Railway Investigation Report R13C0008
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.
Canadian Pacific Railway, freight train 118-19
Mile 50.61 Brooks Subdivision
On 19 January 2013, at 1523 Mountain Standard Time, eastward freight train CP 118-19 struck a vehicle at a level crossing at Mile 50.61 of the Brooks Subdivision. As a result of the collision, both the vehicle, a tanker truck loaded with petroleum crude oil (UN 1267), and the lead locomotive caught fire. The driver of the tanker truck and the two train crew members sustained minor injuries.
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On 19 January 2013 at approximately 0830,Footnote 1 eastward Canadian Pacific (CP) freight train 118-19 (the train) departed Calgary, Alberta, (Mile 174.5) on the Brooks Subdivision, and was destined for Medicine Hat, Alberta, (Mile 0.0) on the Brooks Subdivision (Figure 1). At 1523, as the train approached the public crossing at Township Road 172 (Mile 50.61), a northboundFootnote 2 tanker truck (tractor-trailer) loaded with petroleum crude oil (UN 1267) was also approaching the crossing. The crossing was protected with standard reflectorized crossing signs (SRCS).
The locomotive horn and bell were being sounded as required by the Canadian Rail Operating Rules (CROR) Rule 14(l).Footnote 3 The locomotive head light and ditch lights were displayed on full power.
Realizing that the tractor-trailer was not stopping, the train crew applied the brakes in emergency. The driver of the tractor–trailer did not become aware of the train until just before impact. The vehicle entered the crossing and was struck by the train just behind the cab on the driver’s side near the fifth wheel connection. The force of the impact caused the tractor to disengage from the loaded trailer. The cab of the tractor was propelled north of the main line track and the trailer was pushed to the south. The crude oil in the trailer ignited and engulfed both the tractor and the trailer in flames, resulting in extensive fire damage. The driver of the tractor-trailer sustained minor injuries and was taken to hospital for examination.
The train came to rest 2578 feet east of the crossing. It did not derail. The lead locomotive (CP 8713) sustained extensive damage to the front and was covered in burning crude oil. Once the two crew members felt it was safe, they exited the locomotive cab from the rear door. The collision had also caused damage to the rear handrails, which blocked the route to the rear of the locomotive. The crew members had to jump from the side platform of the locomotive, approximately 6 feet to the ground. Both crew members sustained minor injuries as a result of jumping from the train.
At the time of the accident, the temperature was -6˚C. The sky was overcast, and visibility was good.
The Brooks Subdivision extends from Medicine Hat 175.8 miles west to Calgary. The method of train control is the centralized traffic control system (CTC), as authorized by the CROR and supervised by a rail traffic controller (RTC) located in Calgary. The maximum train speed is 55 mph. The train traffic over this subdivision is between 25 and 28 trains per day.
Crew and train information
The train crew consisted of a locomotive engineer and a conductor. Both crew members were qualified for their respective positions, met current fitness and rest standards, and were familiar with the territory.
The train was composed of two 4400 horsepower (hp) locomotives on the head end pulling 57 loads and two empties. It was 7411 feet in length and weighed 6463 tons. The maintenance and repair records for the locomotives and rail cars were reviewed. The locomotives and rail cars were in serviceable condition.
Driver and vehicle informatio
The driver of the occurrence vehicle began his shift at 0630 in Foremost, Alberta. His first assignment was to pick up a load of crude oil and deliver it to Milk River, Alberta. This task was completed by 1100. The next assignment was to pick up the load of crude oil at DeeThree Battery near Warner, Alberta, and deliver it to the TORQ Transloading Inc. (TORQ) transloading facility located 2.5 miles east of Tilley, Alberta. The driver departed Warner at 1300. He believed that he had to be at the Tilley transloading facility in time for his load of crude oil to be offloaded before 1730. The driver had worked extensively in southern Alberta, but he was not familiar with the specific location of this transload terminal.
