TSB Reports - Rail 1999

The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

Railway Investigation Report Derailment/Collision
VIA Rail Canada Inc.
Passenger Train No. 74
Mile 46.7, Canadian National Chatham Subdivision
Thamesville, Ontario
23 April 1999

Report Number R99H0007

Synopsis

On 23 April 1999, at approximately 1200 eastern daylight time, VIA Rail Canada Inc. train No. 74, travelling eastward on the north main track of the Canadian National Chatham Subdivision, at Thamesville, Ontario, encountered a reversed switch, crossed over to the south main track and derailed at Mile 46.7. The derailed train collided with stationary rail cars on an adjacent yard track. The three cars that were struck were loaded with ammonium nitrate. All four passenger cars and the locomotive of the passenger train derailed as well as four of the stationary cars on the adjacent yard track. The two train crew members in the locomotive cab were fatally injured. Seventy-seven of the 186 passengers and crew on board were treated at hospital. Four people were admitted with serious injuries. Numerous others received first aid on site. Approximately 50 m of main track and 100 m of the adjacent yard track were destroyed. The locomotive was damaged beyond repair and the leading two passenger cars sustained substantial damage.

Section 3 of this report contains the Board's findings. The Board has identified safety deficiencies relating to the level of defences associated with the Occupancy Control System method of train control, particularly in "dark territory," where trains are not always provided with sufficient advance warning of reversed main track switches, and to the storage of dangerous goods in rail cars for prolonged periods of time at locations adjacent to main tracks. Section 4 lists the safety action taken by the industry and Transport Canada. The Board has made three recommendations to address the outstanding safety deficiencies. The first two recommendations are with respect to train operations in "dark territory" and the third recommendation is aimed at clarifying the regulations with respect to the ad hoc storage of dangerous goods. In addition, the Board set out its concern about the need to eliminate some passenger safety hazards in a timely fashion.

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1.0 Factual Information

5.0 Appendices

List of Tables

List of Figures

1.0 Factual Information

1.1 The Accident

At approximately 1200 eastern daylight time (EDT)⁽¹⁾ on 23 April 1999, VIA Rail Canada Inc. (VIA) eastward passenger train No. 74, consisting of one locomotive and four cars, originating at Windsor, Ontario, came upon a reversed⁽²⁾ main track crossover⁽³⁾ switch in the north main track at Mile 46.72 of the Canadian National (CN) Chatham Subdivision at Thamesville, Ontario. The train brakes were placed in emergency while the train was travelling at 80 mph, approximately 180 m from the switch. The train entered the crossover at 74 mph, exited the crossover, derailed and struck 3 of 13 stationary cars on an adjacent track. It was travelling at 68 mph when it collided with the stationary cars loaded with ammonium nitrate.

The derailment and subsequent collision resulted in the death of both operating crew members in the cab of the locomotive. Seventy-seven of the 186 passengers and crew members on board were treated at hospital. Four people were admitted with serious injuries⁽⁴⁾. Numerous others received first aid on site. Approximately 300 tons of spilled ammonium nitrate, an oxidizer, presented considerable potential for fire or explosion. The spilled ammonium nitrate was distributed throughout the derailment area but was concentrated primarily on the south side. When ammonium nitrate is mixed with diesel oil, suitably compacted and exposed to a source of ignition, the risk of explosion is greater; however, there was no fire and the integrity of the locomotive fuel tank was not seriously compromised.

First responders arrived on site within four minutes. They immediately assessed the risks associated with the spilled ammonium nitrate and mitigated the risks by stopping a small fuel leak in the locomotive fuel tank, limiting access and preventing post-accident ignition sources. The contents of the locomotive fuel tank, approximately 1,500 gallons (6 800 litres) of diesel oil, were removed. The extent to which diesel fuel mixed with ammonium nitrate was not quantified; however, most of the diesel fuel that was in the fuel tank at the time of impact was recovered. The evacuation of all passengers and crew members from the train was completed within about 20 minutes. All passengers and crew members were evacuated from the site within 45 minutes. Injured persons were transported to the Chatham-Kent Health Alliance Public General Hospital and the Westover Treatment Centre in Thamesville for treatment.

Figure 1 - Overhead photograph of accident site looking north-west

1.2 Train Operations from Windsor

For the particulars of the CN Chatham Subdivision, see Appendix A (Chatham Subdivision Chart).

The crew members on train 74 commenced duty at 1000 on 23 April 1999 to operate train 74 from Windsor to Toronto, Ontario. Train 74 departed Windsor at 1101 with one locomotive and four cars. The crew members obtained an Occupancy Control System (OCS) clearance giving them authority to operate on the main track of the CN Chatham Subdivision from Mile 105 to Kent, Mile 62.4. The Chatham Subdivision consists of a single main track between Windsor and Kent.

1.2.1 Windsor to Northwood

At approximately 1130, the crew members on train 74 were issued a subsequent OCS clearance authorizing them to proceed on the north track from Kent to Glencoe, Mile 27.8. There are two main tracks between Kent and Glencoe. The clearance contained a number of restrictions, including one requiring the crew to obtain permission from a work train, train 319, to operate within their limits, as well as a number of warnings for switches in the reversed position.

Approaching Northwood, Mile 52.5, the crew on train 74 contacted the crew on train 319 and requested permission to operate between Mile 54 and Mile 46 on the north track. Train 74 was given permission by the crew on train 319 to operate within the stated mileages without restriction.

Figure 2 - Schematic of Northwood and Thamesville

1.2.2 Approaching Thamesville

Approaching Thamesville, Mile 46.7, from the west, the track is tangent. Maximum permissible speed for passenger trains, travelling eastward on the north track, was 80 mph. Highway 21 and County Road 2 intersect the Chatham Subdivision at Mile 46.75 and Mile 46.43 respectively. There was an agricultural co-op facility on the north side of the railway right-of-way and there were a number of tracks immediately adjacent to the main tracks on either side used for switching and storage. On the track south of the south main track, CB40, there were 13 stationary cars. The four cars at the west end of the cut of cars were each loaded with approximately 100 tons of ammonium nitrate. There was a crossover track approximately 100 feet (30 m) east of Highway 21 connecting the north and south main tracks with switches at Mile 46.72 in the north track and Mile 46.68 in the south track. Both of these switches were in the reversed position.

West crossover switch, Mile 46.72, lined and locked in the reversed position

Figure 3 - West crossover switch, Mile 46.72, lined and locked in the reversed position

The crew on train 74 placed the train brakes in emergency approximately 600 feet (180 m) before the west crossover switch. Examination of the locomotive indicated that the emergency brake handle on the conductor's side of the locomotive had been pulled. In addition, the engine stop button on the locomotive engineer's side of the locomotive had been depressed, shutting off the diesel engine. An emergency message was transmitted on the train standby channel at about this time to an opposing VIA passenger train, train 71. Train 71 was approaching Thamesville travelling westward on the south track at approximately 75 mph. The message instructed train 71 to stop and was repeated. Although this transmission was not recorded, its origin was determined to be from the operating cab of the locomotive of train 74.

The locomotive crew members on train 71 were preparing to change radio channels to contact the rail traffic controller (RTC) for additional operating authority as they approached Thamesville. Before changing channels, they received the emergency transmission instructing them to stop, and as the locomotive engineer was applying the brakes, they observed what they believed to be dust and smoke ahead. They unsuccessfully attempted to contact train 74 then placed an emergency radio call to the RTC advising that something had happened at Thamesville. Train 71 continued westward to Thamesville and made a controlled stop just east of the derailed train. The crew members advised the RTC that train 74 was derailed and requested emergency assistance. They then detrained and assisted in the evacuation.

1.3 Occurrence Site Information

1.3.1 Characteristics of the Derailment Area

The accident site was on the southern boundary of the town of Thamesville. Thamesville has a population of 1,000. It is located in south-western Ontario, 65 km west of London and 21 km east of Chatham. Local emergency services include a volunteer fire department and a satellite office of the Chatham-Kent Police. Police, ambulance and hospital services are provided from Chatham. The Chatham-Kent Health Alliance provides emergency services and has a 241-bed capacity at 3 separate hospitals. The topography in the area is flat. Highway 21, a two-lane paved highway, intersects the track at Mile 46.75 at approximately 90 degrees and is protected with flashing lights, bell and gates. Further east, at Mile 46.43, County Road 2, also a two-lane paved highway, intersects the track at 35 degrees, and the crossing is also protected by flashing lights, bell and gates. Land use south of the tracks is primarily agricultural. There was an agricultural co-op facility immediately north of the tracks.

1.3.2 Derailment Sequence

The west crossover switch was found lined and locked for the crossover route. The east crossover switch stand was severely damaged but the switch handle was lined and locked for the crossover route. There was no indication that the east crossover switch point rail had been forced open by any wheel flanges, and the connecting rod from the switch points to the switch stand was not bent in the manner typical of a switch being run through.⁽⁵⁾ This information indicates that the east crossover switch was also lined for the crossover route. Approximately 24 feet (7 m) east of the east crossover switch, the south rail of the south main track was broken. Severe scrapes along the gauge side of the rail continuing westward for approximately 14 feet (4 m) indicated that an extreme lateral force was applied before the rail broke. Marks on the leading wheel set of the first car behind the locomotive and paint marks on the switch stand ties matching the car paint scheme indicate that the east crossover switch was struck by the first car.

Marks on the top of the rail consistent with a wheel flange and extensive damage to the track ties and roadbed indicate that the locomotive derailed approximately 48 feet (15 m) east of the east crossover switch. The head end of the train, after derailing, moved laterally to the south, striking stationary rolling stock on track CB40. The train continued moving eastward striking additional pieces of stationary rolling stock for a distance of approximately 165 feet (50 m), coming to rest with the locomotive on its right side. The four cars of the train derailed, the first three of which were leaning to the right-hand side at decreasing angles from the first to the third.

1.3.3 Particulars of the Track

The main tracks and crossover at the accident location consisted of 115-pound continuous welded rail, manufactured in 1978. The rail was laid on hardwood ties placed at 60 ties per 100 feet (30 m) on crushed rock ballast and secured with four standard track spikes and four standard rail anchors per tie. Track components were in good condition.

