Canadian National’s track and turnout inspection reporting and supervisory review procedures
Background
On 01 March 1998, at approximately 2359 eastern standard time, Canadian National westward freight train No. Q-107-11-28, travelling from Montreal to Toronto, derailed eight cars at Mile 127.54 of the Kingston Subdivision near Lyn, Ontario. Two of the derailed cars contained dangerous goods; however, no product was lost. The derailment occurred while the train was passing through a crossover. Derailed equipment fouled the two main tracks.
The Board determined that the derailment occurred when a car wheel climbed over a defective switch point. This switch point became defective due to the separation or "chipping" of large sections of the running surface along the point of the switch. The application of existing maintenance and inspection practices did not prompt the required remedial action.
In consideration of the facts of this occurrence the Board recommended that:
A system-wide assessment of Canadian National's track and turnout inspection reporting and supervisory review procedures be conducted by either Transport Canada or the railway.
Transportation Safety Recommendation R00-01
A response from the Minister has been received. The extent to which the recommendations have been addressed is assessed below.
Transport Canada's Response to TSB Recommendation R00-01 (July 2000)
Officials of Transport Canada (TC) have met with CN Headquarters engineering management to ensure that the Railway's inspection staff across the CN system understand and take appropriate action to guarantee safe turnout conditions. TC has informed the TSB that CN is reviewing its Standard Practice Circular (SPC) entitled "Turnout Installation, Inspection and Maintenance" (SPC 3500). The review will primarily target the standardization of practices between CN and Illinois Central (IC) lines in order to ensure universal applicability. There has been no indication that the review of SPC 3500 will address the Board's specific concerns.
Board Assessment of Response to R00-01 (September 2000)
The effectiveness of the Board's recommendation cannot be ascertained until the revised SPC 3500 is issued by CN. In consideration that TC has discussed the inspection of turnouts with CN to ensure understanding and appropriate action to guarantee safe turnout conditions and although CN is reviewing its SPC 3500 for universal applicability between CN and IC, there is no mention of a system wide assessment of the procedures from a quality assurance or safety perspective. Therefore, until the assessment is completed and the CN SPC 3500 is revised, the response to Recommendation R00-01 is assessed as having "Satisfactory Intent" only.
Additional Response from Transport Canada (May 2004)
CN and TC inspectors have completed a review and initiated changes to inspection and reporting and supervisory procedures. CN SPC 3500 has been revised to prescribe the following:
59. On point ends which are chipped or broken the thickness must not exceed 3/16” (5 mm).
Board Reassessment of Response to R00-01 (May 2004)
As CN and TC have addressed the safety deficiency the Board reassesses the response to Recommendation R00-01 as being "Fully Satisfactory".