The driver of the tractor-trailer was experienced and held a valid Alberta commercial driver’s license. He had current certification in Transportation of Dangerous Goods (TDG), Workplace Hazardous Material Information System (WHMIS) and Fundamentals and Hydrogen Sulphide H2S Alive. The driver’s work/rest history was reviewed, and there was no information to suggest that fatigue was a factor.
The tractor-trailer was composed of a 2011 Kenworth W900 tractor pulling a 40 foot–long 2005 Heil Tridem tanker trailer with a capacity of 30 000 L. Although the tractor was equipped with a data recorder, the severe damage due to the collision and fire precluded the recovery of any information from the recorder. Maintenance and repair records for the tractor and trailer indicate that they were in serviceable condition prior to the accident.
The tractor was owned and operated by Ridgeview Transport (1990) Ltd. The trailer and its contents were owned by Plains Midstream. The hubodometerFootnote 4 on the tractor registered 178 020 km when it was last inspected on 05 March 2012. Employees of Ridgeview Transport receive safety training from Plains Midstream, and attend safety meetings if they are to haul Plains Midstream products. The driver had attended at least four safety meetings per year since 2009, including a safety meeting two days before the accident.
Truck route to Tilley transload facility
The rural municipality of Tilley is located within the County of Newell, approximately 22 km southeast of the City of Brooks and 78 km northwest of the City of Medicine Hat. The transloading facility is located in Tilley, adjacent to 1st Avenue, which is Township Road 173A within the municipality and becomes Township Road 172A at the crossing where the accident occurred. Both Township Road 173A and Township Road 172A are commonly referred to as Old Highway 1.
From the Trans-Canada Highway, the preferred route for trucks travelling to the Tilley transloading facility is to exit south on Range Road 123, turn west onto Township Road 172, and then head northwest on Old Highway 1 (i.e., Township Road 172A, 171A, 173A). Trucks would then enter the Tilley transloading facility from Township Road 173A. Once the trucks are offloaded, the trucks exit the facility at the northwest corner of the site and then head southeast on Old Highway 1, to follow the same route in reverse back to the Trans-Canada Highway.
The preferred route had been established by the municipality, CP, and the transloading facility. It was intended to discourage trucks transporting dangerous goods from driving through residential areas of Tilley (Appendix A). Companies delivering product to the transloading facility are advised of this route by facility managers when the contracts are established.
The driver in this occurrence had been given verbal directions on the preferred route. He was advised to avoid the residential areas, but he was not provided with detailed information on the preferred route. Approaching Tilley, the driver left Highway 36 and continued north via Highway 875. He then took Township Road 172, which would take him to the transloading facility, but would still avoid the town of Tilley.
The track in the vicinity of the accident consisted of 136 lb. continuous welded rail manufactured by NKK in 2001. The rails were fastened to 14-inch double shoulder tie plates with 3 spikes per plate on hardwood ties. The ballast was in good condition with good drainage.
The most recent track inspection prior to the derailment was conducted by the railway on 18 January 2013, with no defects noted in the vicinity of the crossing. The last rail flaw test had taken place on 28 November 2012. No defects were noted in the vicinity of the crossing.
Township Road 172 is a two-lane, gravel rural road that crosses the railway track at an angle of nearly 40°. The public crossing is protected by standard railway crossing signs, also commonly known as crossbucks. The posted speed limit on Township Road 172 is 80 km/h.
Approximately 264 feet north of the crossing, Old Highway 1A (Township Road 172A) runs parallel to the Brooks Subdivision. This road is a two-lane rural road that runs between Brooks, Alberta, and Suffield, Alberta, and is used as a secondary road between the two towns. As Old Highway 1A intersects Township Road 172 at a 40° angle, it can be difficult for northbound vehicles to execute a left turn onto Old Highway 1A. Stop signs are placed so as to stop traffic in both directions travelling along the Old Highway 1, giving the right of way to traffic moving along Township Road 172 (Figure 2).
The last Transport Canada (TC) crossing inspection was conducted on 03 November 1992. At that time, the traffic count for the crossing was estimated to be 50 cars per day and the number of trains was 28 per day, resulting in a cross productFootnote 5 of 1400.
The railway and the road authority have the primary responsibility for the design and maintenance of the crossing: the railway is responsible for the maintenance of the crossing, while the road authority performs visual inspections of crossings and of crossing signage, which are normally conducted during work such as grading and snow removal.
Traffic counts were conducted by local county officials at the intersection of Township Road 172 and Old Highway 1 (TWP 172A) on 31 January 2013 and 01 February 2013. The updated traffic counts were 113 cars per day (2013) and 28 trains per day, resulting in a cross product of 3164.
There have been at least three previous collisions between vehicles and trains at this crossing, two of which involved tractor-trailers. The collisions occurred in 1983 (train/tractor-trailer), 1989 (train/vehicle) and 2004 (train/tractor-trailer).
The locomotive event recorder (LER) download was reviewed. The following was determined:
The lead locomotive was equipped with a forward-facing camera (LocoCamFootnote 6). The video footage was reviewed. The following was determined:
Requirements for stopping at uncontrolled railway crossings
The Ridgeview Transport guide for its drivers states that any vehicle transporting dangerous goods must come to a complete stop at every uncontrolled railway crossing.
On 05 August 1991, a tractor-trailer loaded with petroleum crude oil collided with a CN freight train at Mile 172.25 on the Wainwright Subdivision near Kinsella, Alberta (TSB Railway Investigation Report R91E0072). The collision resulted in an explosion, fire, and four fatalities. The tractor-trailer did not stop clear of the crossing for the approaching train although the flashing lights and bells were operating. As part of this investigation, the Board recommended that:
The Department of Transport coordinate with the appropriate provincial authorities to require that tank trucks placarded for the transport of dangerous goods stop at all public crossings before proceeding.TSB Recommendation R93-11
In February 2012, TC provided the TSB with data indicating the extent to which each province or territory had addressed the deficiency in their respective traffic legislation (eight of 11 jurisdictions had addressed it), and indicated that it would not be pursuing this issue further. Until the provinces of Ontario and Nova Scotia address the issue, however, the Board considers the response to Recommendation R93-11 to be Satisfactory in Part. The TSB continues to monitor progress on this railway crossing safety issue.
In Alberta, the federal Transportation of Dangerous Goods Act and Regulations (SOR/2001-286) are made by the provincial Dangerous Goods Transportation and Handling Act.
The provincial legislation that governs vehicles transporting dangerous goods that are approaching railway crossings is Section 42 of the Use of Highway and Rules of the Road Regulation (AR 304/2002). Section 42(5) specifies that vehicles carrying flammable liquids or gases (loaded or empty) must stop no closer than 5 meters or no further than 15 meters back from the nearest rail of the railway.
Canadian railway–roadway grade crossings standards
TC’s draft technical standards document, entitled Draft RTD 10 - Road/Railway Grade Crossings - Technical Standards and Inspection, Testing and Maintenance Requirements,Footnote 7 was made available for comment in 2002. It sets out the minimum safety criteria for the construction, alteration, and maintenance (including inspection and testing) of grade crossings and their road approaches. The draft RTD 10 standards are not enforceable, but they have been used as guidelines by TC, the rail industry and road authorities when reviewing safety at grade crossings.
Part B, Section 8, of the document specifies that that the sightline distance required at crossings is a function of the type of vehicle for which the crossing is designed, the time it takes the design vehicle to pass completely over the crossing from a stop, and the maximum train speed.
The draft RTD 10 indicates that installation of an automatic warning system at a grade crossing is warranted when the cross product is 1000 or more.Footnote 8 In addition, gates are warranted when the maximum train speed is greater than 50 mph, or when there are two or more tracks at the crossing.
The draft RTD 10 also indicates that the minimum sightlines for a grade crossing (without a road crossing warning system) must conform to a clear sight triangle. This triangle is based on the maximum train speed for the track and the maximum allowable speed for the road. The sightline distances are measured at a height of 1.0 m (3.3 feet) above the road surface, at the centre of the roadway, and 1.2 m (4 feet) above the top of the track, at the centre of the rail (Figure 3).