A crossover track connected the two main tracks at Thamesville. The crossover consisted of two No. 12 turnouts, each with a standard radius of curvature of 1,104.63 feet (336.7 m), one to the right and one to the left, and switches at Mile 46.72 in the north track (the west crossover switch) and Mile 46.68 in the south track (the east crossover switch). Maximum authorized speed for train movements through this type of crossover is 15 mph; however, such turnouts are designed to handle train movements at up to 30 mph. The switch stands were of the low type, commonly used in main track installations where clearances will not permit the use of a high stand. This type of switch is operated manually by removing a lock, depressing a foot latch and moving a lever that lies horizontal and parallel with the rail, upward in an arc to the vertical position then downward to the horizontal position again on the other side of the switch mechanism, parallel with the rail once again and back into a foot latch. The lock is then reapplied to the foot latch and locked. Although not a formal railway requirement, common practice for the installation and maintenance of this type of switch is that the hand-throw lever be installed with the handle of the lever oriented away from the switch points when the switch is in the normal position⁽⁶⁾, so that derailed rolling stock or dragging equipment, moving in the facing-point direction (towards the switch points), is less likely to reverse the switch.

Each crossover switch was equipped with two targets displaying red for the reversed position and one target displaying green for the normal position (see Figure 3). Affixed to a square steel mast that ascended straight up out of the centre of the switch mechanism was an oval-shaped target 30.5 cm long by 15 cm high. This target had been painted red and had two rectangular pieces of high-intensity reflective material on its surface, one on each side of the centre line. Both the paint and reflective material were soiled and had experienced considerable surface degradation. The bottom of the oval target was about level with the top of the rail. An additional length of square steel rod extended from the top of the mast fastened by a sleeve and securing bolt. Affixed to this extension were two additional targets at 90 degrees to each other, one round and one square. The round target faced the same way as the oval target and was also painted red. The paint was faded and no additional reflective material had been applied. The square target, facing away from the train movement, was painted green. The round target was 20 cm in diameter and the square target was 20 cm by 20 cm. The bottom of these targets was approximately 27 cm above the top of the rail.

TSB investigators approaching the west crossover switch, travelling eastward on the north main track, could identify the red targets from approximately 1,400 feet (425 m). This was done in clear visibility, both from a static Hi-rail vehicle and a slowly approaching locomotive, while actively attempting to locate the switch.

1.3.4 Rail Traffic Control

Train movements on the CN Chatham Subdivision are governed by the OCS authorized by the Canadian Rail Operating Rules (CROR) and supervised by an RTC located in Toronto. There are typically six freight trains and eight passenger trains per day on the Chatham Subdivision.

1.3.5 Weather

At the time of the accident, the temperature was five degrees Celsius with overcast skies, light rain and light winds, reducing the visibility of the track ahead compared with clear conditions.

1.4 Personnel Information

1.4.1 Locomotive Crew on Train 74

There were two locomotive engineers and a locomotive engineer trainee on the train. The locomotive engineer and locomotive engineer trainee who sustained fatal injuries were in the locomotive cab, and the other locomotive engineer was in the club car behind the locomotive. The locomotive engineer trainee was at the controls of the locomotive. All operating crew members were qualified for their positions and met established rest and fitness requirements.

1.4.2 On-Train Service (OTS) Crew on Train 74

There were five on-train service (OTS) crew members on board train 74. The OTS crew comprised one service manager and four senior service attendants. Two senior service attendants were assigned to the club car, one to coach 3351 and one to coach 3313. The senior service attendants assigned to the coaches also shared the duties for coach 3344. All OTS crew members were qualified for their respective positions.

1.4.3 Crew on Train 319

The crew on train 319 consisted of a locomotive engineer, a conductor and a trainman. They were qualified for their respective positions and met established rest and fitness requirements.

1.5 Train Information

Train 74 was an eastward passenger train that operated Sunday, Monday and Friday between Windsor and Toronto. It consisted of one locomotive and four Light, Rapid, Comfortable (LRC) passenger cars, weighed approximately 350 tons and was about 400 feet (120 m) in length.

1.5.1 The Locomotive

Train 74 was powered by a GM F40PH-2D locomotive, manufactured in July 1987 by General Motors (GM) of Canada. This type of locomotive is configured with the short hood leading. The car body is fully enclosed, providing internal walkways for access to the engine room. It is a four-axle, 3,000-horsepower diesel-electric locomotive intended for passenger service. The main generator of the locomotive converts mechanical energy created by the 16-cylinder turbocharged diesel engine into electrical energy. The electrical energy is distributed to four traction motors, each of which is geared to a pair of wheels.

1.5.2 Light, Rapid, Comfortable (LRC) Passenger Cars

Train 74 comprised four LRC passenger cars designed for high-speed service. There are two series of LRC cars built by Bombardier for VIA:

LRC-2 cars (numbered 3300 to 3349);

LRC-3 cars (numbered 3350 to 3375^__coach cars, and

^__

The equipment was marshalled from front to rear as follows:

Club car (LRC-3) 3468^__vestibule doors forward

Coach 03 (LRC-3) 3351^__vestibule doors forward

Coach 04 (LRC-2) 3344^__vestibule doors forward

Coach 05 (LRC-2) 3313^__vestibule doors forward

The car body is an integral welded aluminum construction, except for mechanical subsystems and truck assemblies. Passengers enter and leave the cars through a vestibule area located at one end of the car. Each side of the vestibule is equipped with an electrically controlled sliding side door and a set of manually retractable stairs. A sliding intermediate door separates the vestibule from the passenger seating area. At each end of the car, a sliding end door provides access to adjacent cars.

The interior arrangement includes a galley, two end baggage compartments and two rows of double seats with enclosed baggage compartments mounted overhead. Most passenger seats have adjustable reclining backs and retractable food-service trays. Two washrooms complete the interior structure of the car.

The club car has a seating capacity of 56 people and the coaches can seat 72 people. Club cars are used to accommodate passengers travelling with first class tickets. It is common practice for the club car to be placed either immediately behind the locomotive or at the rear of the train. Both car types have four emergency exit windows, two on each side of the car, two side entrance doors in the vestibule end, and two end doors, one at each end of the car.

1.6 Recorded Information and Train Brake Effectiveness

1.6.1 Locomotive Event Recorder Data from Train 74

Table 1 - Locomotive Event Recorder Information from Train 74

Event	Time (sec)	Brake Pipe Pressure (lb)	Throttle Position	Speed (mph)
	46.3	102	6	80
	47.3	102	6	79
	47.9	102	6	79
	48.1	102	6	79
Brake Pipe Pressure Drops
	48.3	101	6	80
	48.4	91	6	80
	48.5	82	6	80
	48.6	73	6	80
	48.7	65	6	80
	48.8	57	6	80
	48.9	50	6	80
	49.0	44	6	80
Throttle Drops
	49.1	38	1	80
	49.2	33	ID*	80
	49.3	27	ID	80
	49.5	19	ID	80
	49.6	16	ID	80
	49.9	9	ID	80
	50.1	7	ID	80
	50.3	5	ID	79
	50.5	4	ID	79
	50.6	4	ID	79
	50.8	2	ID	79
	50.9	2	ID	79
	51.0	2	ID	79
	51.2	2	ID	79
	51.3	2	ID	78
Brake Pipe Pressure at Minimum
	51.6	1	ID	78
	51.9	1	ID	78
	52.3	1	ID	77
Centre of Victoria Street
	52.9	1	ID	77
	53.0	1	ID	77
	53.3	1	ID	74
Crossover Entrance
	53.9	1	ID	74
	54.3	1	ID	72
	54.9	1	ID	72
	55.3	1	ID	70
	55.9	1	ID	70
	56.3	1	ID	68
Crossover Exit	56.9	1	ID	68
Collision
	57.3	1	ID	57

* ID = Idle

Table 1 illustrates the information retrieved from the locomotive event recorder of train 74 for the period between 1200:46.3 and 1200:57.3. Only the seconds are shown on the table. The following is a summary of the key events:

From Initial Brake Application to Crossover Entry

The emergency brakes were initially applied sometime between 1200:48.1 and 1200:48.3 when the recorded value for brake pipe pressure started to drop. Between 1200:49.0 and 1200:49.2, the throttle dropped from the No. 6 position to idle, consistent with the power cut-off associated with an emergency brake application.

Between 1200:50.1 and 1200:50.3, the recorded speed dropped from 80 mph to 79 mph, and one second later, it dropped to 78 mph. With allowances for the imprecision in event recorder data, the elapsed time from emergency brake application to the beginning of the speed reduction was about 2 to 3 seconds.

Between the time when the brakes were initially applied and just before the locomotive entered the crossover (an elapsed time of about 5 seconds), the train decelerated from 80 mph to 74 mph.

The pneumatic emergency brake application signal travels through the train at the speed of sound, approximately 930 feet (280 m) per second. Given that the train was approximately 400 feet (120 m) in length, the signal commanding emergency braking would have travelled the length of the train in well under a second. However, it would have taken considerably longer for maximum train braking force to be reached due to the time necessary to achieve maximum friction.

Passing Through the Crossover

Between 1200:53.9 and 1200:56.9, the train decelerated from 74 mph to 68 mph.

During Initial Collision

Between 1200:56.9 and 1200:57.3, the train decelerated from 68 mph to 57 mph. It is considered that the collision with the stationary cars occurred at this time.

From Collision to Final Rest

Immediately following the collision, at 1200:57.3, the locomotive event recorder ceased recording data. The train travelled an additional 163 feet and decelerated to 0 mph. It was calculated that this occurred over approximately 4 seconds.

After the emergency brake application was initiated, at between 1200:48.1 and 1200:48.3, until the collision, at between 1200:56.9 and 1200:57.3, the train speed reduced from 80 mph to 68 mph. Approximately 9 seconds elapsed.

1.6.2 Locomotive Event Recorder Information from Train 71

Recorded information indicates that, between 1201:58 and 1204:15, train 71 was slowed from 75 mph to 0 mph. During this period, there was a series of brake pipe pressure reductions and increases indicative of a controlled deceleration of a passenger train with graduated brake capability.

The locomotive event recorders on trains 74 and 71 were not synchronized. Although the comparative record of the elapsed time of any particular event is considered reasonably accurate, the actual initiation of any event may not reflect the exact time.

1.6.3 Train Brake Effectiveness

The TSB compared the initial deceleration of four emergency braking events from similar speeds and trains, using data supplied by VIA. The data reflect emergency brake applications in a variety of track conditions (grade, curvature) and environmental conditions (temperature, precipitation) that are known to result in a wide variability in brake performance. The initial decelerations of these four trains, over the first 5 to 6 seconds after emergency brake application, are summarized in the following table:

Table 2 - Deceleration from Event Recorders

Train	Deceleration (mph per second)⁽⁷⁾
Train 74	1.2 to 1.3
Train A	0.4 to 0.7
Train B	0.4 to 0.7
Train C	1.4 to 1.5
Train D	1.7 to 1.6

The data also indicate that, after the first few seconds, the deceleration rates increased from about 1 mph per second to about 2 mph per second and remained essentially constant.

1.6.4 Calculated Lateral and Longitudinal Forces

TSB engineers examined the dynamics of train 74 throughout its deceleration and its movement through the crossover track at the point of collision and until it came to rest (TSB Engineering Branch report LP 05/99). The following conclusions were made:

Before the collision:

The longitudinal deceleration did not exceed 0.1 g⁽⁸⁾.

Passage through the crossover set up lateral forces due to centripetal acceleration and transferred weight to the wheels on the outside of the curves. The train rocked to the left in the first half of the crossover and then to the right in the second half. The magnitude of this lateral force was calculated to be 0.33 g.

During the collision:

The peak longitudinal deceleration was calculated to be 1.25 g which occurred at the initial collision.

After the collision:

The average longitudinal deceleration following the initial collision was approximately 0.67 g and lasted about 4 seconds.

1.7 Main Track Switches

1.7.1 Procedures for the Use of Hand Operated Switches

CROR Rule 104, which applies to all federally regulated railways, specifies the approved procedures for the operation of hand operated switches, including main track switches. The following procedures are pertinent to this occurrence:

(a)
. . . main track switches must be lined and locked for the main track when not in use. A main track hand operated switch must display a reflectorized target, or light and target, to indicate the following: [green for normal position; red for reversed position]

(b)
When directed by GBO [General Bulletin Order], clearance or special instructions, and protection has been provided against all affected trains or engines, a main track switch may be left lined and locked in the reversed position. When not so directed, it must not be left in the reversed position unless in charge of a switchtender or a crew member who must be in position to restore the switch to its normal position before it is fouled by a train or engine approaching on the main track.

[. . .]

(d)
Except as provided by paragraph (b), the conductor and locomotive engineer must, when practicable, ensure that switches manually operated by their crew members are left in the normal position. Other employees are not relieved of responsibility in properly handling switches.

[. . .]

(f) When a switch has been turned, the points must be examined and the target, reflector or light, if any, observed to ensure that the switch is properly lined.

[. . .]

(n) When a crossover is to be used, the switch in the track on which the train or engine is standing must be reversed first. Both switches must be reversed before a crossover movement is commenced and the movement must be completed before either switch is restored to normal position.

At the time of the occurrence, there were no additional operating procedures requiring specific communication of the position of main track switches among railway employees on CN trackage.

1.7.2 Main Track Switch Targets

In accordance with standard railway operating practices in Canada, main track switch targets are regarded as location indicators used to assist a train crew in pinpointing the exact location of a switch, in addition to indicating the switch position. Unless train crew members have been formally notified that they may encounter a specific switch lined and locked in the reversed position or are instructed to use a specific switch, they are not required to regulate their train speed to be able to stop short of reversed switches. In general, regardless of track curvature or visibility, train crew members are expected to operate their trains as closely as possible to the maximum authorized speed.

1.7.3 Past TSB Safety Action on Main Track Switches

In 1992, the Board issued three recommendations concerning the handling of main track switches subsequent to a hazardous occurrence on the CN Sherbrooke Subdivision in which a VIA passenger train encountered a reversed main track switch near Bromptonville, Quebec (TSB report No. R91D0032).

Recommendation R92-19: The Department of Transport conduct a field audit of current operating practices to confirm the security of main track switches in non-signalled territory.

Recommendation R92-20: The Department of Transport assess locations where main track switches are located in non-signalled territory to ensure that, in the event of a misaligned switch, an emergency stop can be effected by passenger trains before reaching the switch.

Recommendation R92-21: The Department of Transport, in cooperation with the railway industry, sponsor research and development of an electronic method for locomotive crews to ascertain the position of main track switch points sufficiently in advance, so an emergency stop can be made before a misaligned switch.

In 1994, the Department responded that a survey was undertaken of all main track switches in non-signalled subdivisions where passenger trains were scheduled. The results of the survey were addressed with senior officials of CN, Canadian Pacific Railway (CPR) and the Railway Association of Canada (RAC)⁽⁹⁾. As a result of this work, the railways were directed to consider and propose corrective measures with respect to locations where switch target visibility and minimum train braking distances indicated a potential safety risk. This resulted in the removal of some switches and the approach visibility of others being improved. Additionally, Transport Canada (TC) was advised that work was being done to improve the visibility of switch targets in non-signalled territory, with specific attention being given to difficult locations on passenger-carrying tracks.

In August 1993, a VIA passenger train carrying 240 passengers and 18 crew members encountered a reversed main track switch at Mile 58.2 of the CN Sussex Subdivision at approximately 65 mph (TSB report No. R93M0059). The train brakes were placed in emergency approximately 1,000 feet (300 m) before the switch. The train negotiated the switch without derailing at approximately 55 mph. There were no injuries. Subsequently, a TSB Safety Advisory was sent to TC expressing concern that leaving a main track switch lined and locked for a siding and unattended by a switchtender or a member of a train crew creates an unsafe situation. TC responded that CN had been advised to consider improvements to operating rules, training of personnel handling switches, and the visibility of switch targets. CN was also requested to consider the introduction of self-restoring switches⁽¹⁰⁾ in OCS territory and advance warning of the position of switches for train crews. CN has not implemented self-restoring switches in OCS territory on a system-wide basis and no new means of providing advance warning to approaching trains has been established.

In May 1994, the Board noted that, since 1991, there had been at least six occurrences, four of which were in 1994, where trains encountered a switch reversed and the crews were not forewarned of the situation. It was suspected that the occurrence record reflected the improper interpretation and application of new procedures permitting main track switches to be left lined and locked in the reversed position in certain circumstances. In view of the potential for serious collision or derailment, the Board recommended that the Department of Transport examine current field operating practices for the application of Rule 104(b) of the CROR to confirm that adequate protection is being provided against unintentional switching of trains from the main track (Recommendation R94-05).

TC replied that the industry and TC had a number of initiatives underway to ensure compliance with the rule by improving training, supervision and enforcement, and to implement further safeguards to protect trains travelling on non-signalled track. Specifically, TC examined railway operating practices to ensure that train crews handle switches correctly to avoid the problem of trains unexpectedly encountering switches in the reversed position. TC concluded that there was no evidence to support the contention that CROR Rule 104(b) was flawed or unsafe. In addition, TC examined problem sites, "from the engineering perspective," to ensure that train crews have adequate warning should a switch be left in the wrong position. This examination covered non-signalled territory where passenger trains operate at 70 mph and above. TC determined that the larger red target on a high switch stand was visible from a distance of approximately 2,100 feet (640 m), provided it was not obstructed by brush, track curvature, cars in sidings and some weather conditions such as heavy snow or fog. Low stand switches, such as the 36D type used for the crossover switches at Thamesville, were not examined.

In November 1994, TC reported that, on the CN Chatham and Newmarket subdivisions, there was "adequate sighting distances, except at one location. New highly reflectorized material had been placed on all the big switch targets." TC advised that, for another location, CN was developing some type of active signal indicator to give advance warning to train crews that a switch may not be lined for the main track. The device was in the design stage with testing anticipated at a future date; however, at the time of the occurrence, it had not been placed in service. Also, TC indicated that a number of other initiatives were being considered, such as radio procedures, speed restrictions and, for the long term, certain aspects of the Advanced Train Control System (ATCS)⁽¹¹⁾.

In March 1997, TC issued a Notice and Order under Section 31 of the Railway Safety Act instructing CN's RTCs not to act on any information received concerning a main track switch restored to the normal position, unless such information is received from the location of the switch.

In 1993, following a number of incidents involving reversed main track switches, CPR amended the communication requirements contained in CROR Rule 90 for application by train crews on its railway to include the following reference to the main track switch position:

Voice communication - additional requirements

In addition to the requirements of Rule 90, voice communication must be made at the following times and places:
[. . .]

e)
In OCS, immediately before a train or engine enters or leaves a main track through a hand operated switch, stating:
switch location
position, switch is to be left in
clearance number, when switch is left in reversed position Note: Not applicable when switching.

CROR Rule 90 is titled "Communication between Crew Members." This rule and its supporting railway special instructions set out some of the circumstances under which train crew members are required to communicate with each other and, in the case of cabooseless train operations (including passenger trains), make announcements over the designated standby channel.

In October 1994, maximum passenger train speed was increased from 80 mph to 95 mph on the single track portions of the Chatham Subdivision. ATCS research projects were terminated at CN in March 1995 and, at CPR, in March 1996. There are currently no Canadian railways involved in ATCS-related initiatives in Canada.

TC remains an active participant on the Rail Safety Advisory Council in the United States, participating in a number of working groups and examining the implication of new technologies for potential further action in Canada.

1.7.4 TSB Reported Occurrences of Passenger and Freight Trains Encountering Unanticipated Reversed Main Track Switches

The annual numbers of occurrences reported to the TSB wherein trains encountered reversed main track switches are shown in Table 3. The table includes all such occurrences known to the TSB in which a train unexpectedly encountered a main track hand operated switch in the reversed position.

Other occurrences were reported where unauthorized reversed main track switches not known to the RTC were encountered by track and signal maintenance staff. These occurrences are not included in Table 3.

In Centralized Traffic Control System (CTC) and Occupancy Control System (OCS)/Automatic Block Signal System (ABS), advance warning was available to train crews in the form of block signal indications. Consequently, train speeds were regulated approaching reversed switches in most of these occurrences, enabling the trains to stop before fouling the switch. In some occurrences in OCS, advance warning was available in the form of a warning transmitted to the crew and recorded on OCS clearances, but this warning was unsuccessful in eliciting the desired crew response.

Table 3 - Reported Occurrences of Trains Unexpectedly Encountering Reversed Main Track Hand Operated Switches

Year⁽¹²⁾ Passenger
Trains
in CTC Passenger
Trains
in OCS/ABS Passenger
Trains in
OCS
outside
ABS Passenger
Trains in
Yard Limits
or
Cautionary
Limits Freight
Trains
in CTC Freight
Trains in
OCS/ABS Freight
Trains in
OCS
outside
ABS Freight
Trains in
Yard Limits
or
Cautionary
Limits Total

1993 0 0 1 0 0 2 2 0 5

1994 0 0 0 0 3 2 11 0 16

1995 0 0 1 0 2 2 4 0 9

1996 0 0 1 0 0 2 3 0 6

1997 0 0 0 0 0 1 10 0 11

1998 0 0 0 0 3 0 5 0 8

1999 1 0 1 0 3 2 3 0 10

2000 0 0 4 1 0 2 7 0 14

The table shows considerable variability, ranging from a low of 5 in 1993 to a high of 16 in 1994. The annual average is about 10. Only one occurrence involved a "high-speed"⁽¹³⁾ passenger train; however, in other occurrences, the passenger trains were approaching at speeds of up to 70 mph. Passenger trains encounter reversed hand operated switches in non-signalled territory on average about once a year.

1.8 Train 319 Activities

1.8.1 At Windsor, Chatham and Northwood

At 0400, 23 April 1999, a CN train crew was called to operate a work train assignment commencing at 0600 in Windsor. The crew, consisting of a locomotive engineer, a conductor and a trainman, reported for duty at Van der Water Yard in Windsor and then travelled by vehicle to Chatham, departing Windsor at approximately 0630 and arriving Chatham at approximately 0730. Scheduled activities for the day involved working with a track maintenance gang to dump ballast⁽¹⁴⁾ from open top hopper cars on the north main track right-of-way. A crew of four track maintenance employees, including a foreman (ballast gang foreman), was to coordinate with the work train crew to carry out the scheduled activities.

Upon arrival in Chatham, Mile 61.6, the conductor met with the ballast gang foreman to discuss the train movements required. The conductor then briefed the RTC on the anticipated work train movements. Loaded ballast cars located at Thamesville were going to be dumped between Thamesville, Mile 46.7, and Northwood, Mile 52.5. Upon completion, time permitting, the crew would gather the empty ballast cars and take them to London before returning to Chatham. There were 26 empty cars at Chatham. In order to expedite the collection of the empty cars after dumping activities were completed, the conductor arranged to take the empties from Chatham to Northwood, Mile 52.5.

The conductor obtained clearance authority to proceed on the Chatham Subdivision north track from Mile 61 to Mile 54 and a work clearance on the north track between Mile 54 and Mile 46. The conductor rode on the last hopper car between Chatham and Northwood. There was no caboose. The locomotive was in the lead position, but it was facing westward with the long hood leading. There was no pilot⁽¹⁵⁾ on the rear of the locomotive. Railway general operating instructions limit the reverse movement of a locomotive without a pilot at the rear to a maximum speed of 25 mph. The movement reached speeds of 50 mph between Chatham and Northwood.

At 0940, train 319 arrived at Northwood. The crew members planned to set off all cars at Northwood. However, they were only able to set off 17 of the 26 cars because there was a public crossing. The crew members had to avoid placing cars where they would block a motorist's view of approaching trains. They departed Northwood for Thamesville with 9 empty cars at 0955.

1.8.2 At Thamesville

The ballast gang foreman and three track maintenance employees who were to facilitate the dumping of the ballast arrived at Thamesville at approximately 0900. They prepared the loaded cars of ballast for dumping later on. The ballast gang foreman advised the crew on train 319 over the radio that the loaded cars of ballast were on the south side of the south main track on track CB40.

At 1010, train 319 arrived at Thamesville on the north main track and immediately cleared into track CB51, north of the north main track, to allow a track patrol foreman with a Hi-rail vehicle to pass on the north track. Train 319 remained on track CB51 while a passenger train, VIA train 72, passed on the south main track. Subsequently, train 319 obtained an additional work clearance for the south main track between Mile 48 and Mile 45. Train 319 re-entered the north main track and travelled eastward to the main track crossover. The crew then reversed both crossover switches and the train was moved eastward through the crossovers to the south main track. After crossing over, the east crossover switch was restored to the normal position, but the west crossover switch was left in the reversed position. The train continued eastward on the south main track, past the east switch to track CB40, where a crew member reversed the switch and removed the derail. The 9 empty cars were shoved westward into track CB40 and coupled onto 4 loaded cars of ammonium nitrate and 17 loaded cars of ballast which were already on that track. The crew then cut off the locomotive and secured the empty cars. The locomotive was moved eastward back out onto the south main track. The derail was restored and the main track switch at the east end of track CB40 was restored to the normal position.

The locomotive was then moved westward on the south track and stopped clear of the CB40 west main track switch. The switch was reversed, the derail was removed and the locomotive was operated eastward on track CB40 over the Highway 21 crossing and coupled onto the west-end car of the 17 loaded cars of ballast. After the hand brakes were released and the air brakes connected and charged, the locomotive and 17 cars were moved westward back out onto the south main track and stopped clear of the CB40 west switch. When the switch was restored to the normal position and the derail returned to the derailing position, the locomotive and 17 loaded cars of ballast were shoved eastward on the south main track towards the Highway 21 public crossing. The conductor was riding the east-end car and the trainman was on the ground between the two main tracks walking towards the crossing, giving radio instructions to the locomotive engineer concerning vehicle movements in proximity to the crossing and the status of the automatic warning devices⁽¹⁶⁾.

As the movement approached the crossing, the ballast gang foreman inquired over the radio if a train crew member would be available to drive his truck to Northwood. The ballast gang foreman anticipated dumping all the ballast between Thamesville and Northwood. By having his truck moved to Northwood, he would not require a ride back to Thamesville at the completion of the work. The conductor asked the trainman if he would be willing to drive the truck to Northwood and the trainman agreed. Having not previously travelled between these two locations by road, the trainman indicated that he would require directions. He walked to the ballast gang foreman's truck, which was located on a vacant gravel lot belonging to Orford Co-op, just east of Highway 21 and north of the north main track, to speak to the ballast gang foreman. While the trainman was obtaining directions from the ballast gang foreman, the conductor and locomotive engineer moved the train eastward over the Highway 21 crossing, continuing eastward until their locomotive was clear of the east crossover switch.

The plan was to begin dumping ballast immediately west of the crossing on the north main track. Additional ballast was required on the shoulders of the roadbed on the north main track between the Highway 21 crossing in Thamesville and Northwood. Generally, the process of dumping ballast on the shoulder of the track is accomplished by opening the hopper doors on the ballast cars while moving the train slowly in one direction. Railway track maintenance employees position themselves on either side of the cars to facilitate the opening of the hopper doors. The amount of ballast that accumulates in any given spot is regulated by the movement of the train and the extent to which the hopper doors are opened. This activity requires that the train be operated at a speed at which the employees can safely walk alongside the moving train, on the uneven ground, while opening the hopper doors. Further, to avoid gaps in the coverage of new ballast, the hopper doors are usually opened sequentially, moving backward from the first hopper opened.

Since the west crossover switch was still in the reversed position, it was only necessary to reverse the east crossover switch in preparation for the westward movement back over to the north main track. This task was completed by the conductor who then entrained on the locomotive. The following process, or one very similar to it, would have to have been followed to ensure that the two switches were returned to normal position:

The trainman, after receiving directions from the ballast gang foreman, would have to walk southward along the east side of Highway 21, cross the tracks and position himself between the south main track and track CB40, adjacent to the east crossover switch.

The movement would make a brief stop with the locomotive just east of Highway 21, for the ballast gang foreman and track maintenance employees to position themselves on either side of the north track just west of the crossing.

Dumping was to commence just west of the crossing.

As the tail-end car moved west of the east crossover switch, the trainman would restore the switch to the normal position. The trainman would restore the west crossover switch immediately after the last car of the train moved west of that switch and the entire train was on the north main track.

The conductor would request confirmation from the trainman by radio that the crossover switches had been restored to the normal position.

The collective information obtained from the crew members was that they believed that this process had been followed.

Train 319 departed Thamesville at 1056 moving westward at 2 to 3 mph dumping ballast as the ballast gang foreman and track maintenance employees walked alongside. At 1140, the movement was stopped and the ballast gang foreman and his crew boarded the locomotive. Train 319 continued westward to Northwood to clear for trains 74 and 71, arriving at Northwood at 1154 and stopping in the clear at 1156.

The trainman departed Thamesville when the tail end of his train cleared the Highway 21 crossing at approximately 1110. He drove the ballast gang foreman's truck from Thamesville to Kent Bridge where he stopped to check on the progress of his train. He then drove to Northwood where he reversed the east siding switch and removed the derail in order for his train to clear the north main track to allow train 74 to pass.

The locomotive engineer of train 319 gave permission to train 74 to operate on the north main track of the Chatham Subdivision between Mile 54 and Mile 46 without restriction at approximately 1156.

1.9 Vandalism

Between the departure of train 319 from Thamesville and the arrival of train 74 at Thamesville, there was no authorized use of the main track crossover switches. Railway and regional police forces reported no recent acts of vandalism in the Thamesville area. There were no witness accounts of persons in the area of the crossover switches on the day of the accident between the departure of train 319 at approximately 1100 and the arrival of train 74, one hour later.

The crossover switches were secured with high security pad locks. There was no indication that the locks on either of the switches were tampered with. This type of lock gained widespread use in Canada after a VIA passenger train was diverted into a lumber storage track near Ottawa in 1984, colliding with a number of stationary cars after a main track switch had been vandalized. The high security lock was selected because of its rugged design and because the key could not be removed while the lock was open. These features were thought to be more resistant to vandalism. These locks were originally applied to main track switches located in urban areas and close to public road crossings where vandalism most frequently occurs. Their use was subsequently expanded to OCS territory where the provisions of CROR Rule 104(b) were applicable.

1.9.1 Keys for High Security Locks

Keys for high security switch locks were distributed to qualified railway employees. It was determined that, when the locks were originally introduced, the distribution of keys was recorded; however, this practice was not always followed. Although CN and VIA had systems to track which employees had been issued these keys, the issuance of subsequent keys was not consistently recorded.

1.10 Evacuation/Emergency Response

At 1202, an emergency telephone call was made by an employee at the Orford Co-op over the local 911 service. The 911 operator took the initial details of a derailed passenger train and began dispatching emergency services personnel. The train was evacuated in approximately 20 minutes and all passengers were taken off site by approximately 1250.

1.10.1 Passenger and Crew Response

Table 4 represents the train and locomotive consist of train 74 from front to rear and the approximate locations of all passengers and crew.

Table 4 - Passenger and Crew Locations⁽¹⁷⁾

Position in Train	No.	Rolling Stock Type	Passenger Capacity	No. of Passenger	No. of Crew	Total No. of Passengers and Crew
	6423	Locomotive	N/A	0	2	2
1	3468	Club (LRC)	56	19	3	22
2	3351	Coach (LRC)	72	30	1⁽¹⁸⁾	31
3	3344	Coach (LRC)	72	64	1	65
4	3313	Coach (LRC)	72	65	1	66
Total			272	178	8	186

1.10.1.1 Club Car

At the time of the accident, three crew members were in club car 3468 immediately behind the locomotive. They included the second locomotive engineer, the service manager and a senior service attendant. The second locomotive engineer was sitting in the last row of passenger seats on the left side of the car. The service manager was standing at the rear of the car, and the senior service attendant was at the front. All three crew members were thrown forward on impact. The senior service attendant suffered a head injury when he was struck by either unsecured carry-on baggage or a metal emergency tool box stored in the passenger seating area of the car; he experienced transient unconsciousness.

Within minutes, two passengers broke open the L1 (left side, forward) emergency exit window. One of the passengers placed the window curtains over the edge of the window sill so people would not be cut as they climbed out. Approximately 15 passengers evacuated through the L1 window. The senior service attendant was one of the first to be evacuated because of his injury. The second locomotive engineer administered first aid to a passenger who had a severe nosebleed and then he broke open the L2 (left side, aft) emergency exit window and began evacuating passengers. Approximately four passengers evacuated from this exit. All occupants of this car were evacuated to the north side of the track. The service manager determined that none of the injuries to passengers and crew on this car appeared life threatening. Using his portable radio, he attempted to contact the locomotive crew but received no response. Using his cellular phone, he attempted to contact the VIA Operations Control Centre in Montreal, Quebec, but was also unsuccessful.

1.10.1.2 Coach 3351

There were no crew members in the interior of car 3351, located second behind the locomotive, at the time of the accident. Passengers seated adjacent to the R2 (right side, aft) emergency exit window, one of whom was a VIA maintenance employee, broke open the exit window. The R1 (right side, forward) emergency exit window was broken by passengers. Seat cushions were placed on the window sill to protect passengers from being cut as they climbed through the exit window. A senior service attendant, who had been between the first and second cars during the accident, entered the car as the passengers were evacuating. He immediately assumed a leadership role, directing and assisting passengers. He was the last person to exit the car. All occupants of this car evacuated to the south side of the track in proximity to the spilled ammonium nitrate.

1.10.1.3 Coach 3344

On impact, the senior service attendant in car 3344, third behind the locomotive, was thrown approximately 15 m, half the length of the car. Although he incurred fractured ribs, he was able to perform his emergency duties. Using the megaphone to issue commands, he evacuated ambulatory passengers by the north side entrance door of the car and directed emergency response personnel to those passengers who were unable to evacuate the train because of their injuries.

1.10.1.4 Coach 3313

The senior service attendant present in car 3313, the fourth car behind the locomotive and last car in the train, was propelled forward on impact and sustained a head injury. He lost consciousness and was unable to perform his emergency duties. The passengers expected a crew member to tell them what to do and their initial response was to locate travelling companions, administer first aid and collect their carry-on baggage. The passengers made no attempt to exit the car until instructed to do so by first responders approximately 10 minutes after the accident. First responders banged on the end door and shouted for passengers to open it and get out. At least one passenger tried to open the sliding end door but could not. The end door was eventually opened from the outside and passengers began exiting. Shortly thereafter, additional first responders entered the car from the forward vestibule and began evacuating passengers to the north side of the track.

1.10.2 Chatham-Kent Police Service

The Chatham-Kent Police Service was notified at 1203. Officers began arriving on site at approximately 1210. The police assumed a command role and participated in various ways, including but not limited to the following:

evacuating passengers, particularly from the last car on the train;

marshalling passengers who had evacuated on the south side of the track to the north side;

directing passengers to a nearby warehouse for shelter;

securing the accident site;

notifying other appropriate response organizations/individuals of the derailment, as required;

conducting a search of the train to ensure everyone had evacuated;

setting up triage for passengers;

establishing a manifest of all persons who had been on the train;

taking statements from railway employees directly or indirectly involved in the accident;

taking statements from passengers; and

coordinating response activities with all organizations on site.

After assisting in the evacuation, the primary focus of the police involved assessing the need for a criminal investigation and acting on behalf of the coroner.

1.10.3 Chatham-Kent Fire Services

Chatham-Kent Fire Services were notified at 1203 of a train derailment at Thamesville. Beginning at 1206, 33 fire-fighters/rescue personnel and six fire-rescue vehicles from Thamesville and Bothwell volunteer fire stations started to arrive on site. The local fire chief went directly to the locomotive and observed that fuel was leaking from the fuel tank. Orford Co-op staff advised the fire chief that a large quantity of ammonium nitrate had been spilt during the accident. Given the risk of an explosion, fire-fighters focused on eliminating any potential source of ignition and controlling the spillage of diesel fuel. A local company specializing in transportation and clean-up of hazardous material was summoned to the accident site and arrived shortly thereafter. In addition, fire-fighters immediately began evacuating passengers from the club car and directing them away from the area. At approximately 1224, fire inspectors from the Chatham Fire Station arrived with an additional vehicle equipped with specialized equipment for dangerous goods response.

1.10.4 First Aid and Medical Attention

Emergency first aid was administered to some passengers and crew in a small machine shed on the Orford Co-op property just north of the tracks and at the Westover Centre⁽¹⁹⁾ in Thamesville. Twelve ambulances from a number of local communities responded. Those who required further medical attention were taken by ambulance to the Chatham-Kent Health Alliance Public General Hospital in Chatham. A total of 77 passengers and crew were taken to the hospital. Seventy-three were treated and released and four were admitted.

1.10.5 Injuries

	Crew	Passengers	Others	Total
Fatal	2	-	-	2
Serious	1	3	-	4
Minor/None⁽²⁰⁾	5	175	-	180
Total	8	178	-	186

Two train crew members suffered fatal injuries when the locomotive collided with the hopper cars. Three passengers and one OTS crew member were admitted to hospital with serious injuries. These injuries included a fractured hip, a fractured tibia, a fractured frontal sinus, multiple lacerations and soft tissue trauma. Seventy-three other passengers and crew were taken to the hospital, received treatment in the emergency department and were later released. Numerous passengers were provided first-aid treatment on site. Others reported that they went to their family physician when they returned home. All of the passenger injuries were incurred when the passengers were thrown from their seats or when they were struck by unrestrained objects.

The majority of injuries sustained by the OTS crew, all of whom were standing at the time of the accident, were incurred when they were propelled forward through the passenger cars. Two OTS crew members were unable to perform their emergency duties as a result of their injuries. It appears that one of the two incapacitated OTS crew members was also struck by unrestrained carry-on baggage and/or a metal tool box stowed in the passenger seating area.

1.11 Passenger Safety

Numerous issues relating to passenger and crew safety were identified during this investigation. Some of these issues were noted in previous occurrences, others are new. Detailed descriptions, including past TSB safety action and related background information, can be found in Appendix B. In the course of the derailment/collision and subsequent evacuation, a number of these issues were encountered by passengers, crew and first responders and are listed below. Other issues discovered by investigators, but not believed to have played a role in the accident, are also listed below.

1.11.1 Passenger Safety Issues Encountered

The following safety-related issues were encountered by passengers, crew and first responders either during the derailment and collision or in the aftermath.

Secondary Impact Injuries

The TSB injury analysis indicated that many passengers were injured either when they were projected from their seats or struck by other unrestrained passengers.

Emergency Signage^__Manual Operation of LRC Side Doors

Emergency personnel responding to the accident indicated that they had difficulty identifying the emergency access panel because the panel and the signage were not sufficiently conspicuous.

Stowage/Securement of Carry-on Baggage

Unsecured carry-on baggage resulted in passenger injury and was an impediment to the evacuation. It is VIA's policy that items of carry-on baggage, weighing up to a maximum of 50 pounds, be stowed in the end baggage compartments at the "B" end of the passenger cars. This policy allows for excess carry-on baggage to be stored unrestrained in the passenger seating area. End baggage compartments have an open bay design, facilitating easy stowage. VIA does not have a system to inform passengers of this policy or to monitor compliance.

Storage of Emergency Tool Kit in Passenger Seating Area

An unsecured tool box, weighing approximately 20 kg, that had been stored in the end baggage compartment was projected into the passenger seating area. Section 10.19 of the On Board Trains Occupational Safety and Health Regulations states, "Where tools, tool boxes or spare parts are carried on rolling stock, they shall be securely stored."

Passenger Seats

During the accident, one bank of passenger seats (seats 25-26, car 3351) detached from the floor at the attachment point. The seat separated because it was not locked into position. Railway procedures for installation of passenger seats do not indicate how much to tighten the centre locking device or how to determine if and when the seat is locked. Forces generated were of sufficient magnitude to pivot seats that were not locked in position creating an obstruction to passengers and first responders.

OTS Crew Emergency Communication

Hand-held communication devices were projected away from the individuals to whom they were assigned.

Distribution of Portable Communication Systems

Some OTS crew members were provided with radio receivers only and could not communicate safety information.

1.11.2 Potential Passenger Safety Hazards

The following passenger safety-related hazards were not encountered by passengers, crew or first responders, but were identified during the investigation.

Emergency Signage

Emergency signage regarding manual operation of side entrance doors from the interior was incomplete. Emergency signage information regarding the location of emergency exits and the location of emergency equipment was inaccurate in coach cars.

Emergency Information Cards

All the emergency information cards in the coach cars were inaccurate as to the location of the emergency exit windows and emergency equipment. Emergency information cards were not readily apparent or accessible to passengers in aft-facing seats.

Passenger Seats^__Configuration at Emergency Exit Windows

Passenger access to emergency exit windows was partially restricted at 6 of 16 such exits due to the passenger seat configuration.

