1994 TSB Recommendations & TC Responses

R92D0065 – Yard Collision and Leakage, Tank car PROX60066, Mile 146.2, CN's Saint-Laurent Subdivision, Montréal, Québec – April 30, 1992 (R94-01)

TSB Recommendation R94-01

Audit of Canadian railway hump yard operations

The Department of Transport conduct a comprehensive operational audit of Canadian railway hump yard operations, and make public its findings within a reasonable period. R94-01

Transport Canada's Response (R94-01)

(signed by the Minister on May 25, 1994)

As indicated in the department's comments on the draft Report, the accident was followed up in detail by Surface Group Railway Safety Officers. Safety Officers ensured that CN was taking measures to prevent a repetition of this accident through appropriate training and supervision of new hump yard controllers throughout the CN system. The situation was also addressed to the Railway Association of Canada for the attention of the members companies.

The Board's Recommendation is based on a number of hump yard accidents referred to in the Report. However, there is no information provided as to the essential details of these accidents. Prior to deciding on the nature or focus of any audit, Transport Canada would require details of the accidents referred to, including the nature of the accidents, the severity, any causal factors as well as locations and times. Until this information is available, Safety Officers will pay particular attention to hump yard operations.

I look forward to receiving material which supports the Recommendation made to my department.

R92V0126 – Employee Fatality, Mile 4.35 of CN Rail's North Shore Industrial Line, Lynn Creek, British Columbia - June 18, 1992 (R94-02)

TSB Recommendation R94-02

Occupational Physical Fitness Standards

The Railway Association of Canada strongly recommend to its members a requirement that train service employees periodically demonstrate their ability to meet company occupational physical fitness standards. R94-02

Transport Canada's Response (R94-02)

(signed by the Minister on July 12, 1994)

Transport Canada concurs with the recommendation. I would appreciate your providing the Department with a copy of the RAC's reply.

Stand Alone Recommendation, Regarding field operating practices when handling main track switches, Safety Recommendation dated 94-05-12 (R94-05)

TSB Recommendation R94-05

Operating Practices for Operating Rule 104(b)

DOT examine current field operating practices for the application of rule 104(b) of the Canadian Rail Operating Rules to confirm that adequate protection is being provided against unintentional switching of trains from the main track. R94-05

Transport Canada's Response (R94-05)

(signed by the Minister on August 5, 1994)

In accordance with your previous Recommendation R92-20, a field assessment was carried out of all main track switches to non-signalled, passenger train carrying subdivisions. This extensive study was analysed by the Railway Safety Directorate and the results were addressed with senior officials of CN and CP in conjunction with the Railway Association of Canada. Since this is a complex topic and possible solutions are many and varied, the railways were directed to consider and make proposals for corrective measures with respect to locations where switch target visibility and minimum train braking distances indicated a potential safety risk. To date, some switches have been removed and the approach visibility of others has been improved.

Extensive work continues in this field, including examination of ways to improve visibility of switch targets in non-signalled territory, with specific attention being given to difficult locations on passenger carrying track.

This review is also considering the efficacy of the Rule itself as Transport Canada considers that safety performance with respect to Rule 104 (b) is unacceptable. A number of initiatives are underway within the industry and by my Department to ensure compliance with the Rule by improving training, supervision and enforcement and to implement further safeguards to protect trains operating on non signalled tracks. It is known that the previous version of the Rule, which was replaced by CROR 104 (b), was not in itself foolproof and had been subject to compliance failures. We, unfortunately, do not have information on the number of violations of the previous and current Rules governing the handling of main track switches. We would appreciate receiving any definitive information on the incidence of violations of the previous and current Rules that the Board may have.

As already stated, a number of activities are under consideration or are already being implemented to ensure compliance with the Rule and to improve safety in the area of main track switches. Besides improving the visibility of switch targets and enhancing training, supervision and enforcement, other items being considered include:

• radio procedures to ensure that all train crew members receive confirmation that instructions received from the Rail Traffic Controller have been complied with at the time switch handling occurs. This will ensure that trains entering main tracks are authorized to do so without normalizing switches and that this condition is reported to subsequent rail movements,
• imposing speed restrictions at certain locations,
• determining whether automated advance warning of switch alignment is feasible at certain locations, and
• for the longer term, implementation of certain aspects of the Advanced Train Control System which would provide further safeguards.