Under the proposed Grade Crossing Regulations (GCR) that were published in the Canada Gazette Part I on 8 February 2014, “road authorities, private authorities and railway companies would be required to maintain sightlines at the grade crossing.”Footnote 9
Safety assessments of crossings
Transport Canada indicates that it is the responsibility of the railway company and the road authority to conduct safety assessments at their grade crossings. The proposed GCR would require the railways and road authorities to share detailed information in writing on every crossing within five years of the regulations coming into force. The GCR would not require safety assessments of grade crossings, but Transport Canada expects that sharing this detailed information would make it easier for the railways and road authorities to conduct grade crossing safety assessments voluntarily.
Transport Canada published The Canadian Road/Railway Grade Crossing Detailed Safety Assessment Field Guide in April 2005Footnote 10 to help railway companies and road authorities with safety assessments; it contains these instructions:
Railway companies and road authorities would also be required to share crossing information when a new grade crossing is constructed or when there is an alteration or operational change at an existing crossing. Railway companies would be required to retain the most recent informa¬tion shared.
Driver attention to visual stimuli
Drivers must continually perform visual scans to monitor the outside environment. The field of view comprises the fovea and peripheral fields. The fovea field of view can be described as a narrow 30° cone at the center where visual acuity (i.e., ability to see details) is the greatest. The peripheral view is approximately 180° forward-facing and is particularly good at detecting motion.Footnote 11 The eyes will be oriented towards the direction deemed to be of greatest importance. In the case of drivers proceeding on a road, visual attention will be directed on the road in front of them. How far ahead is dependent on several factors such as traffic, time of day, weather, speed, and road geometry. Drivers periodically shift their visual attention to look further ahead or closer to their vehicle, again depending on traffic flow, presence of vehicles ahead, etc. Drivers will also perform periodic shifts to the left and to the right, specifically to monitor road signs. It typically takes approximately 0.5 seconds to complete these shifts, i.e., to refocus visual attention.
In this occurrence, the angle of intersection of the track at the crossing for the direction of travel (i.e., for an eastward train and a northward vehicle) was greater than 90°and was outside the driver’s peripheral field of view. The truck’s side mirror and side pillars did not obstruct the driver’s view to the left. However, to achieve a clear view of an approaching eastbound train at this crossing, a northbound driver would have to lean forward and rotate his head to the left.
Driver behaviour at grade crossings
When approaching a grade crossing, driver behaviour is largely determined by the expectation of seeing (or not seeing) a train. If drivers do not usually encounter trains at crossings, the perception that a train is unlikely is reinforced. A literature review by M. Yeh and J. MulterFootnote 12 determined that drivers who were familiar with a crossing would be less likely to look for a train at the crossing or to reduce their speed on their approach to the crossing than drivers who were unfamiliar with the crossing. The same review also determined that slightly more than one third of drivers approaching passive crossings and almost two thirds of drivers approaching crossings with active warning systems made no head movement to inspect for oncoming trains.
On the day of the occurrence, the driver had traversed nine public grade crossings prior to the accident. Four of the public grade crossings were protected by automated warning systems and five were equipped with standard rail crossing signs. He did not encounter any trains at these crossings.
Transportation and transloading of liquid hydrocarbons
Various modes of transportation, including pipelines, tractor-trailers (i.e., highway), and rail, are used to transport liquid hydrocarbons. One mode or a combination of all three can be used (e.g., crude oil from a pipeline to a storage tank, then into a tractor-trailer that will travel through the highway system to a transloading facility, and then into a rail car to be shipped to a refinery).
This transportation of liquid hydrocarbons has increased exponentially since the mid-2000s and the trend is expected to continue in the coming years. The volume of crude oil shipped by rail has increased dramatically in North America in recent years. For instance, in Canada in 2009, about 500 carloads of crude oil were shipped by rail; in 2013, that had increased to over 160,000 carloads. In North America, roughly 1 million barrels of crude are moved by rail each day—a volume that is expected to grow to 4.5 million barrels a day in the next 10 years. CP currently has three transloading facilities adjacent to its rail lines in Alberta.