Decorative Artwork in the Club Car

Decorative artwork was potentially injurious due to its weight, framing material and method of securement.

1.11.3 Passenger Safety Improvements

The investigation determined that significant improvements have been made in a number of passenger safety-related areas. General safety briefings had been given to all passengers departing Windsor and specific briefings had been given to those passengers seated near emergency exits. Each car was equipped with readily accessible multi-trauma medical kits and emergency information pamphlets were available at every passenger seat. Legible luminescent emergency signage was posted throughout the train.

1.12 Locomotive Crashworthiness

1.12.1 Current Design Standards

The design standard for locomotive crashworthiness in effect at the time of this occurrence was Association of American Railroads (AAR) standard S-580. A copy of this standard is attached as Appendix C. This version of the standard was adopted in 1989, two years after the occurrence locomotive was manufactured, and applied to all newly manufactured locomotives. The following is a brief comparative description of the requirements of AAR standard S-580 and the previous design standard for the occurrence locomotive.

Collision Posts - Collision posts are strong structural members located at the front of the locomotive, which extend upwards from the underframe. They are intended to protect the control cabin in the event of a head-on collision. Standard S-580 requires at least two collision posts, designed to withstand longitudinal forces of 500,000 pounds applied at deck level and 200,000 pounds applied 30 inches above deck. The collision posts on the subject locomotive exceeded this requirement; they were designed to withstand a force of 500,000 pounds applied 30 inches above the deck. The collision posts extended all the way from the top of the underframe upward, the entire height of the short hood. The top of the short hood is about 30 inches above the control cabin floor.

Anti-Climber - An anti-climber is a device intended to counter the tendency, in a head-on collision, for the object being struck to rise above the underframe and strike the control cabin. Standard S-580 requires the anti-climber on the short hood end of the locomotive to withstand a 200,000-pound upwards force. The subject locomotive did not meet this requirement, and was only designed to withstand a 150,000-pound upwards force.

Short Hood Structure - Standard S-580 requires the skin of the short hood to be a one-half inch steel plate at 25,000 pounds per square inch (psi) yield strength (or equivalent where thickness varies inversely with the square root of the yield strength). The subject locomotive met this design requirement. It was constructed using a one-quarter inch steel plate with a 90,000 psi yield strength which is considered to be equivalent.

1.12.2 Proposed Changes to Current Design Standard

A Railroad Safety Advisory Committee Working Group, comprised of the AAR, the U.S. Federal Railroad Administration (FRA), manufacturers (including GM of Canada), operators, and unions, has been working to revise standard S-580 to enhance the level of crashworthiness protection. Although this work is in the draft stage, amendments are being considered to include stronger collision posts on short hoods and the addition of corner post and window post requirements.

1.12.3 Structural Damage to Locomotive 6423

Figure 4 - Right side shown after locomotive was righted.
Damage is more extensive at the front right and along the right side of the locomotive.

Figure 5 - View of locomotive from front after having been righted.
A - Right collision post B - Left collision post C - Pilot D - Anti-climber

Figure 6 - Interior of cabin looking forward from top of locomotive

After the accident, the locomotive was taken to Ottawa where a crashworthiness analysis was conducted.⁽²¹⁾ The following is a description of damage to locomotive 6423, specifically relating to its crashworthiness features.

Collision Posts - The right collision post was forced aft and to the left whereas the left collision post was not significantly displaced. Even though the left collision post was not visibly deformed, the short hood near the top of the post was dented and sheared away. The right collision post was not bent along its length; however, the top of it was pushed aft. The structure which supports it at the bottom of the underframe was fractured. Close examination of the left collision post found similar damage to its underframe support structure, but which had not progressed to the same extent.

Pilot and Vicinity - The right end of the pilot was pushed aft, while its left side was comparatively undamaged. The left ditch light was not broken. A large number of fine scratches on the surface of the right end of the pilot were consistent with having been caused by contact with the roadbed. The pilot or its surrounding area beneath the underframe did not contain deep gouges or severe structural damage as seen on the upper surfaces of the short hood that were consistent with contact with the hopper cars.

Anti-Climber - The right end of the anti-climber was bent upwards. One gouge was observed on the underside of the anti-climber consistent with impact with the hopper cars. It is considered that much of this upwards bending likely resulted from damage to the underframe when the right collision post was forced aft.

Short Hood - The short hood on the right was pushed back along with the right collision post. The short hood on the left was dented and sheared near the top of the left collision post. The left side of the short hood at the base of the collision post did not show any significant impact damage. The right side of the short hood contained numerous deep gouges in the metal where it contacted the loaded covered hopper cars.

Control Cabin - The roof of the cabin was found separately, and was considered to have been torn away by the collision. The electrical cabinet, located behind the operators, was pushed towards the rear, more on the right than on the left. On the right side, the control console and short hood were pushed back beyond the operator's seat and downwards almost level with the cabin floor. On the left side, the operator's seat pedestal was still securely fastened to the floor, was visibly deformed towards the rear, and was not covered by the short hood or console. No buckling was observed in the cabin floor.

Fuel Tank - The right side of the fuel tank was dented and punctured but the left side did not show any visible damage. The large number of fine scrapes suggested that the fuel tank was most likely damaged by contact with the roadbed and not with the hopper cars. There was one small puncture observed, less than 1/4 inch (6 mm) in diameter.

A number of other potential locomotive safety features, some of which are under consideration by U.S. regulatory authorities, were examined for their applicability to this particular type of accident. A brief description of each is contained in Appendix D.

1.13 Dangerous Goods at Thamesville

The Orford Co-op at Thamesville operates a fertilizer plant that is the main wholesale distributor of dry fertilizer products for Growmark Corporation in south-western Ontario. The plant handled approximately 29,000 tons of dry product in 1998. It has a storage capacity of approximately 9,000 tons of dry product. Most of the dry fertilizer products received at the plant arrive by rail and include:

mono-ammonium phosphate

ammonium nitrate

di-ammonium phosphate

potassium chloride

potassium sulphate

potassium-magnesium sulphate, refined (langbeinite)

super-phosphate (acid phosphate, other than ammonium)

urea, other than liquor or liquid

The plant receives approximately 600 car loads per year. Peak periods for fertilizer shipments are spring and fall. Most of the product is distributed from the warehouse; however, occasionally, product is transshipped directly from rail cars to customer trucks on track CB55. Plant personnel indicated that, although they place their orders to arrive in 3 to 5 car shipments, the railway often brings up to 15 cars of product to Thamesville at a time, storing them on various tracks. The plant also distributed 750 metric tonnes of anhydrous ammonia in 1998. There is an 80,000-gallon (363 680 L) anhydrous ammonia storage tank at the plant located approximately 850 feet (260 m) north of the main tracks. All of the anhydrous ammonia was received by truck. While in the transportation system, the dangerous goods are subject to federal jurisdiction.

At the time of the accident, there were about 500 tons of ammonium nitrate in storage in the warehouse at the plant, north of the north main track. There were four loaded cars south of the south main track on track CB40, on the west end of a cut of 13 cars, awaiting placement at the co-op. These four cars contained approximately 400 tons of ammonium nitrate. They were numbered as follows from west to east:

NW177434

NW177257

NW178169

SOU88691

Railway records indicate that these cars arrived in Thamesville at 0615 on 17 April 1999 and were placed on track CB58, north of the north main track. At the time of the accident, the cars were located on track CB40, south of the south main track. It was determined that the cars were handled on Norfolk and Southern Railway Company (NS) train 344. Train 344 was authorized by OCS clearance to operate on the south main track through Thamesville on 17 April 1999. This operating authority did not permit the crew on train 344 to set the cars off on track CB58, north of the north main track. Railway records do not show any movement of the cars from track to track at Thamesville between the date they arrived and the date of the accident.

Tracks at Thamesville are used for the switching, storing and off-loading of these products. All tracks at Thamesville are owned by the railway, although the fertilizer plant restricts the use of the portion of track CB58 that goes into its facility. Neither the railway nor TC considers track CB40 to be an ammonium nitrate storage facility. Cars stored on track CB40 are not accessible to Orford Co-op personnel. Orford Co-op did not consider cars stored on track CB40 to be under its care and control.

1.13.1 Risks Associated with Ammonium Nitrate

Ammonium nitrate is a crystalline compound with powerful oxidizing properties. It melts at about 169 degrees Celsius and decomposes considerably at 210 degrees Celsius. At 301 degrees Celsius, the decomposition accelerates considerably and, above 325 degrees Celsius⁽²²⁾, ammonium nitrate deflagrates⁽²³⁾. Such deflagration may change to detonation. The velocity of detonation of pure ammonium nitrate is between 1 140 and 2 700 m/sec. However, when ammonium nitrate is mixed with any organic or combustible material such as fuel oil, it explodes much more readily⁽²⁴⁾, with a higher velocity of detonation and a more powerful explosion.

Ammonium nitrate is one of four dangerous goods for which it was deemed necessary in Canada to issue regulations pertaining to storage. Originally, Canadian Transport Commission General Order 0-36 was developed to provide regulations respecting the design, location, construction, operation and maintenance of storage facilities for ammonium nitrate and ammonium nitrate mixed fertilizers. Later, this General Order was consolidated as Chapter 1145 of the Handbook of Railway Operating, Engineering and Traffic Regulation. Further information on the risks associated with ammonium nitrate and other commodities handled at Thamesville can be found in Appendix E.

1.13.2 Regulations Pertaining to the Storage of Dangerous Goods

Regulation of dangerous goods in North America dates back to the beginning of the 20^th century. As a result of numerous accidents involving explosives and chemicals in the United States, the AAR established the Bureau of Explosives in 1905. The purpose of the Bureau was to establish and enforce, on all member railroads, standards of safety in the transportation of dangerous materials. In Canada, the Board of Railway Commissioners issued Order No. 7881, entitled Regulations for the Carriage of Explosives, on 27 February 1909. This Order was applicable to explosives in transportation only.

In time, it became evident that not only the transportation, but also the delivery and storage after delivery, of other dangerous goods posed significant risk. On 16 January 1917, the Board of Railway Commissioners adopted additional requirements developed by the AAR and issued General Order No. 100 instructing that explosives not remain on railway property for more than 48 hours after arrival at a destination point. On 31 December of that same year, the General Order was expanded to include all dangerous goods and it stipulated that any such material not be left at any point within the transportation system for more than 48 hours. These requirements were known as the 48-hour rule.

