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Transportation Safety Board of Canada

Transportation Safety Board of Canada (340)

Calgary, Alberta, 17 December 2014 – In its investigation report (R13C0069) released today, the Transportation Safety Board of Canada (TSB) identified intense and unprecedented flooding as the major factor contributing to the failure of the Bonnybrook Bridge in June 2013. A Canadian Pacific Railway (CP) freight train derailed six tank cars. There were no injuries in the accident and the tank cars were safely removed without spill or damage to the environment.

On 27 June 2013, at 03:20 Mountain Daylight Time, a CP freight train, proceeding eastward from Calgary to Medicine Hat, Alberta, derailed six tank cars which remained upright on the Bonnybrook Bridge. The original single track bridge had been built in 1897, was expanded to accommodate an additional two tracks in 1912, and another bridge for a fourth track was added in 1969. The bridge failed at Pier No. 2 of the original bridge under the 67th and 68th cars.

A comprehensive examination of the bridge failure was conducted. It revealed that flood water flow had attacked the shale bedrock/clay pier foundation, eroding and undermining it. Scouring action of the flooding Bow River on the downstream end of Pier No. 2 resulted in a loss of foundation support to the pier.

The investigation determined that train handling did not contribute to the accident, and the CP inspections of the bridge before the accident exceeded Transport Canada requirements. It also highlighted that the unified command structure initiated by the City of Calgary Fire Department worked well in securing the site and in developing and executing the plan to safely remove the derailed cars from the bridge.

Following the accident, Transport Canada issued a number of safety communications regarding bridge inspections to all railway companies. In addition, CP revised its bridge inspection practices, its inspector training program and is investing in research for the early detection of scour and erosion at railway bridges.

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Calgary, Alberta, 16 December 2015 – Today the Transportation Safety Board of Canada (TSB) released its investigation report (R13C0049) into a May 2013 collision between two Canadian Pacific Railway (CP) trains just east of Dunmore, Alberta. The accident highlights the need for action on two of the TSB's Watchlist issues: following railway signal indications and on-board video and voice recorders.

On 18 May 2013, at about 1330 Mountain Daylight Time, a westbound CP train, approaching Dunmore on the Maple Creek Subdivision, passed a stop signal and struck the side of an eastbound CP train that was leaving Dunmore. Two locomotives and four cars derailed; a number of other cars were damaged but there was no impact to the environment. A train conductor suffered minor injuries.

The investigation found that the attention of the crew members on the westward train was likely diverted away from the task of establishing a common understanding of the wayside signals by the demands of other operational tasks. The train was then operated as though the way was clear. Because these occurrences continue to happen, the TSB has called for additional physical safety defences to ensure that railway signal indications governing operating speed or operating limits are consistently recognized and followed.

The investigation further found that until locomotive in-cab video and voice recorders are installed on lead locomotives, there is a risk that valuable information will continue to be unavailable. Objective data is integral in helping investigators understand the sequence of events leading to an accident and in identifying operational issues and human factors. That is why the TSB has called on the railway industry to ensure communications in the locomotive cab are recorded, and is committed to working with Transport Canada and the industry to remove any legislative barriers that would prevent the installation of these devices.

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Calgary, Alberta, 15 December 2014 - The Transportation Safety Board of Canada (TSB) will be available to the news media to discuss the release of its investigation report (R13C0069) into the bridge failure and derailment of Canadian Pacific Railway freight train at Calgary’s Bonnybrook Bridge in 2013. The Investigator-in-Charge will make a short presentation and then be available to answer questions. A French language spokesperson will be available by telephone.

When:

17 December 2014 at 10:00 am. Mountain Standard Time

Where:

The Joffre Room, Conference Centre, Area 160
Harry Hays Building, 220 4th Avenue S.E.
Calgary, Alberta T2G 4X3

Who:

George Fowler, Investigator-in-Charge
A French language spokesperson is available by telephone at (819) 994-8053.

This event is for media only. Media representatives will need to show their outlet identification.