TORQ is an oilfield service provider focused on transloading oilfield fluids and materials from truck and pipeline to rail. TORQ currently operates the Tilley transloading facility and five others across Alberta and Saskatchewan.
The loading area at the Tilley facility is approximately 320 meters long by 50 meters wide and is situated between the railway siding and Township Road 173A. The loading area is designed to allow trucks to offload the product (i.e., crude oil) through a mass flow meter into the bottom valve of a railway tank car.
The Tilley facility opened in April 2012. It was designed to be scalable to load up to 15 to 20 rail cars per day. The maximum capacity of each rail car was approximately 597 barrels (94 915 L). The facility has rail car storage capacity for approximately 42 tank cars. When the plant opened, an average of four to five rail cars per day were loaded; volumes were expected to grow in 2012 to eight to 10 rail cars per day. The facility was loading an average of eight rail cars per day at the time of the accident.
TORQ is developing a large-scale unit train crude by rail facility in Kerrobert, Saskatchewan, that will be able to handle two 120-car unit trains per day, or up to 168 000 barrels per day, starting in the third quarter of 2014. The facility is designed to have a storage capacity of 500 000 barrels.
Train horn audibility
Section 11.2 of Transport Canada’s Locomotive Inspection and Safety Rules specifies (in part) that locomotives must be equipped with a horn that is “capable of producing a minimum sound level of 96 dB(A) at any location on an arc of 30 meters (100 feet) radius subtended forward of the locomotive by angles 45 degrees to the left and to the right of the centerline of the track in the direction of travel”. The occurrence locomotives were fully compliant with the Canadian regulatory requirements.
A number of TSB investigations have identified shortcomings in the effectiveness of locomotive train horns to alert vehicle drivers and pedestrians to the presence of a train. In the investigation of a collision between a truck and a VIA Rail passenger train at a passive grade crossing near Munster, Ontario, (R04H0009) the Board found that when a train horn is installed mid-locomotive, the horn is not positioned for maximum sound projection, increasing the risk that vehicle drivers at crossings will not hear the horn.
Subsequent investigationsFootnote 13 also concluded that the effectiveness of the horn can be compromised due to a combination of horn placement on the locomotive and ambient noise levels inside the road vehicle (notably large trucks and buses).
Referring to studies conducted in the United States on the effect of horns on crossing safety, Yeh and MulterFootnote 14 indicated that the train horn, despite its limitations, had a positive effect on safety. It was noted that crossings where whistle bans were in place had higher rates of accidents than those where no whistle bans were in effect.
A TC study in 2003Footnote 15 analyzed sound measurement data from various types of locomotives travelling at different speeds with different horn configurations. The study determined that horns mounted behind and close to the engine exhaust hood (i.e., mid-locomotive) performed much worse than those mounted at other locations on the locomotive. The study suggested that existing main line locomotives with a horn positioned behind and close to the engine exhaust hood should either have their horn moved to the front or have an alternative emergency horn added to the front of the locomotive. If the alternative horn is to be used only for emergency situations, then the normal horn(s) should be positioned on the locomotive such that it provides a 30.5 m (100 feet) equivalent output (i.e., sound) of at least 100 dB(A) at angles between 25º and 45º from the forward-facing direction when measured at full operating speed.Footnote 16
The sounding of the locomotive horn as the train approaches a crossing provides an auditory warning to drivers and pedestrians in the vicinity of the crossing. The effectiveness of the horn is diminished by the attenuation of the sound pressure levels. Forward-propagating sound pressure levels are reduced with
In addition, inside a motor vehicle, the effectiveness of the locomotive horn can be affected by closed windows, engine and road noise, and radio and fan noise. Nevertheless, some frequencies of the horn sound can still be perceived by the human ear inside a vehicle if these are not masked by other sounds with the same frequencies and higher sound pressure levels.
In this occurrence, the locomotive horn on the freight train was positioned on top and in the middle of the locomotive in an area that was recessed (Photo 1).
