THE TRANSPORTATION SAFETY BOARD OF CANADA ISSUES THREE RECOMMENDATIONS IN ITS FINAL INVESTIGATION REPORT ON THE RAILWAY ACCIDENT IN MONT-SAINT-HILAIRE, QUEBEC
(Gatineau, Quebec) 26 September 2002 - The Transportation Safety Board of Canada (TSB) issued three recommendations in its final investigation report on the derailment and collision of two Canadian National (CN) trains that occurred 30 December 1999 in Mont-Saint-Hilaire, Quebec. Two people were fatally injured in the accident.
In its final report published today, the TSB recommended that Transport Canada review the regulations on emergency response plans for the transportation of hydrocarbons, the design specifications for event recorders, and the requirements for the quality control of thermite welds.
The investigation highlighted some weaknesses in the regulations concerning unit trains, such as the Ultratrain, carrying liquid hydrocarbons in urban areas. According to the Transportation of Dangerous Goods Regulations, neither the shippers nor the transporters are required to establish emergency response plans for the transportation of liquid hydrocarbons.
The event recorders of the two locomotives were damaged as a result of the fire, and the data could not be retrieved. Information on the train's movements just before the accident is critical to understand rail accidents.
The investigation also revealed weaknesses in the existing inspection procedures and quality control of field welds. The quality assurance system in place did not detect the welds that did not meet the company's standards (mismatch between rail ends, absence of a weld tag, weld not entered in the inventory of continuous welded rail [CWR] repairs and adjustments.)
The Board also raised a safety concern relating to the fact that shipping documents accompanying the cars may be electronic copies generated using the electronic data interchange (EDI) system. Many people enter data in the system, but there is no control system to identify errors and correct them. The shipping documents contain information on the products and quantities carried by trains; their accuracy is therefore essential to emergency response plans. The Board is concerned about the risks relating to the potential inaccuracies because erroneous data used in an emergency response can expose emergency response personnel and the general public to unsafe conditions.
Background__On 30 December 1999, at approximately 1900 eastern standard time, CN Ultratrain No. U-783-21-30 (783) was travelling westward from Saint-Romuald, Quebec, on the north track of the Saint-Hyacinthe Subdivision. Near Mont-Saint-Hilaire, cars from train 783 derailed, fouling the adjacent south track. CN Ultratrain No. M-306-31-30 (306), which was travelling eastward on the south track at the time, collided with the cars of train 783 as they derailed. There was an explosion and some cars burned for more than four days, creating a smoke plume about 500 m high. The two crew members on train 306 were fatally injured in the accident. Approximately 350 families had to be temporarily evacuated. Two locomotives and 61 cars were damaged in the accident. Approximately 2.7 million litres of hydrocarbons spilled and caught fire, damaging private property, public property and the environment.
The Transportation Safety Board of Canada is an independent agency operating under its own Act of Parliament. 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.
The report R99H0010 and Chairperson's speech are also available on this site.
TSB Rail Safety Recommendations
as a Result of the Accident in Mont-Saint-Hilaire
During its investigation, the Transportation Safety Board of Canada (TSB) identified all related factors susceptible to compromise rail safety. The Board recognizes that some progress has been made to reduce the risks; however, several other critical deficiencies were not addressed. The TSB has therefore issued three safety recommendations to encourage the railway industry and the regulators to quickly take the necessary corrective action.
Regulations on Emergency Response Plans for the Transportation of Hydrocarbons
The introduction of unit trains carrying liquid hydrocarbons through urban areas creates unusual operating conditions that are not adequately addressed by the existing safety regulations. No emergency response plan, where roles, resources and priorities for emergency response are well defined, is required by regulations. The Board thinks that, without such an emergency response plan, it is difficult to ensure immediate implementation of the appropriate action and to reduce the risks in the event of an accident. Therefore, the Board recommends that:
Design Specifications for Event Recorders
In order to advance rail safety, information contained in the event recorders is critical. Without that information, it can be difficult, even impossible, to understand the nature of accidents or certain parts of an accident. In this accident, the data would have been saved had crashworthiness standards been similar to standards in effect in other modes of transportation. Therefore, the Board recommends that:
Requirements for the Quality Control of Thermite Welds
The TSB recognizes the efforts by CN to reduce risks associated with field weld defects. The TSB also acknowledges that the rate of thermite weld defects may have declined and that flash butt welds are gradually replacing thermite field welds.
However, the Board is still concerned and thinks that residual risks need to be reduced further on some sections of track such as main tracks used by high-speed passenger trains or by trains carrying large quantities of dangerous goods (such as the Ultratrain) in urban areas. Welds are critical elements of the track infrastructure and as such need particular attention. Therefore, the Board recommends that: