1995 TSB Recommendations & TC Responses
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R93T0201 - Derailment, CN North America, Train No. 219-13, Mile 255.6, Bala Subdivision, Sudbury, Ontario - 13 August 1993 (R95-01)
Transport Canada's Response R95-01
(signed by the Minister on August 29, 1995)
In addition to the comments provided to the Board on December 8, 1994, in response to the Draft version of this report, Part X1 of the TDG Regulations allows for the issuance of permits for equivalent level of safety when conditions set out in Section 11.2(1) are satisfied. As the Board is aware, Equivalent Level of Safety Permit SR 4574 was issued on October 12, 1994, to allow for the use of 14 specially equipped Specification 105J600W tank cars in Hydrogen Sulphide service under special operating conditions. Transport Canada continues to believe that these cars can operate safely in such service when all of the permit conditions are complied with. Nevertheless, Surface Group Safety Officers will continue to monitor the operating performance of these cars and will again reassess the continued need for this permit prior to its expiry date of March 31, 1996.
The Board may wish to note that there have also been incidents involving loss of product with the movement of hydrogen sulphide in ton containers. Of recent note is the incident of June 23, 1995, at the Port of Montreal. Surface Group Safety Officers are investigating and have suspended movement of these "tonners" pending further investigation.
As mentioned in previous correspondence, a task force was set up, which included the Railway industry, the AAR and representatives of the manufacturing companies, to review the issue of side bearing clearance and worn truck components. The Board will be provided with information as it becomes available.
R93C0103 - Head-on Collision, CN North America and Canadian Pacific Limited, CN 1559 Sarcee Yard Assignment and CP 1500 Ogden Park Yard Assignment, Mile 0.45, F-200 Foothills Industrial Lead off Mile 131.88 of the Drumheller Subdivision Calgary, Alberta - 03 December 1993 (R95-02)
TSB Recommendation R95-02
CROR Rule 105 - Speed on Other Than Main Track
The Board recommends that:
The Department of Transport review the application of CROR Rule 105 with a view to ensuring that an appropriate safety factor is maintained with opposing movements. R95-02
Transport Canada's Response (R95-02)
(signed by the Minister on October 11, 1995)
As indicated in the departmental response to the Draft Report on this incident, Surface Group Safety Officers have already initiated the review of the adequacy of the existing CROR Rule 105. Following the yard collision in Foothills Industrial Park on December 3, 1993, Surface Group Safety Offices identified all locations on rail lines under federal jurisdiction where situations similar to those at the Foothills Industrial Park existed. Once these areas were identified, the operating rules and procedures in effect at these locations were evaluated.
In the course of the review, CROR Rule 105 was found to be the stand-alone rule governing operations at many of the locations identified. In some cases, additional instructions were found to be in place to address the peculiarities of operations at particular locations. In none of these cases were the operating rules and procedures in effect found to be deficient in terms of safety.
Surface Group Safety Officers have corresponded with CN and CP officials on the question of the railways having issued instructions following the accident requiring inter-railway communication when working in the Foothills Industrial Park area. Both railways responded that they view such communications as little more than general information and continue to stress to their operating crews, the importance of being in compliance with CROR Rule 105. This rule remains the single most important factor affecting the safety of operations on other than main track. To further reinforce this fact, the RAC advised its members, at the Railway Safety Directorate's request, as well as the Chairman of the RAC Operating Rules Subcommittee, of this matter and its seriousness.
While recommendation 95-02 questions the appropriateness of CROR Rule 105 in opposing traffic situations, it must be recognized that several thousand movements are safely made each day in such territory without incident. Compliance with this rule, to maintain an adequate safety margin, is believed to be straightfoward; crew members must either be so positioned and in control of the movement to observe the track in the direction of movement, or speed must be reduced consistent with sight lines available to the employee controlling the movement.
Ultimately, the issue appears to be one of non-compliance with fundamental rules of railway operations, and not he adequacy of the rule. In this regard, as mentioned in previous correspondence, the railways are focusing on alertness and ergonomics research to provide solutions to problems in the area of employee operating performance.
Additionally, the Department is discussing the development of a personal computer based simulation with CN and CP. This engineers to comply with the reduced speed requirement of CROR Rule 105 when opposing movements are involved. Such a tool would serve to heighten general awareness of Rule 105 and the requirements of reduced speed to enhance training of locomotive engineers in a safe environment when given opposing movements.
The Board will be advised of any significant developments in this area. In the meantime, Surface Group Safety Officers will continue to monitor railway operations to ensure that current operating rules and practices remain the most effective way to maintain safety.
