Reassessment of the response to TSB recommendation R94-03
Baggage restraint for overhead racks
Background
On 09 September 1991, while travelling southward at a speed of approximately 45 mph, Ontario Northland Railway (ONR) train 122 was unintentionally diverted from the main track through an open switch at Mile 225.8 of the Newmarket Subdivision. It struck the engine of a Canadian National (CN) yard assignment that was standing 257 feet from the main track, on a wye track, waiting for the passenger train to pass.
TSB Recommendation R94-03 (March 1994)
The Board found that the impact from the collision caused baggage to be projected from the overhead baggage racks onto passengers, resulting in personal injuries. There was no passenger baggage restraint system in place on the racks. In order to reduce the risk of passenger injuries from unrestrained baggage in an emergency, the Board recommended that:
The Ontario Minister of Transportation ensure that passenger coaches on the Ontario Northland Railway have adequate means for securing baggage in overhead racks or bins.
Transportation Safety Recommendation R94-03
Ministry of Transportation of Ontario’s response to Recommendation R94-03 (May 1994 and July 1994)
In May 1994, a Ministry of Transportation of Ontario (MTO) response indicated that MTO had no comments to offer on the recommendation. On 15 July 1994, MTO's subsequent response indicated that they had no responsibility for the ONR as it was governed by its own act and must operate according to federal regulations.
Transport Canada’s response to Recommendation R94-03 (August 1994)
A response from Transport Canada (TC) on 17 August 1994 deemed it appropriate for TC to follow up on our recommendations. The Minister noted that the recommendations were addressed solely to the Province of Ontario even though the accident occurred on CN track which brought it under federal jurisdiction. TC had been advised that all the equipment of the type involved in this occurrence has been taken out of service. The equipment that has replaced it is equipped with trough-type overhead baggage storage which should secure baggage properly.
TSB assessment of the response to Recommendation R94-03 (January 1995)
The trough-type of overhead baggage storage should retain baggage from falling out as long as the equipment is not involved in a derailment or collision. However, as this does not provide securement in such an event the response was assessed as Unsatisfactory.
Transport Canada’s response to Recommendation R94-03 (September 1997)
The Board received the TC-approved Railway Passenger Car Inspection and Safety Rules with Part III, Rule 27.1, which states: "Overhead parcel and luggage racks on new or remanufactured cars shall be of the enclosed type or equipped with restraints."
TSB reassessment of Transport Canada’s response to Recommendation R94-03 (December 1997)
The new rules mandate that restraints are applied to, other than, enclosed-type baggage bins. However, it is too soon to assess how industry will respond. Therefore the response was reassessed as Satisfactory Intent.
TSB reassessment of Transport Canada’s response to Recommendation R94-03 (December 2005)
TC's updated response indicated that the ONR passenger equipment has trough-type overhead baggage storage which should secure baggage properly. However, the TSB has identified overhead baggage storage systems similar to that of the replacement ONR passenger cars as ineffective in a derailment/collision situation. Without a means to ensure that baggage will not leave the storage area, the risk of passengers and crew sustaining injury through contact with unsecured baggage remains, and therefore the Board reassessed the response to Recommendation R94-03 as Unsatisfactory.
Transport Canada’s response to Recommendation R94-03 (October 2006)
TC apprised the TSB that, in the coming months, representatives from the Department will be in discussion with ONR officials to clarify TC's expectation that ONR operations on federally regulated railways are in compliance with the Railway Passenger Car Inspection and Safety Rules with respect to securement of baggage in overhead baggage compartments. TC indicated it will update the Board on the results of these discussions forthwith.
TSB reassessment of Transport Canada’s response to Recommendation R94-03 (October 2006)
In consideration that TC indicated its initiative to address the safety issue with the ONR in the short term, and the results of its address have not been implemented, the Board reassessed the response to R94-03 as Satisfactory Intent.