In comparison, for locomotives in passenger service, TC issued modified Railway Locomotive Inspection and Safety Rules in 2010Footnote 17 that required the installation of a new horn by 01 January 2012 on locomotives operating in the lead position and travelling in excess of 65 mph. The new horn must be capable of generating two sound levels: a high-level mode used for emergencies and a lower-level mode used in normal train operations. The horn must be placed near the front of the roof, no more than 5 feet behind the rear of the cab, with no obstructions or exhaust outlets ahead of or beside it.
Research into passive crossing safety
In 1998, the U.S. National Transportation Safety Board (NTSB) published a studyFootnote 18 that identified common causes for accidents at passive crossings and the means to improve safety at crossings. Some of the safety issues included
The study concluded that, while the installation and enforcement of stop signs at passive crossings can provide consistent information, instruction, and regulation to the motoring public, stop signs should be considered only as an interim measure. The study notes that interim intelligent transportation system solutions—such as signs or signals that can alert a motorist to the presence of a train without depending on expensive track circuitry—are possible. While the installation of stop signs may be effective in some cases, the real opportunity to advance public passive crossing safety is through low-cost active warning devices, i.e., devices that warn drivers about the presence of an oncoming train.
In 2010, the U.S. Federal Railroad Administration published a technology assessment of low-cost active warning devices for application at passive highway-rail grade crossings.Footnote 19 The research determined that low-cost active warning sign systems can accurately warn drivers of approaching trains and provide adequate warning times.
Other promising, low-cost train-detection technologies that can be used to control active warning signs are based on global positioning systems (GPS), magnetic flux (e.g., wheel sensors), and radar. As these technologies are not track circuit–based, they can be installed, maintained, or replaced without great cost or impact on railway operations. Such systems can be stand-alone, or take advantage of existing smart systems in modern vehicles, locomotives, and wayside signal systems to provide drivers with advance warning of a passive crossing and the presence of a train. However, the use of active warning signs, although showing potential, is not widespread.
In Canada, the TC Rail Safety Directorate is working with the Transportation Development Centre (TDC) to implement a research project to further develop hybrid crossing warning systems for railway–highway grade crossings in Canada. The main objective of this project is to develop an intermediate grade crossing warning system between conventional passive (i.e., just passive signal) and full-scale active warning systems (i.e., signals, flashing lights, bell, and gates).
After the TSB’s investigation into the 2012 passive crossing accident near Broadview, Saskatchewan, (R12W0182) the Board issued a Safety Concern that expressed the Board’s concern that, in the absence of timely implementation of low-cost alert systems, the risk of accidents at passive crossings would continue.
The condition of the track, the mechanical condition of the train, and the manner in which the train was operated did not contribute to the accident. There was no indication that the mechanical condition of the tractor-trailer contributed to the accident. The analysis will focus on driver behaviour, tractor cab configuration, and audibility of the locomotive horn.
As the tractor-trailer approached the crossing travelling northbound on Township Road 172, the vehicle slowed down but it did not stop. The trucking company required trucks to come to a complete stop at every uncontrolled railway crossing if the vehicle was transporting dangerous goods. The collision occurred when the vehicle continued onto the crossing and into the path of the eastbound train and was struck just behind the cab of the tractor-trailer.
The driver was unfamiliar with the exact location of the transloading facility. He had been verbally briefed on the preferred route and was told to avoid the residential areas, when possible. However, he was not provided with detailed information on the preferred route and was not advised to avoid specific railway crossings.
As the driver wanted to reach the transloading facility in time to unload the crude oil, he chose a route that he believed would take him to the facility in an expeditious manner while not travelling through the town. For the chosen route, the tractor-trailer would have to negotiate an acute (40°) left-hand turn onto Township Road 172A almost immediately after clearing the crossing. As the driver approached the crossing, he was preoccupied with reaching the transloading facility in time to have his product offloaded and with the left hand turn beyond the crossing. Consequently, the driver did not stop at the passive grade crossing.
