1996 TSB Recommendations & TC Responses

R96T0111 - Interim Railway Safety Recommendations concerning Emergency Window Exits on Ontario Northland Railway Passenger Coaches ((R96-01 to R96-04)

TSB Full Text Report (R96T0111):
http://www.tsb.gc.ca/eng/rapports-reports/rail/1996/r96t0111/r96t0111.asp

TSB Recommendations R96-01, R96-02, R96-03, R96-04

Emergency Window Exit - (Action Required, as presented in the TSB Report)

The Board recommends that:

The Ministry of Northern Development and Mines of Ontario ensure that:

  1. an immediate, one-time, functional test on all emergency window exits on ONR passenger coaches is conducted; and
  2. a program for regular functional verification of emergency window exits on ONR passenger coaches is established; (R96-01)

The Ministry of Northern Development and Mines of Ontario ensure that explicit instructions for use of the emergency window exits on ONR passenger coaches are readily available; and (R96-02)

The Ministry of Northern Development and Mines of Ontario ensure that seats and luggage racks do not interfere with the use of the emergency window exits in the passenger coaches. (R96-03)

The Board also recommends that:

The Ontario Northland Transportation Commission undertake research with an aim to installing, in ONR passenger coaches, emergency exit windows that can be readily removed by able-bodied passengers. (R96-04)

Note: These recommendations were directed at Ministry of Northern Development and Mines of Ontario. Transport Canada did not respond to the recommendations made by the TSB.

R94T0357 - Fire - VIA Rail Canada Inc. - VIA Passenger Train No. 66 - Struck a Piece of Rail Placed on the Track Mile 242.07, CN North America Kingston Subdivision - Brighton, Ontario - 20 November 1994 (R96-05 to R96-11)

TSB Full Text Report (R94T0357):
http://www.tsb.gc.ca/eng/rapports-reports/rail/1994/r94t0357/r94t0357.asp

TSB Recommendations R96-05 and R96-06

Crashworthiness of Passenger Locomotives Fuel Tanks - (Action Required, as presented in the TSB Report)

The Board recommends that:

The Department of Transport assess the design of the current passenger locomotive fuel tanks and require, in the short term, that measures be taken to improve their crashworthiness, including limiting fuel spillage; (R96-05)

and

The Department of Transport require that design standards for new passenger locomotives take into consideration the need for crash-resistant fuel tanks and fuel systems. (R96-06)

Transport Canada's Response (R96-05 and R96-06)

(signed by Minister on October 15, 1996)

Transport Canada is currently gathering information in regards to the extent of any problems concerning fuel tanks, their crashworthiness and fuel spillage. Since the LRC locomotive fuel tanks are an intricate part of the frame, VIA Rail has no plans to modify the configuration of fuel tanks on the seven locomotives remaining in service.

The Department has raised the issue of crash-resistant fuel tanks and fuel systems with the Railway Association of Canada (RAC). We propose that the RAC formulate a rule that would be similar to the Association of American Railroads' (AAR) "Performance Requirements for Diesel Locomotive Fuel Tanks" which would be incorporated in the proposed Railway Locomotive Inspection and Safety Rules that are currently being developed by the railways. The new rule would include new passenger locomotives as well as new freight locomotives.

LRC pilots are in compliance with the "Regulations Respecting Railway Safety Appliance Standards General Order No. 0-10. These are already more stringent than regulations existing in the United States.

TSB Recommendation R96-07

Electrical Cables - (Action Required, as presented in the TSB Report)

The Board recommends that:

The Department of Transport assess the routing of the electrical cables on LRC passenger locomotives and require that measures be taken to minimize the vulnerability of the cables to accidental damage. (R96-07)

Transport Canada's Response (R96-07)

(signed by Minister on October 15, 1996)

Transport Canada has held discussions with VIA Rail concerning the feasibility of re-routing the high power electrical cables. VIA Rail plans to overhaul one or two locomotives in 1997. This is an opportune time for VIA Rail to evaluate the re-routing of the high power electrical cables to a more protected area. The Department has been assured that this matter will be fully examined at this time.

