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Dorval, Quebec, 22 February 2017 – Following the October 2015 uncontrolled movement and derailment of a parked cut of rail cars (a group of cars coupled together) on a non-main track in Montréal, Quebec, the Transportation Safety Board of Canada (TSB) today released its investigation report (R15D0103), citing that human intervention likely put the rail cars in motion.

On 29 October 2015, a cut of 26 empty intermodal cars, which had been previously secured on a storage track near the Canadian Pacific Railway (CP) Hochelaga Yard in Montréal started to roll. The cars rolled uncontrolled about 120 feet before striking a hinged derail. The derail, a mechanical device designed to stop uncontrolled rolling stock and equipment by derailing it, derailed only the first car before getting torn from the track. The remaining cars continued to descend the grade, reaching a second derail located approximately 400 feet further, which led to the derailment of the following four cars. Meanwhile, the first derailed car traveled over an embankment and struck a residential property. The occupants of this property, as well as those of six nearby homes, were evacuated. The residential property, the cars and the track sustained damage. No dangerous goods were involved, and there were no injuries.

The cut of cars had not moved since it was stored in May 2015. Since there had been no reports of extreme weather in the region, and that handbrake effectiveness does not generally degrade over time, the investigation determined that a human intervention had likely reduced the braking force, allowing gravity to set the cars in motion. Despite heightened surveillance in the area, railway personnel had been encountering trespassers regularly along the tracks where the cars were stored. However, the railway did not identify this condition as a hazard when choosing to store cars at this location, and no special inspections of the cars were being conducted.

In Canada, between 2006 and 2015, 397 occurrences involving uncontrolled movements of rolling stock or equipment were reported to the TSB, and about 8% of these occurrences were caused by human intervention. Because it is relatively simple to release the handbrake mechanism on a rail car, stored rail cars are vulnerable to tampering by unauthorized persons. If measures to prevent tampering with hand brakes on cars stored in areas frequented by trespassers are not taken, there is an increased risk that rolling stock will move uncontrolled. The Board has previously issued a recommendation for the requirement of fencing along the railway right-of-way in areas where there are frequent pedestrian incursions (R91-01).

Following the occurrence, CP took a number of additional measures to eliminate trespassing at this location.

See the investigation page for more information.

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Edmonton, Alberta, 20 February 2017 – Following the release of its investigation report (A15F0165) today, the Transportation Safety Board of Canada is reminding aircraft passengers to comply with flight and cabin crew instructions and to wear their seat belts after 21 people were injured during a turbulence event encountered by Air Canada flight ACA088 in December 2015.

On 30 December 2015, a Boeing 777, operating as flight ACA088, departed Shanghai, China at 1123, travelling toward Toronto, Canada. The flight was planned for 13 hours and 40 minutes. About five hours into the flight, the flight crew received a meteorological information bulletin that forecasted an area of severe turbulence over the southern coastal mountains of Alaska. Approximately two and a half hours later, 35 minutes before entering the area of known turbulence, the first officer directed that the inflight service be stopped and that the cabin be secured. Seat belt signs were turned on, and several announcements were made in English, French and Mandarin, stating that the flight was approaching an area of turbulence and asking the passengers to fasten their seat belts. Despite these measures, many passengers were not wearing their seat belts when the flight encountered severe turbulence.

During the turbulence encounter, 21 passengers were injured, one of whom sustained a serious injury. Once the turbulence subsided, first aid was provided on board the aircraft, as the flight diverted to Calgary, Alberta. This short video describes the occurrence and depicts, in a generic aircraft, what effects the forces associated with severe turbulence would have on passengers who are not wearing seat belts. The investigation found that the flight crew's decision to secure the cabin and reduce to turbulence penetration speed contributed to preventing significant numbers of injuries in the cabin and potential damage to the aircraft.

The investigation also determined that the flight crew were last exposed to information on jet streams (fast-flowing air currents) and turbulence in training taken in 2011 and 2012. Air Canada dispatchers had also received training on clear air turbulence weather and jet streams. However, training material given to both pilots and dispatchers did not contain information on the increased likelihood of turbulence through a wide range of altitudes when jet streams cross mountainous terrain. If training material does not contain complete information pertaining to all of the factors that contribute to turbulence, then there is a risk that the best course of action will not be taken.

Following the occurrence, Air Canada issued bulletins providing dispatchers with guidance on reporting and providing information to support flight crews in avoiding turbulence.

See the investigation page for more information.

Published in Transportation Safety Board of Canada
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Sudbury, Ontario, 16 February 2017 – Today the Transportation Safety Board of Canada (TSB) is issuing a recommendation (R17-01) calling for Transport Canada (TC) to develop strategies to reduce the severity of derailments involving dangerous goods. This recommendation was issued as part of its investigation (R15H0013) into the February 2015 derailment and fire involving a Canadian National Railway (CN) crude oil unit freight train near Gogama, Ontario.

On 14 February 2015, a CN unit train transporting 100 tank cars loaded with petroleum products derailed. It was travelling at 38 mph, below the 40 mph speed limit in place at the time. Twenty-nine tank cars of petroleum crude oil derailed and 19 of these breached, releasing 1.7 million litres of product. The crude oil ignited, resulting in fires that burned for 5 days. There were no injuries.

"This accident occurred at a speed below the maximum speed permitted by the Transport Canada approved Rules Respecting Key Trains and Key Routes," said Kathy Fox, Chair of the TSB. "The TSB is concerned that the current speed limits may not be low enough for some trains—particularly unit trains carrying flammable liquids. We are also calling for Transport Canada to look at all of the factors, including speed, which contribute to the severity of derailments, to develop mitigating strategies and to amend the rules accordingly."

The investigation found that the derailment occurred when joint bars in the track failed. Pre-existing fatigue cracks in the joint bars at this location had gone unnoticed in previous inspections. Once the fatigue cracks reached a critical size, the combination of the cold temperatures (-31 °C) and repetitive impacts from train wheels passing over the joint caused the joint bars to fail. These defects went undetected as the training, on-the-job mentoring, and supervisory support that an assistant track supervisor received was insufficient.

The cars in this train were Class 111 tank cars built to the newer CPC-1232 standard. Although this standard requires the cars to have additional protective equipment, the TSB determined that the speed of the train had a direct impact on the severity of the tank-car damage. Additionally, the lack of thermal protection contributed to thermal tears in those cars located in the pool fire, which led to additional product release. Consequently, the cars displayed similar performance issues as in the Lac-Mégantic derailment.

"The Transportation of flammable liquids by rail has been on the TSB Watchlist since 2014", said Chair Fox. "While stronger tank cars are being built, the current ones will be in service for years to come. The risks will also remain until all of the factors leading to derailments and contributing to their severity are mitigated. This is the focus of the recommendation we issued today."

See the investigation page for more information.

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