Transport Canada’s response to Recommendation R94-03 (February 2008)
TC apprised the TSB that based on the low risk, the low number of severe accidents involving the ONR and based on the jurisdictional issues, TC will not do any follow up and TC considers this recommendation closed.
TSB reassessment of Transport Canada’s response to Recommendation R94-03 (March 2008)
In consideration that TC has indicated its reluctance to address the safety issue with the ONR in the short term, and the reversal of its previously expressed intent to address the issue, the Board reassesses the response to R94-03 as Unsatisfactory.
Ontario Northland Railway’s response to Recommendation R94-03 (May 2008)
ONR has indicated it is in the process of hiring a consultant to look at the passenger fleet and future needs of the company, that is, should they refurbish the existing equipment or buy new equipment. The study will include a review of safety features. ONR indicated that any upgraded or new equipment will comply with the Railway Passenger Car Inspection and Safety Rules. The baggage racks will be equipped with restraints, as per section 27 of the Rules. According to TC Rail Safety, a lip on the rack would not be considered a restraint, but netting would.
TSB reassessment of Ontario Northland Railway’s response to Recommendation R94-03 (May 2008)
The ONR has taken positive steps that, if implemented will eliminate the safety deficiency. TC indicated that it will not be able to address the safety deficiency with the ONR. Therefore the Board reassesses TC's response to R94-03 to remain Unsatisfactory.
Transport Canada’s response to Recommendation R94-03 (November 2009)
TC has no jurisdiction over the ONR as it is not a federally regulated railway. However, ONR complies voluntarily with the Railway Safety Act and its related regulations, rules and standards. The Railway Passenger Car Inspection and Safety Rules require the overhead luggage racks of all new or refurbished cars to be enclosed or have baggage restraints. In addition, TC will target the host railway for compliance (that is, when ONR operates on CN or Nipissing Central). Both CN and Nipissing Central are aware of the requirements, and should ONR operate any non-compliant equipment on federally regulated lines, appropriate action shall be taken.
Ontario Northland Railway’s response to Recommendation R94-03 (June 2010)
The ONR has 37 passenger coaches most in service at this time. The ONR indicates that coaches used on federally regulated service have a lip on the overhead baggage racks functioning as a restraint. There are no ONR coaches equipped with enclosed or netted overhead baggage racks and ONR indicates it has no intent to modify any cars with netting at this time. ONR conductors have been instructing passengers not to place heavy articles in overhead bins and conductors monitor compliance with this instruction.
TSB reassessment of the response to Recommendation R94-03 (September 2010)
As TC has indicated that the issue will be monitored when ONR operates on federally regulated railway, the Board reassesses the response to Recommendation R94-03 as Satisfactory in Part.
Ontario Northland Railway’s response to Recommendation R94-03 (July 2016)
ONR no longer operates passenger trains over federally regulated track.
TSB reassessment of Ontario Northland Railway’s response to Recommendation R94-03 (March 2017)
ONR no longer operates passenger trains on federally regulated track.
Since the mid-1990s, ONR has not been using the series of passenger cars involved in the original collision. These cars were replaced with cars equipped with a trough-type overhead baggage storage racks. Although there is no netting, the trough-type overhead storage racks have a lip on the rack. ONR conductors have been instructing passengers not to place heavy articles in overhead bins, and conductors are monitoring compliance with this instruction. In the replacement cars’ approximately 20 years of service, there have not been any significant events where baggage restraint was an issue.
In addition, ONR has indicated that any upgraded or new equipment will comply with the Railway Passenger Car Inspection and Safety Rules, including section 27 pertaining to baggage restraints.
Given that ONR is no longer using the original cars, the replacement cars have an improved trough-type overhead storage design, and ONR conductors are checking for heavy articles in overhead bins, the residual risk is being appropriately mitigated.
Therefore, the response to the recommendation is considered to be Fully Satisfactory.
This deficiency file is Closed.