TSB Recommendations R96-08 and R96-09

Work-related Material on Rights-of-Way - (Action Required, as presented in the TSB Report)

The Board recommends that:

The Department of Transport, in consultation with Canadian railways, ensure that railway rights-of-way are maintained clear of track-related material; (R96-08)

and

The Railway Association of Canada, through its members, encourage railway employee work practices that would minimize work-related material being left along railway rights-of way. (R96-09)

Transport Canada's Response (R96-08 and R96-09)

(signed by Minister on October 15, 1996)

Transport Canada concurs with the intent of both recommendations, noting that it is the railways' responsibility to ensure safety and Transport Canada's role is to monitor their compliance with safety rules and regulations.

The Department has discussed the issue of railway rights-of-way clearance with the industry and our Railway Safety Officers have been and will continue to systematically monitor the situation. Transport Canada is aware of, and agrees with, steps taken to date.

TSB Recommendations R96-10

Railway Passenger Safety - (Action Required, as presented in the TSB Report)

The Board recommends that:

The Department of Transport, in consultation with the railway industry, establish standards governing all emergency aspects of railway passenger safety; (R96-10)

Transport Canada's Response (R96-10)

(signed by Minister on October 15, 1996)

Transport Canada concurs with the recommendation. The Department is presently reviewing VIA Rail's emergency preparedness training program and a rule will be developed under the Railway Safety Act that will encompass safety aspects of all passenger carrying railways under federal jurisdiction.

TSB Recommendation R96-11

The Department of Transport review its procedures regarding regulatory oversight of railways to ensure that the required level of railway passenger safety is maintained. (R96-11)

Transport Canada's Response (R96-11)

(signed by Minister on October 15, 1996)

Transport Canada would like to inform the Board that the up-coming modifications to the Railway Safety Act (RSA) will permit the Railway Safety Directorate (RSD) to strengthen its regulatory umbrella in all matters of railway safety as well as passenger safety. The Department will continue to be vigilant in its regulatory oversight to maintain all aspects of railway safety.

The RSD will also concentrate more on monitoring for compliance to rules and on auditing the railways. New ticketing provisions, which will be in effect shortly under the Contraventions Regulations, and future Fencing Regulations will be of great help to reduce trespassing and avoid recurrence of this type of unfortunate accident such as the one which occurred in Brighton.

R94T0334 - CN North America - Collision between Freight Train No. 386 and Stationary Freight Train No. 448, Mile 5.8, Halton Subdivision Etobicoke, Ontario - 28 October 1994 (R96-12)

TSB Full Text Report (R94T0334):
http://www.tsb.gc.ca/eng/rapports-reports/rail/1994/r94t0334/r94t0334.asp

TSB Recommendation R96-12

Cabooseless Trains Without an Illuminated Rear Marker - (Action Required, as presented in the TSB Report)

The Board therefore recommends that:

The Department of Transport re-assess the risk associated with operating cabooseless trains without an illuminated rear marker. (R96-12)

Transport Canada's Response (R96-12)

(signed by Minister on October 23, 1996)

Transport Canada concurs with the Board's determination of this accident. The crew did not comply with the Canadian Rail Operating Rules (CROR) and violated speed restrictions. This accident would not have occurred had the movement been operated at a reduced speed and prepared to stop within half the range of vision of equipment.

As the Board is aware, the new generation of sense and braking units (SBUs) are equipped with both light and reflector. Technological advances have allowed extension in battery life and simultaneous reduction in weight. Illuminated rear markers are primarily intended to define the tailend of a train for the purposes of a number of rules applications, not to prevent an occurrence of this nature. In view of the fact that the lack of lighted rear markers was not identified as a cause of this accident, given that the new technology is moving towards a dual system, Transport Canada does not see the necessity to further review the issue of lighted rear markers at this time.