The Board of Railway Commissioners issued special permits exempting the applicants from certain regulatory requirements in situations where it was deemed necessary to hold cars in excess of 48 hours. Whenever special permits were issued, any conditions considered necessary to enhance safety were prescribed.

In 1949, an amendment was issued which excluded weekends and statutory holidays from being included in the 48-hour rule.

The requirements of the 48-hour rule were retained through several periods of restructuring of the railway safety framework in Canada. In 1985, the regulations issued pursuant to the Railway Act, R.S.C. 1985, c. R-3, including the 48-hour rule, were administered for a brief period by the National Transportation Agency⁽²⁵⁾ (NTA). The administration of these regulations was transferred to TC with the proclamation of the Railway Safety Act, S.C. 1988, c. 40, on 01 January 1989. The following is the text of the 48-hour rule as it existed in the Regulations for the Transportation of Dangerous Commodities by Rail at the time of the proclamation of the Railway Safety Act:

S. 74.582 Movement to be expedited.
(a) Carriers must forward shipments of dangerous commodities promptly and within 48 hours, Saturdays, Sundays, and holidays excluded after acceptance at originating point or receipt at any yard, transfer station, or interchange point, except that where bi-weekly or weekly service only is performed, shipments of dangerous commodities must be forwarded on the first available train.

Additionally, these regulations contained provisions for the issuance of special permits as follows:

S. 71.6 Special Permits; standard requirements and conditions.
(a) The Director of Operation, R.T.C.⁽²⁶⁾, may issue special permits to any person or class of persons granting such exemptions from any of these regulations as he determines will not appreciably lower the standards of safety established hereby.

With the proclamation of the Railway Safety Act, consequential amendments and repeals were made to other acts and regulations as a standard procedure to prevent incompatibility. As a part of these amendments and repeals, the Regulations for the Transportation of Dangerous Commodities by Rail were amended by specifically vesting the Minister of Transport with responsibility for the issuance of special permits. In response to the increasing demands of administering outstanding individual special permits and the processing of additional applications, TC, together with the member railways of the RAC, chose to replace individual site-specific permits for storage of dangerous goods with one special permit covering all storage sites in Canada. Further, TC suggests that this change would result in consistent application of common conditions and site selection criteria to all storage site locations across Canada.

In addition to the sites for which applications had been previously issued, approximately 40 sites were pre-selected for the storage of various commodities. These sites were inspected several times each year. The railway companies were encouraged to upgrade access roads and improve the quality of the track. Some sites were required to be lighted and equipped with fire hydrants and a supply of neutralizing agents.

On 11 July 1989, Special Permit 3255 was issued and the (then) 10 member railways of the RAC were named as "Special Permit Holders." The permit allowed storage of dangerous goods anywhere in Canada in excess of 48 hours, provided that the Special Permit Holders complied with 13 different conditions described in the Permit as summarized in Appendix F. This Permit was issued for a duration of nearly two years, with an expiry date of 30 June 1991.

On 30 August 1989, the NTA initiated an inquiry into all matters connected with the storage of dangerous goods on railway property, based on a number of occurrences relating to marshalling and storage activities. The inquiry concluded that there was a lack of compliance with the terms of Special Permit 3255, as well as a lack of effective regulatory overview. In response to the recommendations of the inquiry, TC set up multi-disciplinary inspection teams, each comprising a Dangerous Goods Rail Inspector, a Railway Safety Inspector, a Railway Dangerous Commodities Officer, a Risk Management Officer and representatives of local emergency response organizations (usually fire departments). These teams visited 121 sites which had been designated for storage of dangerous goods under Special Permit 3255. Of the 121 sites proposed by the railways, 60 sites were disqualified by this group. Some locations were disqualified because of their proximity to high-speed passenger train operations, proximity to dwellings, places of public assembly, etc. Many of the remaining 61 sites were found suitable, with restrictions to the type of products to be stored, the use and operations of storage and train operations on adjacent tracks. Thamesville was not identified as a site for storage of dangerous goods; therefore, it was not visited or assessed.

On 27 June 1991, Special Permit 3255 was revised and extended until 30 June 1994. The only safety-oriented change was that, where the original permit required hand brakes to be applied on all stored cars of dangerous goods, hand brakes were required to be applied only on as many cars as necessary to prevent their movement, consistent with the general application of CROR Rule 112, Securing Equipment. No other revisions of the permit were made before its expiry date.

A document entitled Special Permit 3255.1 was issued by TC on 01 March 1995. This document was a modified version of the previous permit that removed a number of the safety conditions. Schedule "B" of this document contained a table of minimum acceptable distances between dangerous goods of different classes and "commercial establishments, residences, places of assembly and sensitive environment areas." The table did not specify quantities of dangerous goods, nor did it distinguish between single residences, hospitals or protected environments. TC intended that the quantity of dangerous goods acceptable for storage be determined by inspectors as part of the process of the site qualifying with the inspectors' minimum acceptable conditions. The expiry of this document was 30 June 1995.

In the fall of 1995, the RAC issued Circular No. DG-1, entitled Recommended Practice for the Safe Handling of Railway Cars Loaded with Dangerous Goods Delayed in Transit on Railway Property, and section 74.582 (48-hour rule) was revoked by TC. In the regulatory impact analysis statement that led to the revocation of the 48-hour rule, it was indicated that the regulatory and industry conclusion was that there was "considerable doubt that a public safety concern is being addressed by these provisions."

There are significant differences between the terms of original Special Permit 3255 and Circular DG-1, although the site selection criteria were derived from the original document. Special Permit 3255 had been issued on terms prescribed by federal regulations and any deviation from the prescribed terms constituted a punishable offence. RAC Circular DG-1 specifies only recommended safe practices from an industry association to its member companies and carries no requirement for compliance or consequence for non-compliance. RAC Circular DG-1 specifies conditions under which TC and the member railways of the RAC believe that safe storage of dangerous goods can take place on railway property. Under this new arrangement, RAC member railways are obliged to respect their own industry practices as set out in the circular. In addition, RAC Circular DG-1 applies to "delayed" cars "in transit." When cars are not delayed, the circular is not considered applicable. Furthermore, when a car has arrived at its destination, it is considered to be no longer in transit. CN considered the four loaded cars of ammonium nitrate on track CB40 at Thamesville to have arrived at destination, and that they were therefore exempt from RAC Circular DG-1.

The following summarizes other safety-related changes to dangerous goods handling and storage under RAC Circular DG-1:

RAC Circular DG-1 does not require the railways to maintain an accurate record of the railway vehicles containing the dangerous goods, the dangerous goods and the location where the dangerous goods are held, including the mileage, subdivision, track and additional information, as appropriate, nor to make this record readily available to TC upon request.

RAC Circular DG-1 does not require that the movement of railway vehicles on an adjacent track be made at a speed consistent with safety.

RAC Circular DG-1 does not require that TC be involved in the selection of holding sites.

RAC Circular DG-1 lengthens the inspection requirements to every 48 hours after the fifth day cars have been held to ensure that they are not leaking except when the distances specified in the primary selection criteria have not been met. Under these circumstances, a visual walk-around inspection has to be performed every 24 hours after the fifth day a dangerous goods car is held at one location.

1.14 Train Control Systems

Train control systems are used to provide for the safe operation of trains on the main track and to protect track work activities. These systems must provide for the separation of trains travelling in the same direction and the safe passing of trains travelling in opposing directions both in single-track and multi-track applications. There are currently three methods of train control authorized by the CROR, two of which are in widespread use in Canada by both federally and provincially regulated railways: CTC and OCS. The third, Special Control System (SCS), provides rules for the introduction of a new train control system.

1.14.1 Centralized Traffic Control System (CTC)

CTC has been in widespread use in Canada for decades. It has traditionally been the preferred method of train control on territories with higher traffic volumes. In CTC, interconnected track circuits are used to indicate the occupancy of main tracks, signalled sidings and signalled yard tracks. Track occupancy, broken rails and switches in the reversed position are detected by the track circuitry. The system displays activated track circuits to the RTC and signal indications to train crews on wayside signals, which are actuated when the wheels of a train modify an electric circuit. The signals are known as block signals. A block is defined in the CROR as:

A length of track of defined limits, the use of which by a train or engine is governed by block signals....

In CTC, an RTC can control some signals, known as controlled block signals, but only to the extent that they can be requested to display a permissive signal indication instead of the "stop" indication which is their default indication. The actuation of the signals by an approaching train and the status of the blocks ahead dictate the degree of permissiveness that the signals can display. In addition, the RTC has control over some main track switches. These "power"⁽²⁷⁾ or "dual control"⁽²⁸⁾ switches are at locations known as controlled locations. Between controlled locations, train movements are governed by intermediate block signals that are not controlled by the RTC. Due to the manner in which track circuits are interconnected, under normal circumstances, the system provides at least two consecutive block signals' advance warning to train crews approaching such conditions as occupied track, broken rails⁽²⁹⁾, open hand operated main track switches or controlled block signals set at stop.

1.14.2 Occupancy Control System (OCS)

Before December 1990, federally regulated railways were operated under the Uniform Code of Operating Rules (UCOR). Under the UCOR, there were also three methods of train control: Train Orders, CTC and Manual Block System (MBS). The majority of train operations were under Train Orders or CTC. MBS rules provided for a method of train control that was in limited use on low-traffic density track until the late 1980s. At about this time, CN and CPR introduced separate versions of computer-assisted MBS. Unlike the original MBS which required the RTC to issue and record track authorities on paper, the computer-assisted systems used an electronic database to record this information. A series of procedures was developed for the operation of this system. These procedures were later revised and adopted as the OCS rules under the CROR. Operating software for these systems was designed around the logic of the OCS rules and is intended to prevent the issuance of conflicting track authorities. The OCS rules, as well as other operating rules, promote accurate communication and data entry through requirements to repeat information, make written records, and provide acknowledgement of accuracy.

In OCS, a track authority is normally transmitted by the RTC to crews by two-way radio, although in some instances, authorities are sent electronically to remotely located computers or fax machines. When authorities are received by radio, crews make a written record and repeat this information to the RTC from the prescribed form for verification. There are procedures to ensure that the same information is entered into the OCS computer and copied by the crews.