Before concluding, I would like to note that there are some minor factual inaccuracies in the example items provided in your letter. Example 1, page 1, occurred on the Sherbrooke Subdivision of Canadian National Railways, not Canadian Pacific Limited and CP's Brooks Subdivision; example 4, page 2, is in signalled track, not non-signalled as suggested in your letter. Example 2 and 4 occurred on signalled territory. In these cases, the signal systems functioned as intended, the appropriate indications were given and expected action was taken to protect the movement of the trains involved. Of course, in signalled territory train crews are governed by signal indications and do not use paper clearances in the same manner as in non signalled territory where the paper clearance is the only authority to proceed.

I believe that my department is taking appropriate action on this issue and we will notify the Board of any regulatory or industry action to be taken.

R93M0001 - Canadian Pacific Limited, (Canadian Atlantic Railway), Runaway Cars, Mile 5.42, McAdam Subdivision, Saint John, New Brunswick - 03 January 1993 (R94-06)

TSB Recommendation R94-06

Installation of Derails

The Board recommends that:

The Department of Transport ensure that derails are installed at all locations across Canada where the track gradient could contribute to rail cars rolling free and obstructing the main track. R94-06

Transport Canada's Response (R94-06)

(signed by the Minister on August 17, 1994)

The incident took place as the result of the failure of yard crews to properly secure the cars, as required by Rule 112 of the Canadian Rail Operating Rules. As indicated in a letter to the Board on September 30, 1993, the railway disciplined the responsible crew and has carried out extensive information sessions with operating employees to reinforce the need for correct securement of standing equipment. This interim action satisfied the department at that time.

With respect to the Recommendation, I am informed that CP has installed a derail at the location in question bringing it into compliance with the Track Safety Rules. Furthermore, of the 3500 turnouts checked during our 1993 infrastructure monitoring program, some 15 locations failed to comply to the requirement for installation of a derail. In these cases, immediate action was taken by my department to ensure compliance with the Track Safety Rules. Surface Group Regional Offices are aware of this situation and Regional Safety Officers will continue to pay particular attention to this aspect of the program during the 1994 infrastructure monitoring program. In addition, a copy of this letter, along with the report, is being forwarded to the Railway Association of Canada for them to alert member railway companies of the action being taken by my department.

The Board Report also refers to seventeen instances of runaway cars since 1989. It would be appreciated if specific information on these occurrences could be provided to enable the department to assess the need for derails at these locations.

R91S0013 - Crossing Collision, Via Rail Inc., Mile 71.31, Chatham Subdivision, Tillbury East, Ontario - 30 January 1991 (R94-07)

TSB Recommendation R94-07

Strategy for the Prevention of Railway Crossing Accidents

The Board recommends that:

The Minister of Transportation for the province of Ontario initiate an evaluation of driver behaviour at grade crossings on the CN North America Chatham Subdivision with a view to implementing measures to reduce the crossing accident rate. R94-07

Transport Canada's Response R94-07

(signed by the Minister on September 20, 1994)

Although the recommendation is not directed to Transport Canada, the following information is relevant to the investigation.

In 1990, Surface Group Railway Safety Officers carried out an evaluation of all private and public crossings on the Chatham Subdivision. This information is updated yearly through the Surface Group's ongoing crossing monitoring program. In addition, last year, Transport Canada requested VIA Rail, in co-operation with CN Rail, to execute a crossing and trespassing study on the Chatham subdivision. By the end of September 1994, the railway is to provide the Railway Safety Directorate with the findings and the railway's proposed remedial action.

The Board will be made aware of these findings once the department has evaluated the conclusions of the study.

R92W0300 - Derailment, CN, Train no. 218-16, Mile 41.06 of Rivers Subdivision, Oakville, Ontario, December 18, 1992 (R94-08)

TSB Recommendation R94-08

Bearing Failure Warning

The Board recommends that:

The Department of Transport urge all Canadian railways to implement heat detection systems on locomotive suspension bearings to warn crew members of failing bearings. R94-08

Transport Canada's Response (R94-08)

(signed by the Minister on February 22, 1995)

The Railway Safety Directorate has reviewed the findings of the Board and carried out a study prior to deciding to implement the recommendation. Information was gathered from Canadian and American railways and from our Winnipeg regional office.

The results of our study indicate that the risk of a suspension bearing failure is very low and it is difficult to justify modifying the existing motive power with a heat detection system when they will eventually be replaced by new high horsepower locomotives equipped with roller suspension bearings.