R94C0137 - Derailment - Canadian Pacific Limited - Mile 108.05, Taber Subdivision - Lethbridge, Alberta - 17 October 1994 (R96-13)

TSB Full Text Report (R94C0137):
http://www.tsb.gc.ca/eng/rapports-reports/rail/1994/r94c0137/r94c0137.asp

TSB Recommendation R96-13

Class 111A Tank Cars: Susceptibility to Damage and Loss of Product - (Action Required, as presented in the TSB Report)

The Board recommends that:

The Department of Transport take immediate action to further reduce the potential for the accidental release of the most toxic and volatile dangerous goods transported in Class 111A tank cars -- for example, require design changes to improve tank car integrity in crashes or further restrict the products that can be carried in them. (R96-13)

Transport Canada's Response (R96-13)

(signed by Minister on February 11, 1997)

Transport Canada concurs with the Board's recommendation. The Department has reviewed the list of 16 dangerous goods referenced in the subject TSB Final Report and determined that both ethylene dichloride, UN 1184, and chloroform, UN 1888, should be added to the list of products currently prohibited from being transported in Class 111A tank cars. These changes will be reflected in the next amendment to the Canadian General Standards Board (CGSB) tank car standards.

Work is being done to upgrade Class 111A aluminum and nickel tank cars. A full head shield will be a future requirement of such cars when in dangerous goods service.

Transport Canada, the US Department of Transportation, and the Association of American Railroads have each been undertaking an active role in various research and development projects aimed at identifying and classifying critical tank car anomalies. Class 111A tank cars are included in this evaluation. CP Rail has indicated that it will continue to actively participate in any initiative to deal with this issue.

As for track issues mentioned in the Board's Final Report, CP Rail has informed us that the review of the adequacy of existing technology has been completed and the project is focusing on a single alternative technology involving Electromagnetic Acoustic Transducers (EAT). Laboratory testing was sufficiently promising that the project will proceed to field testing during the summer of 1997. CP Rail continues to work with its rail testing contractors to effect incremental improvements in testing reliability.

R95D0055 - Pedestrian Fatalities - Canadian National - Freight Train No. 395 Mile 125.15, Kingston Subdivision - Brockville, Ontario - 20 April 1995 (R96-14)

TSB Full Text Report (R95D0055):
http://www.tsb.gc.ca/eng/rapports-reports/rail/1995/r95d0055/r95d0055.asp

TSB Recommendation R96-14

Protection for Pedestrians (action required - as indicated in the TSB's Report)

The Board recommends that:

The Department of Transport, in cooperation with the railways, the provincial and local authorities, implement, on a priority basis, a program to upgrade the pedestrian protection systems on those multiple-track mainline crossings in populated areas warranting immediate attention. (R96-14)

Transport Canada's Response (R96-14)

(signed by the Minister on February 11, 1997)

Transport Canada concurs with the intent of the Board's recommendation and has indicated a number of actions needed to determine where pedestrians may be at such a risk and the potential effectiveness of additional measures to reduce such risks.

With respect to upgrade for pedestrian protection systems at such crossings, the Department has initiated a study of the means to warn pedestrians of the approach of a second train at multiple-track highway-rail crossings at grade.

The study will examine technologies which are being used to alert pedestrians at railway crossings when a second train is about to arrive at the crossing. The study will focus on technologies used in Europe, Japan, the United States and other jurisdictions where this technology may be available. It will also examine the degree to which such additional measures may or may not be effective in reducing pedestrian risk at such locations.

Transport Canada is also consulting with CN Rail which is already examining means to warn pedestrians of the presence of a second train.

The draft study report will be delivered to Transport Canada by early February 1997, and a copy will be sent to the Board for information and comment. We anticipate the final report will be delivered to the Department by the end of March 1997.

In Canada, there are approximately 1230 double mainline public crossings and 1775 multi-track public crossings (mainline and one or more other tracks). Work is underway to identify which of these crossings are located in populated areas with significant pedestrian traffic.

Transport Canada has also identified six pedestrian fatalities involving second trains at multi-track crossings since 1988 and is working with others to identify the circumstances of each accident for the purpose of characterizing crossings that could meet the criteria in the Board's recommendation.

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