Stand-Alone Recommendations, Via Rail, Spalled Manganese Wing Rails, Dated 95-12-05 (R95-03)(R95-04)(R95-05)(R95-06)
TSB Recommendation R95-03
Spalled Wing Rails
The Department of Transport require that all spalled manganese wing rail that could damage LRC wheel treads be located, and repaired or removed. R95-03
Transport Canada's Response (R95-03)
(signed by the Minister on March 4, 1996)
CN has reviewed the damage to the wheels with a leading North American expert on wheel failure phenomena, Dr. D.H. Stone of the Association of American Railroads (AAR). The department was provided with information that indicated that the damage to the LRC wheels would not lead to catastrophic failure or further deterioration that could lead to derailments.
It has not been shown that operation of trains over a chipped-out section of manganese wing rail constitutes a compromise to railway safety. However, as indicated under the response to recommendation R95 05, both VIA and CN reacted quickly, with action taken including track inspections along the entire Montréal-Toronto corridor and extensive train evaluation. As an added precaution, VIA is removing or reprofiling wheels detected with marks or gouges on the wheel tread.
Transport Canada Safety officers are satisfied that the measures currently being taken by the industry are appropriate and adequate to address the safety concerns identified.
TSB Recommendation R95-04
Effect of Speed on the Impact Forces on Manganese Wing Rails
The Department of Transport evaluate the effect of speed on the impact forces on manganese wing rails during weight transfer of LRC wheels, and impose speed restrictions if required. R95-04
Transport Canada's Response (R95-04)
(signed by the Minister on March 4, 1996)
At a meeting with the railway industry, Transport Canada requested information on action being taken by CN and VIA to determine the root cause of these incidents. CN has contracted with CANAC International Inc. (CN consulting and technology transfer business unit) to:
- examine six damaged VIA wheels for traces of manganese-rich materials in the indentations;
- prepare a piece of normal work-hardened manganese with a sharp edge, mounted in such a way as to be pressed into sections of VIA Class B wheels and sections of CN Class C and U wheels. Force and deformation graphs will be plotted and analysed;
- devise some form of drop-hammer test to simulate the type of rolling impact action that might occur when a speeding wheel strikes a hard angular object. Tests will be run on both Class B, Class C and Class U wheels;
- continue to closely monitor CN, TTR and VIA plant components and facilities for any condition that could cause this situation to recur.
With respect to speed restrictions, a voluntary slow order was placed on LRC trains by CN on December 8, 1995 to reduce their speed to the equivalent of conventional passenger trains, a reduction of up to 10 miles per hour. Further to consultations with Dr. D.H. Stone of the AAR, track inspections along the entire Montréal-Toronto corridor and extensive train evaluations, CN concluded that the slow order was not needed to maintain safe railway operations at LRC speed, and it was removed on December 14, 1995.
TSB Recommendation R95-05
Adequacy of Inspection and Maintenance Standards and Practices
The Department of Transport confirm the adequacy of the inspection and maintenance standards and practices for manganese wing rails used by CN North America on track used by LRC trains. R95-05
Transport Canada's Response (R95-05)
(signed by the Minister on March 4, 1996)
Transport Canada Safety Officers had the opportunity to visit the TSB laboratories. They examined the extent of the damage to the frogs and wheels. These issues were discussed with railway officials on December 13, 1995. Also, when they learned of these problems, both VIA and CN reacted quickly with action taken including track inspections along the entire Montréal Toronto corridor and extensive train evaluations. In addition, departmental safety officers inspected all mainline frogs between both cities and were satisfied that there was no threat to safe railway operations. Furthermore, Transport Canada routine infrastructure safety monitoring program covers this aspect and any indications of defects in the wing portions of manganese frogs were and continue to be investigated and corrective actions taken by the railway. We are satisfied that the inspection and maintenance standards and practices of the railway are appropriate and adequate for safe railway operations. Nevertheless, Transport Canada will review the CANAC report upon completion and will take any necessary action deemed necessary at that time to ensure safe railway operations.
TSB Recommendation R95-06
Spalled Manganese Wing Rails in Operation Outside the LRC Corridor
The Department of Transport determine whether conventional passenger car or freight wheels are being damaged by spalled manganese wing rails in operations outside the LRC corridor. R95-06
Transport Canada's Response (R95-06)
Signed by Minister 96-03-04
The Department undertook a nation wide inspection process as part of the regular inspection program to determine if any wheels were being damaged by spalled manganese wing rails operating outside the LRC corridor. The results of the investigation indicated that no other situation existed.
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