In the interim, the Department will encourage the railways to continue the transition from friction type suspension bearings to roller type suspension bearing with special emphasis being placed on high horsepower locomotives in high mileage service. In addition, the Department will require that all federally regulated railways report to the Railway Safety Directorate each occurrence of a suspension bearing found overheated or failing while in service.

The Board's attention should be drawn to Amendment Schedule No. 21 to the Transportation of Dangerous Goods Regulations which was published in the Canada Gazette, Part 1, on January 21 of this year. This new Amendment, when published, (Canada Gazette 2), will make mandatory the use of the revised tank car standard CAN/CGSB 43.147 94. The revised version will further restrict the use of Class 111A tank cars including the removal of over 80 dangerous goods currently authorized for transportation in these tanks.

R94T0357 - 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 (R94-09)(R94-10)

TSB Recommendation R94-09

Emergency Exit Windows and Hammers

The Board recommended that:

TSB Recommendation R94-10

Instructions Regarding Emergency Windows

The Department of Transport, as a matter of urgency, assure that sufficient instructions, for the quick and easy breaking of emergency window exits on VIA LRC coaches and club cars, are clearly conveyed to passengers. (R94-10, issued December 1994)

Transport Canada's Response (R94-09 and R94-10)

(signed by the Minister on January 18, 1995)

Immediately following the accident, Surface Group Safety Officers undertook several safety measures two of which related to the subject of the TSB recommendations. Action has been taken by Transport Canada and VIA Rail in both cases.

Regarding Recommendation R94-09, VIA Rail is already in the process of equipping its LRC passenger cars with hammers of a modified design that are of suitable dimensions, weight and hardness, to adequately break the windows and replacement should be completed by the middle of January 1995. These hammers have been tested to ensure they perform as intended. In addition, the Department is pursuing the issue to ensure that such hammers are also included in conventional (non LRC) equipment.

With respect to recommendation R94-10, the Department is working with VIA to evaluate not only information regarding the window exits, but also emergency evacuation systems, including lighting and signing, the adequacy and location of medical kits and on-board staff first aid training on all passenger equipment.

A number of additional aspects are also being examined including:

• location and signage of emergency tool kits,
• adequacy of evacuation procedures,
• simulation of emergency procedures,
• clearing of railway rights of way of rail and other track material,
• locomotive design, including fuel tank integrity, and
• passenger briefing on safety procedures.

In the interim, any additional information that the TSB may have collected during the investigation would be appreciated by the Department.

The TSB issued 8 other recommendations (R96-05, R96-06, R96-07, R96-08, R96-09, R96-10, R96-11 and R96-12) in the Final Report, as described hereafter.

R93Q0020 - Via Rail Inc. - Derailment, Via Train no. 134-08, Mile 17.53, Saint-Maurice Subdivision, Rapide Blanc, Quebec, 9 April 1993 (R94-11)

TSB Recommendation R94-11

Emergency Broadcast Capability

The Board recommends that:

The Department of Transport review the type of communication facilities and procedures used on passenger trains operated in Canada to ensure an effective emergency broadcast capability. R94-11

Transport Canada's Response R94-11

(signed by the Minister on March 10, 1995)

Surface Group Safety Officers are presently reviewing the type and capabilities of the communication equipment, facilities and procedures presently being used on passenger trains operated in Canada to ensure an effective emergency broadcast capability. This will include an analysis of the location and effectiveness of radio towers and the portable equipment required to maintain effective communications. Particular attention will be placed on remote areas and dead spots. Once the information has been gathered and analysed, appropriate action will be taken. A preliminary review indicates that VIA has already taken some action to improve the capabilities of portable radios on remote area services. The Board will be informed of developments as they become available.

The Board made reference, in the preamble, to a washout on the Kinghorn subdivision. In our reply to Draft report R94W0101, we indicated that CN identified certain areas presenting a potential threat for land and rock slide during spring runoff on the Kinghorn subdivision. CN will apply train speed restrictions of 10 mph at these locations during spring runoff to eliminate any threat to safe railway operations.

In addition, CN has set up a Water Management Program to help employees across Canada meet the several challenges presented by water. A video about abnormal water conditions and posters illustrating the safe handling of drainage problems are now used during an awareness campaign for track maintenance employees, local supervisors, rail traffic controllers and train crews nation wide. They are also developing a technical manual and a training video that will cover such topics as natural drainage systems, the composition of the roadbed, the unplugging of blocked culverts, nuisance beaver removal, the correct way to dismantle dams and the controlled handling of water.