The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. 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.

For more information or to schedule an interview, please contact:
Transportation Safety Board of Canada
Media Relations
819-994-8053

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Toronto, Ontario, 11 December 2014 – In its investigation report (R13T0060) released today, the Transportation Safety Board of Canada (TSB) determined that a rail fracture caused by the impact of a broken wheel led to the derailment of a Canadian Pacific (CP) freight train near White River, Ontario. Three Class 111 tank cars released product. Two of the tank cars released petroleum crude oil and one released canola oil as a result of the accident. There were no injuries.

On 3 April 2013, a CP freight train, travelling from Edmonton, Alberta to Toronto, Ontario, experienced an undesired emergency brake application near White River. This occurs automatically when air pressure in a train's braking system is interrupted anywhere along the train. Twenty-two cars derailed, nine of which were Class 111 tank cars. Seven of nine tank cars contained dangerous goods (petroleum crude oil – UN 1267). During the derailment, several cars rolled down an embankment. Two of the Class 111 tank cars released almost 102,000 litres of crude oil, while another Class 111 tank car released 18,000 litres of canola oil, which is not considered a dangerous good.

The investigation determined that there were no issues with respect to train handling and there were no track defects in the area of the derailment. Four days prior to the occurrence, a trackside wheel impact load detection system had recorded a wheel impact that was greater than the Association of American Railroads (AAR) wheel removal threshold, but company guidelines permitted the wheel to remain in service. Subsequently the wheel failed, fractured the rail, and caused the derailment. The top and bottom fittings on the dangerous goods tank cars did not adequately protect against product release during the derailment.

Following the occurrence, Transport Canada and the AAR began discussions on design improvements to Class 111 tank car bottom outlet valves to prevent product releases during a derailment. The AAR has since proposed design improvements to tank car bottom outlet valves.

The transportation of flammable liquids by rail is a Watchlist issue.

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Gatineau, Quebec, 10 December 2014 – The Transportation Safety Board of Canada today released its investigation report (M13C0071) into the striking and subsequent grounding of the cargo ship Claude A. Desgagnes in the St. Lawrence Seaway near Iroquois, Ontario on 6 November 2013.

The investigation found that, as the vessel proceeded downriver, the pilot and master of the Claude A. Desgagnes disagreed on manoeuvres to use while approaching the Iroquois Lock. They both knew that the vessel's speed of approach needed to be reduced; however, each thought that a different method was the best way to slow the vessel. As a result, the vessel was not slowed by any means, continued on its path and struck the Iroquois Lock upper approach wall. Following the striking, they attempted to realign the vessel, but they were unable to regain control. The vessel crossed the channel and ran aground.

Although normal procedures state that the pilot issues orders and advises the master, the master is ultimately responsible for the safety of the vessel and for all decisions made, including which orders to enact.

The challenge in crew communications found in this occurrence is consistent with the findings of TSB's safety issues investigation (SII) of 1995: A Safety Study of the Operational Relationship between Ship Masters/Watchkeeping Officers and Marine Pilots.” The SII determined that misunderstandings between masters and pilots, often caused by a lack of adequate communication, were a significant factor in many marine occurrences involving piloted vessels.

After this occurrence, the owner, Transport Desgagnés Inc., revised and updated its Bridge Manual Instructions.

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Gatineau, Quebec, 26 November 2014 – Through its updated Watchlist for 2014, the Transportation Safety Board of Canada (TSB) is once again raising awareness about the safety issues that pose the greatest risk to Canada’s marine, rail, and air transportation sectors.

“Our role at the TSB is to shine a spotlight on the areas where strong action must be taken by the regulator and transportation industry officials, and our evidence is found in hundreds of accident investigations, thousands of hours of research, and dozens of TSB recommendations,” said Kathy Fox, Chair of the TSB.

On this Watchlist, the one multi-modal issue is safety management and Transport Canada (TC) oversight. While all federally-regulated rail companies are required to have safety management systems (SMS), not all operators in the marine and air industry are required to have formal safety management processes to manage their risks. The TSB is therefore asking TC to require all companies to implement some formalized process to proactively identify and reduce risk.

