The Transportation Safety Board of Canada (TSB) found that inadequate securement and insufficient employee supervision led to the March 2016 uncontrolled movement of a tank car in Regina, Saskatchewan. The results of the investigation are detailed in the report (R16W0059) released today.
On 1 March 2016, while a Cando Rail Services assignment was switching tank cars loaded with asphalt at the Co-op refinery in Regina, one of the tank cars rolled away uncontrolled. The tank car, which travelled about 2.7 miles (4.3 kilometres) before coming to rest, reached a speed of 19 mph and traversed seven public crossings and a railway interlocking that crossed the Canadian Pacific Railway Lanigan Subdivision. The grade crossing warning system at each of the seven crossings functioned as required, protecting the roadway traffic. There were no injuries nor dangerous goods involved.
The investigation determined that the incident occurred when the crew left the tank car unattended, secured only by emergency air brakes. These slowly lost pressure until they released, allowing the car to roll away. Hand brakes had not been applied to the unattended equipment, nor had crew members performed hand brake effectiveness tests, conducted a briefing with all crew members, or initiated an emergency radio broadcast when the tank car rolled away. Although the crew did attempt to catch the runaway car with their locomotive, they were unable to do so without violating the restrictions of their operating limits.
The TSB’s investigation revealed that routine adaptations to rules and procedures by employees went undetected by the company prior to the incident. If adaptations are made to operating rules and procedures, safety margins built into the rules are often reduced, increasing the risk of unsafe operations and accidents.
Most uncontrolled railway movements in Canada are directly related to securement issues. Following the 2013 Lac-Mégantic accident, the TSB recommended that Transport Canada (TC) require Canadian railways to put additional physical defences in place to prevent runaway equipment (TSB Recommendation R14-04). Although TC revised the rules regarding train securement, the report indicates that the number of runaway equipment occurrences due to inadequate train securement had increased, from 21 in 2014 to 33 in 2015. There were 27 in 2016.
Following this occurrence, Cando Rail Services took a number of measures to increase the safety of its operations. This included issuing a system-wide bulletin requiring that all equipment have the minimum number of hand brakes applied, even if attended by an employee.
See the investigation page for more information.
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.
Photo from: www.candoltd.com