Safety communications for TSB investigation (R15H0013) into the February 2015 derailment and fire of a Canadian National crude oil train near Gogama, Ontario
The occurrence
On 14 February 2015, a Canadian National Railway (CN) crude oil unit train was proceeding eastward on CN's Ruel Subdivision near Gogama, Ontario. The train was equipped with 2 head-end locomotives hauling 100 Class 111 tank cars loaded with petroleum products (Class 3 flammable liquids). Specifically, 68 cars were carrying Petroleum Crude Oil (UN 1267) and 32 cars were carrying Petroleum Distillates (UN 1268). The train was 6089 feet long and weighed 14 355 tons. These Class 111 tank cars were built to the CPC-1232 standard.
At about 23:50, while travelling at 38 mph, the train crew felt a heavy tug on the train and a train-initiated emergency brake application occurred near Mile 111.7. Subsequently, the crew observed a fire about 10 cars behind the locomotives, so they detached the locomotives from the train. The temperature at the time was −31°C and the maximum permitted track speed was 40 mph.
This accident occurred on an isolated stretch of rail in Northern Ontario. Twenty-nine (29) tank cars of petroleum crude oil derailed, and 19 were breached, releasing about 1.7 million litres of product. The crude oil ignited, and the resulting fires burned for 5 days.
TSB safety concerns
Safety concerns are expressed in final investigation reports. A safety concern focusses on an identified unsafe condition for which there is insufficient evidence to validate a systemic safety deficiency, but the risks it poses warrant highlighting. A safety concern provides a marker to the industry and the regulator that the Board has insufficient information to make a recommendation, but that as more data and analysis become available, the Board will return to this unsafe condition if it is not redressed.
Safety concern issued on 16 February 2017
The derailment occurred at a speed that was less than the 40 mph speed restriction required by TC's ministerial order in place at the time of the accident and by the current Rules Respecting Key Trains and Key Routes. Given the severity of the outcome in this and other occurrences, the Board is concerned that a speed restriction of 40 mph may not be sufficient for some key trains, particularly unit trains transporting Class 3 flammable liquids in tank cars that do not meet the TC-117 standard.
TSB recommendations
The Canadian Transportation Accident Investigation and Safety Board Act specifically provides for the Board to make recommendations to address systemic safety deficiencies posing significant risks to the transportation system and, therefore, warranting the attention of regulators and industry. Under the Act, federal ministers must formally respond to TSB recommendations within 90 days and explain how they have addressed or will address the safety deficiencies.
Recommendation made on 16 February 2017
The Department of Transport conduct a study on the factors that increase the severity of the outcomes for derailments involving dangerous goods, identify appropriate mitigating strategies including train speeds for various train risk profiles and amend the Rules Respecting Key Trains and Key Routes accordingly.
Transportation Safety Recommendation R17-01
Safety communications for TSB investigation (R15H0013) into the February 2015 derailment and fire of a Canadian National crude oil train near Gogama, Ontario
The occurrence
On 14 February 2015, a Canadian National Railway (CN) crude oil unit train was proceeding eastward on CN's Ruel Subdivision near Gogama, Ontario. The train was equipped with 2 head-end locomotives hauling 100 Class 111 tank cars loaded with petroleum products (Class 3 flammable liquids). Specifically, 68 cars were carrying Petroleum Crude Oil (UN 1267) and 32 cars were carrying Petroleum Distillates (UN 1268). The train was 6089 feet long and weighed 14 355 tons. These Class 111 tank cars were built to the CPC-1232 standard.
At about 23:50, while travelling at 38 mph, the train crew felt a heavy tug on the train and a train-initiated emergency brake application occurred near Mile 111.7. Subsequently, the crew observed a fire about 10 cars behind the locomotives, so they detached the locomotives from the train. The temperature at the time was −31°C and the maximum permitted track speed was 40 mph.
This accident occurred on an isolated stretch of rail in Northern Ontario. Twenty-nine (29) tank cars of petroleum crude oil derailed, and 19 were breached, releasing about 1.7 million litres of product. The crude oil ignited, and the resulting fires burned for 5 days.
TSB safety concerns
Safety concerns are expressed in final investigation reports. A safety concern focusses on an identified unsafe condition for which there is insufficient evidence to validate a systemic safety deficiency, but the risks it poses warrant highlighting. A safety concern provides a marker to the industry and the regulator that the Board has insufficient information to make a recommendation, but that as more data and analysis become available, the Board will return to this unsafe condition if it is not redressed.
Safety concern issued on 16 February 2017
The derailment occurred at a speed that was less than the 40 mph speed restriction required by TC's ministerial order in place at the time of the accident and by the current Rules Respecting Key Trains and Key Routes. Given the severity of the outcome in this and other occurrences, the Board is concerned that a speed restriction of 40 mph may not be sufficient for some key trains, particularly unit trains transporting Class 3 flammable liquids in tank cars that do not meet the TC-117 standard.
TSB recommendations
The Canadian Transportation Accident Investigation and Safety Board Act specifically provides for the Board to make recommendations to address systemic safety deficiencies posing significant risks to the transportation system and, therefore, warranting the attention of regulators and industry. Under the Act, federal ministers must formally respond to TSB recommendations within 90 days and explain how they have addressed or will address the safety deficiencies.
Recommendation made on 16 February 2017
The Department of Transport conduct a study on the factors that increase the severity of the outcomes for derailments involving dangerous goods, identify appropriate mitigating strategies including train speeds for various train risk profiles and amend the Rules Respecting Key Trains and Key Routes accordingly.
Transportation Safety Recommendation R17-01