In addition, in recent investigations, including the one into the tragic accident in Lac-Mégantic, the TSB has identified problems with TC oversight, including a failure to identify companies' ineffective processes, and an imbalance between auditing processes versus traditional inspections.

“An SMS on its own is not enough,” added Ms Fox. “That's why we are also calling on TC to regularly oversee all safety management systems and processes to ensure they are effective. And when transportation companies are unable to effectively manage safety, TC must intervene in a way that succeeds in changing unsafe operating practices.”

Furthermore, the TSB is calling on TC to ensure flammable liquids are safely transported by rail by requiring railway companies to properly classify these products, ship them in containers of the safest design, and conduct a route risk assessment to proactively mitigate risks.

Despite some progress on issues included on previous Watchlists—there are still persistent risks in all modes. On our waterways, too many Canadian fishermen are still losing their lives each year. In rail, the number of collisions with vehicles at railway crossings remains high; the problem of railway signal indications not being recognized and followed continues; and there is still no requirement for on-board locomotive video and voice recorders. And in the air industry, approach-and-landing accidents continue to occur; and there is still an ongoing risk of aircraft colliding with vehicles or other aircraft at airports.

“For each of the issues identified on our Watchlist—issues supported by our science, and our thorough examination of the facts and findings in every accident we investigate—we believe actions taken to date are insufficient,” added Ms Fox. “We expect Transport Canada and the transportation industry to take concrete steps to eliminate those identified risks. Canadians deserve no less than the safest possible transportation system.”

WATCHLIST 2014 ISSUES

Multi-modal

Safety management and oversight

Marine

Loss of life on fishing vessels

Rail

Following railway signal indications
On-board video and voice recorders
Railway crossing safety
Transportation of flammable liquids by rail

Air

Approach-and-landing accidents
Risk of collisions on runways

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Edmonton, Alberta, 4 December 2014 – In its investigation report (P13H0013) released today, the Transportation Safety Board of Canada (TSB) cited a number of causal factors that led to the February 2013 crude oil pipeline leak near Wrigley, Northwest Territories. The report highlights the use of methanol as a drying agent following pneumatic testing and high residual tensile stresses in the vicinity of the girth weld as contributing factors to the internal stress corrosion cracking which caused the leak.

On 8 February 2013, a pipeline crew was performing a planned investigative dig at kilometer post 391 of Enbridge Pipelines Inc.'s Line 21 as part of its integrity management program. During the excavation, odours and crude oil sheen were noticed. Further examination revealed a crack on the pipe surface near a girth weld. Although no free standing oil was present, approximately 54 cubic meters of oil-contaminated soil was removed from the site during clean-up.

The investigation determined that the pipeline failure was a result of internal stress corrosion through 98% of the pipe wall thickness, and had likely initiated prior to Line 21 being commissioned in 1985. The investigation also determined that the methanol used as a drying agent following the pneumatic test at the time of construction had likely produced an internal pipe environment conducive to the initiation and propagation of stress corrosion cracking. The crack propagated through the remaining 2% of the pipe wall thickness as a result of fatigue caused by normal pipeline operations.

The National Energy Board issued Order AO-002-SO-E102-2011 on 22 March 2013, requiring Enbridge to complete an additional engineering assessment on the Wrigley-Mackenzie segment of Line 21 to evaluate the fitness-for-service of that segment from a leak-dependent perspective; to submit an assessment of currently available leak detection technologies to determine which is most applicable to Line 21; to submit a plan outlining how and when it will implement the selected technology; to conduct a leak detection and soil contamination assessment at any remaining excavation sites that would not be assessed before the spring 2013 break-up; and to continue to consult with potentially affected people about the incidents and remediation to be taken on Line 21. Enbridge has since complied with all conditions of the Order.