OCS is applied to territories both with and without ABS. Where OCS is applied alone, it is known in the railway industry as OCS outside ABS, or "dark territory," and there are no supplementary physical defences associated with this method of operation. Traffic density in dark territory is usually lower than in OCS/ABS territory.

ABS is defined in the CROR as follows:

A series of consecutive blocks which are governed by block signals, cab signals, or both, in which ABS rules apply. The signals in ABS are actuated by a train or engine, or by other conditions affecting the use of a block.

In OCS/ABS, conditions such as the occupancy of the main track ahead by rolling stock, broken rails and open main track switches are normally protected through the indications of the block signals. Although the signals do not provide answers as to the reasons for their indications, the requirements attached with these indications restrict the permissible speed of trains when a condition is detected and the rules require crews to be on the lookout for the causes. ABS signals are not controlled by the RTC and their indications are not available for the RTC to view.

1.14.3 Human Error and Train Control Systems Design

Simply defined, a system is an entity that exists to carry out some purpose.⁽³⁰⁾ A system is composed of humans, machines and other elements (e.g. procedures, software) that interact to accomplish a goal. One of the fundamentals in the design of safety critical systems is understanding how human error will have an impact upon that system. Basic principles of systems design seek to reduce the outcome of human error. Common strategies include decreasing opportunities for operators to produce errors within the system, making errors visible and reversible, and mitigating error consequence.

When it is not practicable to eliminate human error through design, system defences can be put in place. Typically, defences can be either physical or administrative. In the context of a train control system, physical defences could include audible alarms, visual indicators, such as wayside or cab signal indications, or automatic train stop protection. Similarly, administrative defences could include safety regulations, policies, procedures and operating rules.

1.14.4 Past TSB Safety Action

On 06 April 1999, the TSB issued a Rail Safety Advisory to TC concerning the safety defences associated with the OCS method of train control. Three occurrences in early 1999 in which communication errors between train crews and RTCs potentially compromised safety prompted the issuance of the advisory. The TSB did not investigate the occurrences, but it recorded pertinent data from all of them. In each case, the unsafe conditions were detected by railway employees involved, who took immediate action to reduce the potential risk. The operating railway investigated each of the three occurrences. It attributed two of the occurrences to a lack of dedication to normal assigned duties on the part of an employee and the third to confusion resulting from similar sounding station names on the same subdivision. The TSB expressed that, although a number of procedural measures exist to promote accuracy between communicating parties, such as repeats, underscoring and acknowledgments, there are no other physical or administrative means by which the system is able to verify the accuracy of the information ultimately held by either party. In this environment, an error in data entry or a failure in established procedures to correct an inaccuracy is all that is necessary to compromise the integrity of the system.

On 15 September 1999, TC responded to the advisory indicating that it had reviewed the safety measures associated with OCS, specifically those control defences associated with ensuring accurate communication and verification of information, and that it is of the view that the existing control defences are adequate to ensure that OCS is a safe method of train control. TC advised that it had implemented a formal auditing process with respect to providing assurance that railway companies are conducting rail traffic control operation in compliance with approved rules and existing regulations as well as internal railway safety management procedures.

1.14.5 Regulatory Requirements for Control of Passenger Trains at High Speeds

In Canada, regardless of the type of train control or the presence/absence of ABS, there is no federal requirement for the setting of train speed. Maximum allowable speeds for passenger and freight trains are determined by the railway based upon track and roadbed engineering criteria that are governed by the TC-approved Railway Track Safety Rules.

In the United States, an investigation was conducted by the Interstate Commerce Commission (ICC) in the mid 1940s to determine whether it was necessary, in the public interest, to require any railway under its jurisdiction to install a block signal system, interlocking, automatic train stop or train control, cab signals or other similar appliances, methods, and systems intended to promote the safety of railroad operation. The ICC concluded that higher speeds and a greater number of trains had increased hazards and necessitated more and better protection for the travelling public. Subsequent to this investigation, the ICC issued orders that required the installation of block signal systems or manual block systems⁽³¹⁾ where passenger trains were to be operated at speeds of 60 mph or more and freight trains were to be operated at speeds of 50 mph or more. Those restrictions remain in effect today in the United States.

2.0 Analysis

2.1 Introduction

From the facts obtained during this investigation, it was readily apparent that the derailment and collision resulted from a misaligned crossover switch. In the terminology of safety investigations, the crew and passengers on VIA train 74 encountered an "unsafe condition"^__the reversed main track crossover switches. An unsafe condition can be described as a situation or condition that has the potential to initiate, exacerbate, or otherwise facilitate ann undesirable event. The TSB's investigation targeted the determination of the circumstances that precipitated the existence of that unsafe condition, the reasons why it remained undetected and uncorrected, and methods of reducing the associated risks of accidents and their consequences.

This section of the report will draw together the factual information presented to identify safety deficiencies and residual risks, including:

the reversed main track crossover switches at Thamesville;

OCS system defences;

the derailment, collision and post-accident response;

locomotive crashworthiness;

dangerous goods cars at Thamesville; and

passenger safety.

2.2 Reversed Main Track Crossover Switches
at Thamesville

The investigation did not determine the circumstances surrounding the reversed main track crossover switches with absolute certainty. However, the facts permit consideration of a number of hypotheses and a determination of the only reasonable explanation.

Vandalism

There was no information to suggest that vandalism had occurred. A vandal would have had to act in the relatively short time between the last authorized use of the switches and the approach of train 74 to Thamesville^__approximately one hour. The time of day and physical location of the crossover switches would have necessitated a prospective vandal to act in daylight, within clear view of residences and businesses. Further, both crossover switches were locked in the reversed position with high security locks that showed no indication of tampering. Although CN's tracking of the keys for these locks was found to be inconsistently applied, there was no information to suggest that keys for high security switch locks were readily available to non-railway employees. Railway and municipal police records contained no information supporting a history of vandalism in the area.

Sabotage

It is unlikely that an act of sabotage by railway employees precipitated this accident. The potential consequences would be known to railway employees. All railway employees working in the vicinity of Thamesville on 23 April 1999 were interviewed by the TSB in the conduct of the investigation and all were cooperative and forthright. There was no information to suggest that a disgruntled railway employee or former railway employee had acted out of malice.

Inadvertent Error

The recollection of the work train crew was that the two switches were restored to the normal position and locked. They confirmed that intra-crew communications occurred to verify that the switches were restored. Although this information would suggest that this crew left the switches in the normal position, the absence of any other plausible explanation for the situation encountered less than one hour later by train 74 raises questions about the accuracy of the recall of the work train crew.

In the course of the ballast train positioning process, the trainman walked to the ballast gang foreman's truck to get instructions about driving the truck to Northwood. It is not known if this work interruption affected the actions necessary to the appropriate lining of the switches. However, such departures from regular operational routines increase the risk of error in performing tasks.

It is likely that the trainman's concentration on the task of restoring the crossover switches was reduced by his planning to remain behind to drive the foreman's truck to Northwood. In any case, and regardless of the exact sequence of events, it is most likely that the crossover switches were left reversed by the work train crew and that the actions that resulted in the crossover switches being left reversed were inadvertent.

Train control in areas such as Thamesville is such that, once a work train receives authority to operate in a designated area, it is the crew's task to restore switches to normal and to permit the passing of any through traffic, sometimes with certain restrictions. This system is generally effective, but it depends on human memory, training and procedures. Even with well trained, well rested and motivated employees, there will be slips, lapses,

Synopsis

Table of Contents

1.0 Factual Information

1.1 The Accident

1.2 Train Operations from Windsor

1.2.1 Windsor to Northwood

1.2.2 Approaching Thamesville

1.3 Occurrence Site Information

1.3.1 Characteristics of the Derailment Area

1.3.2 Derailment Sequence

1.3.3 Particulars of the Track

1.3.4 Rail Traffic Control

1.3.5 Weather

1.4 Personnel Information

1.4.1 Locomotive Crew on Train 74

1.4.2 On-Train Service (OTS) Crew on Train 74

1.4.3 Crew on Train 319

1.5 Train Information

1.5.1 The Locomotive

1.5.2 Light, Rapid, Comfortable (LRC) Passenger Cars

1.6 Recorded Information and Train Brake Effectiveness

1.6.1 Locomotive Event Recorder Data from Train 74

1.6.2 Locomotive Event Recorder Information from Train 71

1.6.3 Train Brake Effectiveness

1.6.4 Calculated Lateral and Longitudinal Forces

1.7 Main Track Switches

1.7.1 Procedures for the Use of Hand Operated Switches

1.7.2 Main Track Switch Targets

1.7.3 Past TSB Safety Action on Main Track Switches

1.7.4 TSB Reported Occurrences of Passenger and Freight Trains Encountering Unanticipated Reversed Main Track Switches

1.8 Train 319 Activities

1.8.1 At Windsor, Chatham and Northwood

1.8.2 At Thamesville

1.9 Vandalism

1.9.1 Keys for High Security Locks

1.10 Evacuation/Emergency Response

1.10.1 Passenger and Crew Response

1.10.1.1 Club Car

1.10.1.2 Coach 3351

1.10.1.3 Coach 3344

1.10.1.4 Coach 3313

1.10.2 Chatham-Kent Police Service

1.10.3 Chatham-Kent Fire Services

1.10.4 First Aid and Medical Attention

1.10.5 Injuries

1.11 Passenger Safety

1.11.1 Passenger Safety Issues Encountered

1.11.2 Potential Passenger Safety Hazards

1.11.3 Passenger Safety Improvements

1.12 Locomotive Crashworthiness

1.12.1 Current Design Standards

1.12.2 Proposed Changes to Current Design Standard

1.12.3 Structural Damage to Locomotive 6423

1.13 Dangerous Goods at Thamesville

1.13.1 Risks Associated with Ammonium Nitrate

1.13.2 Regulations Pertaining to the Storage of Dangerous Goods

1.14 Train Control Systems

1.14.1 Centralized Traffic Control System (CTC)

1.14.2 Occupancy Control System (OCS)

1.14.3 Human Error and Train Control Systems Design

1.14.4 Past TSB Safety Action

1.14.5 Regulatory Requirements for Control of Passenger Trains at High Speeds

2.0 Analysis

2.1 Introduction

2.2 Reversed Main Track Crossover Switches at Thamesville

2.2 Reversed Main Track Crossover Switches
at Thamesville