Township Road 172 intersects the Brooks Subdivision at a 40° angle. For the northbound tractor-trailer, the angle of intersection at the crossing meant that the driver’s view to the west (i.e., scanning for eastbound trains) was outside his peripheral vision. Approaching the crossing or stopped at the crossing, the driver would have to lean forward to look left out the window. The view from inside the cab of the tractor-trailer that resulted from the acute angle of crossing made it more difficult to see the approaching eastbound train.
Expectation and visual stimuli
Crossing protection systems provide visual and auditory stimuli to warn drivers of danger when approaching railway crossings. These systems can comprise active warnings such as lights, bells and gates or, as in this occurrence, passive warnings such as crossbucks and advance warning signs. For safe operations at a crossing, the stimuli provided by the warning system must be sufficiently compelling for the vehicle driver to become aware of impending dangers and take appropriate action. On the day of the occurrence, the driver had traversed nine grade crossings prior to the accident. He had not encountered any trains, likely reinforcing the perception that a train would not be encountered in this instance. If there are no compelling audio or visual stimuli at grade crossings, and vehicle drivers are not expecting a train, they may not stop, increasing the risk of crossing collisions.
Train horn audibility
The locomotive horn was sounded as the train approached the crossing as required by the Canadian Rail Operating Rules. However, the horn did not become audible to the tractor-trailer driver until just before the collision. The locomotive horn was positioned mid-way back on top of the locomotive and slightly recessed, ahead of the exhaust stack. For freight locomotives, this style of horn placement meets current regulatory requirements.
Other TSB investigations have determined, however, that this particular style of locomotive horn placement is suboptimal. In addition, research conducted by Transport Canada indicate that horns mounted behind and close to the engine exhaust hood (i.e., mid-locomotive) performed much worse than those mounted in other locations on the locomotive.
Revised regulatory requirements for passenger locomotives require (in part) that the horn must be placed near the front of the roof, no more than 5 feet behind the rear of the cab, with no obstructions or exhaust outlets ahead of or beside it.
Locomotive horn sound pressure levels are designed to warn those using a railway grade crossing of an approaching train. If the configuration of the locomotive horn, including its location, does not provide sufficient sound pressure levels in the vicinity of the crossing, the horn will not provide adequate warning, increasing the risk of a crossing accident.
Transportation and transloading of liquid hydrocarbons
The transportation of liquid hydrocarbons has increased exponentially since the mid-2000s and this trend is expected to continue in the coming years. In Canada in 2009, about 500 carloads of crude oil were shipped by rail, while in 2013 there were more than 160,000. This dramatic increase in the shipment of liquid hydrocarbons by rail has led to an increase in truck traffic servicing transloading facilities. When the vehicle–train cross product increases, more robust crossing protection systems are often necessary to ensure the interface between vehicular traffic and trains remains safe. If an increase in the transportation of liquid hydrocarbons results in a higher vehicle–train cross product at public grade crossings, there will be an increased risk of crossing accidents.
Findings as to causes and contributing factors
Findings as to risk
Safety action taken
After the accident, Ridgeview Transport Ltd. suspended all trucking operations. Before resuming operations:
Two rail crossing safety bulletins were prepared and circulated to employees at Plains Midstream (see Appendix B). The bulletins were presented and discussed at a number of Plains Midstream safety meetings.
Transport Canada indicated that it had asked the Transportation Development Centre (TDC) to undertake a research project pertaining to the audibility of train horns. The aim of this research project is to analyse a horn’s effectiveness with the “long hood leading”.
This report concludes the Transportation Safety Board’s investigation into this occurrence. The Board authorized the release of this report on 6 August 2014. It was officially released on 12 August 2014.
Appendix A – Preferred route vs actual route
Appendix B – Rail Crossing Safety Bulletin #1 disseminated by Plains Midstream Canada
This is a facsimile of the email disseminated by Plains Midstream Canada. It is available in English only.
Appendix C – Rail Crossing Safety Bulletin #2 disseminated by Plains Midstream Canada
This is a facsimile of the email disseminated by Plains Midstream Canada. It is available in English only.
- Footnote 1
All times are Mountain Standard Time (Coordinated Universal Time minus 7 hours).