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Gatineau, Quebec, 24 November 2014 – Following a catastrophic failure on one of the cargo handling cranes aboard the bulk carrier Seapace in Bécancour, Quebec, the Transportation Safety Board of Canada (TSB) today issued a warning to vessel owners.

On 13 August 2014, the bulk carrier Seapace sustained a failure of its cargo crane #4. The slewing ring bearing broke apart and the complete cabin and jib assemblies collapsed into a cargo hold, injuring the crane operator. The TSB is participating in the investigation of the occurrence with Transport Malta’s Marine Safety Investigation Unit.

There is a possibility that the same progressive failure of a slewing ring bearing will occur on any vessel fitted with similar cargo handling cranes. While the TSB has asked the International Association of Classification Societies (IACS) to share information about the safety risks, there is no known central database of such vessel owners. The TSB is therefore communicating this message to help reach vessel owners.

The bulk carrier is one of a series of 443 sister ships that were constructed between 2008 and 2014, by various shipyards located in China. The cargo handling crane was built for Ishikawajima-Harima Heavy Industries Co. Ltd. (IHI) of Japan, under licence by Wuhan Marine Machinery Plant Co. Ltd. (WMMP) of China. It was an electro-hydraulic jib crane of the slim type SS36T (serial number DC09-11102-4). The slewing ring bearing assembly was fabricated by Dalian Metallurgical Bearing Co. Ltd. of China under the standard JB/T2300 of the type 133.34.2300.00.03 (2-row roller slewing ring bearing with internal gear, serial number D00984). For pictures of the occurrence, visit our Flickr page.

Vessel owners should take whatever measures considered appropriate to ensure the integrity of any similar unit in service on board vessels. The TSB would appreciate being advised of any measures implemented either by phone at 1-800-387-3557 or by email at This email address is being protected from spambots. You need JavaScript enabled to view it..

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Ottawa, Ontario, 24 November 2014 - The Transportation Safety Board of Canada (TSB) will hold a news conference to release its 2014 Watchlist. The Watchlist contains the issues that the TSB considers to be the biggest risk to Canada’s transportation system.

When:

26 November 2014 at 1:30 pm. Eastern Savings Time

Where:

Lady Elgin Room
Lord Elgin Hotel
100 Elgin Street, Ottawa, Ontario

Who:

Kathy Fox, Chair
Faye Ackermans, Member of the Board
John Clarkson, Member of the Board
Joseph Hincke, Member of the Board

This event is for media only. Media representatives will need to show their outlet identification.


The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. 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.

For more information or to schedule an interview, please contact:
Transportation Safety Board of Canada
Media Relations
819-994-8053

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Vancouver, British Colombia, 21 November 2014 – In its investigation report (M14P0023) released today on the February 2014 loss of propulsion of a tug on the South Arm Fraser River in British Columbia, the Transportation Safety Board of Canada (TSB) highlighted the need to follow manufacturer’s recommendations for engine maintenance.

On 11 February 2014, the tug Jose Narvaez sustained a loss of propulsion due to a main engine seizure while towing an empty barge down the South Arm Fraser River in British Columbia. The tug and barge were towed back to the dock and secured. The main engine was deemed a constructive loss. There were no injuries or pollution.

The investigation determined that the lubricating oil was contaminated with combustion, freshwater, and/or anti-freeze, because the system had never been completely flushed out and cleaned after past major engine failures—even though this was recommended by the manufacturer. Investigators also found that the oil cooler was not maintained as per the manufacturer's recommendations, and it developed internal leaks that further contaminated the oil system, ultimately resulting in a loss in oil pressure. Furthermore, the loss of lubrication and piston cooling caused by the contaminated oil caused the engine cylinders to overheat. This further exacerbated the overheating of the rest of the engine and eventually led to its seizure and loss of propulsion.

Following the occurrence, Lafarge, the owner/operator of the tug, initiated weekly meetings to review safety procedures, drills, and preventive maintenance at the beginning of a shift. They also replaced the main engine and the cooling system on the Jose Narvaez, including upgrades to the monitoring system and alarm panel.

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