Mile 34.3 of CN's Edson Subdivision. Wabamum, Alberta, October 3, 1990 (R93-10)
TSB Recommendation R93-10
Communication of Sensitive Safety Information
The Department of Transport evaluate company practices for communicating sensitive safety information to all personnel operating track units. R93-10
Transport Canada's Response (R93-10)
(signed by the Minister on January 19, 1994)
The department has reviewed the issue of conveying essential safety information to operators of track units and concluded that radio communication can not be relied on for this purpose. There is the problem of potential confusion associated with varying numbers of units working within designated limits, as well as the potential failure to receive important safety instructions because operators are subjected to continuous background noise.
The central problem identified in this accident is the failure by railway employees to observe existing Regulations and rules. At Wabamun, the crew of the track units did not observe the requirements of CN Rail Form 1233E, Maintenance of Way Rule 4.4.8 which requires that track unit operators and crew stop the units on the approach of a train and take up safe ground positions for visual inspection of both sides of the train. Had the operators complied with this Rule, and others including 4.4.10, 4.6.1 and 4.6.2 of 1233E, this accident would not have occurred. Transport Canada Surface Group safety officers have brought the issue of rule observation to the attention of senior officials of the railway. CN has indicated that safety initiatives have been undertaken, such as a "Job Briefing" program to reinforce safety procedures before the commencement of the work day, increased focus on safety information programs and an interactive "Track Unit Safety" course. The Company will also continue circulation of safety information through "Safety Flashes" and other communiqués to reinforce safety awareness.
As previously mentioned, CN is exploring employee management in the airline industry for application to railway personnel in conjunction with ergonomic analysis and design. CN reports that results to date are encouraging.
The Surface Group will evaluate the effectiveness of CN's initiatives and, if the department is not satisfied, will take action under the Railway Safety Act to ensure safe railway operations. I appreciate receiving the assistance and advice of the Board in the interest of public safety.
R91E0072 – Collision at a public crossing, Between a CN freight train and a tractor trailer loaded with petroleum crude oil, Mile 172.25 of CN's Wainright Subdivision, Kinsella, Alberta - August 5, 1991 (R93-10)
TSB Recommendation R93-11
Requirements for Tank Trucks
The Department of Transport co-ordinate with the appropriate provincial authorities to require that tank trucks placarded for the transport of dangerous goods stop at all public crossings before proceeding. R93-11
Transport Canada's Response (R93-11)
(signed by the Minister on March 23, 1994)
In September 1981, the U.S. National Transportation Safety Board (NTSB) published a Report entitled Special Study - Railroad/Highway Grade Crossing Accidents Involving Trucks Transporting Bulk Hazardous Materials (No. NTSB-HZM-81-2). Based on this special study, the NTSB recommended that the requirement for mandatory stops at crossings protected by active devices when these devices are not activated be removed.
In response, the U.S. Department of Transportation conducted a research project, completed December 1985 and published early in 1986, entitled Consequences of Mandatory Stops at Railroad - Highway Crossings (FHWA/RD-86/014). In agreement with the NTSB, this report concluded that abolishing mandated stops at railroad crossings with active devices when the devices are not activated would reduce both non train and train accidents for hazardous material transporters.
However, this second report was challenged by the U.S. Bureau of Motor Carrier Safety through a report prepared by Events Analysis, Inc. This third report resulted from the Bureau of Motor Carrier Safety's Task Order No. 1 (DTFH61-86-P000277), dated January 21, 1986. As a result, the U.S. Department of Transportation determined it could not come to a conclusion with respect to any action it might take resulting from the NTSB recommendation referred to above. In light of these three reports, I am reluctant to forward your recommendation to the provinces without the opportunity of reviewing any supporting material you may have.
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