- Footnote 2
The tractor-trailer will be considered to have been proceeding north even though its compass direction was predominantely east. The CP Brooks Subdivision will be the reference and train movements on this subdivision are designated east–west.
- Footnote 3
CROR 14(l) Engine Whistle Signals requires, in part, two long–one short–one long whistle signals to be sounded from every whistle post in the approach to a public crossing at grade, and that the signals be prolonged and repeated until the crossing is fully occupied. The whistle post is located approximately ¼ mile before the public crossing.
- Footnote 4
A hubodometer is a device mounted on the axle of a vehicle that measures distance traveled.
- Footnote 5
“’Cross-product’, with respect to a grade crossing, means the product of the average annual daily traffic of trains and engines on the line of railway and the average annual daily number of vehicles on the road that pass over the grade crossing.” Transport Canada, Draft Railway-Roadway Grade Crossings Policy, March 21, 2012, 1(1), p. 1, available at http://www.tc.gc.ca/media/documents/railsafety/draft-grade-crossings-policy.pdf (last accessed 18 July 2014).
- Footnote 6
LocoCam is a digital video recording system that captures and stores synchronized audio, video, and key locomotive parameters. The system records images from a forward-looking camera that is mounted below the locomotive engineer’s side overhead console and against the windshield. The system also uses an external microphone located in the air rack equipment area to capture the whistle, bell, air brake operation, and rail interface sounds.
- Footnote 7
Transport Canada, Draft RTD 10 - Road/Railway Grade Crossings - Technical Standards and Inspection, Testing and Maintenance Requirements (24 October 2002), available at http://www.tc.gc.ca/eng/railsafety/rtd10-805.htm (last accessed on 21 July 2014).
- Footnote 8
TC’s proposed Grade Crossing Standards (2014 February) now specify a cross product of 2000.
- Footnote 9
Government of Canada, Grade Crossing Regulations, Regulatory Impact Analysis Statement, Canada Gazette, Part I, Vol. 148, No. 6 (08 February 2014), available at http://www.gazette.gc.ca/rp-pr/p1/2014/2014-02-08/html/reg2-eng.php (last accessed 18 July 2014).
- Footnote 10
Transport Canada, TP 14372E, Canadian Road/Railway Grade Crossing Detailed Safety Assessment Field Guide (April 2005), available at http://www.tc.gc.ca/eng/railsafety/guideline-tp14372-288.htm (last accessed on 08 July 2014).
- Footnote 11
W. Karwowski, Handbook on standards and guidelines in ergonomics and human factors (Routledge: 2006), p. 401.
- Footnote 12
M. Yeh and J. Multer, DOT/FRA/ORD-08/03, Driver Behavior at Highway-Railroad Grade Crossings: A Literature Review from 1990-2006 (U.S. Department of Transportation: 2008), pp. 66–67.
- Footnote 13
TSB railway investigation reports R13D0001, R11T0175, R10W0123, R08M0002, and R04H0014.
- Footnote 14
M. Yeh and J. Multer, DOT/FRA/ORD-08/03, Driver Behavior at Highway-Railroad Grade Crossings: A Literature Review from 1990-2006, (U.S. Department of Transportation: 2008), p. 54.
- Footnote 15
G.W. English et al, TP14103E, Locomotive Horn Evaluation: Effectiveness at Operating Speeds (Transport Canada: 2003), pp. 78-79
- Footnote 16
Ibid, p. 102.
- Footnote 17
Transport Canada, TC O 0-112, Railway Locomotive Inspection and Safety Rules, Revised February 4th, 2010, available at http://www.tc.gc.ca/eng/railsafety/rules-tco76-331.htm (last accessed 21 July 2014).
- Footnote 18
National Transportation Safety Board, NTSB/SS-98/02, Safety study: Safety at passive grade crossings, Volume 1: Analysis (Washington: 1998), available at https://www.ntsb.gov/doclib/safetystudies/SS9802.pdf (last accessed on 21 July 2014).
- Footnote 19
Ngamdung Hellman, DOT/FRA/ORD-10/06, Low-Cost Warning Device Industry Assessment, (U.S. Department of Transportation: 2010).
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