Rail Safety Recommendations

Date Issued: 23 January 2014

Forwarded to:
The Honourable Lisa Raitt, P.C., M.P.
Minister of Transport
Transport Canada
Ms. Cynthia L. Quarterman
Administrator
Pipeline and Hazardous Materials Safety Administration

Background
On 05 July 2013, at about 2250 Eastern Daylight Time, Montreal, Maine & Atlantic Railway
(MMA) freight train MMA-002 (the train), en route from Montral, Quebec, to Saint John,
New Brunswick, was stopped at Nantes, Quebec (Mile 7.40 of the Sherbrooke Subdivision), the
designated MMA crew change point. The train, consisting of 5 head-end locomotives, 1 VB car
(special purpose caboose), 1 box car, and 72 Class 111 tank cars carrying flammable liquids
(petroleum crude oil, UN 1267, Class 3), was then secured on the main track on a descending
grade.
Shortly before 0100 on 06 July 2013, the unattended train started to move and gathered speed as
it rolled uncontrolled down the descending grade towards the town of Lac-Mgantic, Quebec.
Sixty-three (63) Class 111 tank cars and the box car derailed near the centre of the town. Most of
the derailed cars released their contents due to tank car damage. The released product ignited
almost immediately, resulting in a large pool fire that burned for more than a day. The
petroleum crude oil that did not burn permeated and contaminated the downtown soil, with
some crude oil reaching two rivers and Mgantic Lake. The 63 derailed tank cars were
transporting 6.72 million litres of petroleum crude oil from the Bakken field in North Dakota.
During the derailment, approximately 5.98 million litres (89%) of product was released. This
derailment is among the largest on-land oil spills in North American history.
Forty-seven (47) people were fatally injured. Many buildings, vehicles, and the railway tracks
were destroyed. About 2000 people were initially evacuated from the surrounding area (TSB
occurrence R13D0054).

-2-

Safety Issues Context

In recent years, the transportation of crude oil by rail has increased dramatically in North
America such that the amount of crude oil that is now being shipped by rail is staggering. In
Canada, shipments of crude oil by rail have increased from a mere 500 car loads in 2009 to
160 000 car loads in 2013.1 In the United States, crude oil shipments have increased from
10 800 car loads in 2009 to about 400 000 in 2013.2
According to the Rail Energy Transportation Advisory Committee and data from the North
American Freight Car Market, longer-term projections for crude oil and its shipment by rail
include:

The United States could produce as much as 11.6 million barrels per day (b/d) of crude by 2022.

The Canadian production is expected to reach as much as 5.6 million b/d of crude by 2025.

In North America, roughly 1.0 million b/d of crude is currently moved by rail and the total
volume of crude transported by rail is expected to grow to 4.5 million b/d in the next 10 years.

Given this significant projected growth, the TSB is concerned that infrastructure and operating
conditions may not ensure a safe rail system now and in the future. With the introduction of
unit trains,3 which can consist of 80 tank cars or more carrying large volumes of liquid
hydrocarbons over long distances and through urban areas, the risks to the public and the
environment along the trains route have increased significantly.
Efforts are ongoing to reduce the risk of accidents involving trains carrying dangerous goods
and to reduce the consequences to the public and the environment from derailments. Over the
years, these efforts have focused on restricting the products carried, improving the
crashworthiness of tank cars transporting dangerous goods, and adopting operational measures
to minimize the frequency and consequences of derailments involving dangerous goods.
As part of its ongoing investigation into the Lac-Mgantic accident, the TSB has identified three
key safety issues that must be addressed to further improve the safety of the Canadian rail
system:

1
2
3

vulnerability of Class 111 tank cars to sustain damage,

route planning and analysis for trains carrying dangerous goods, and
requirements for emergency response assistance plans.

Source: Railway Association of Canada

Source: Association of American Railroads
Unit trains carry one commodity with one type of railway rolling stock. Commodities that have
been carried by this type of train include coal, potash, sulphur, grain, and petroleum crude oil.
Unit trains typically operate directly from the loading point to the customer, or to a destination
distribution centre.

-3-

Vulnerability of Class 111 Tank Cars to Sustain Damage

There are approximately 228 000 Class 111 tank cars currently in service in North America.
These cars carry many types of dangerous goods, mainly Class 3 (flammable liquids) and
Class 8 (corrosives). The majority of these tank cars are general-service cars such as
DOT-111A100W1.
Many Class 111 tank cars do not have top fitting protection, head shields or thermal protection,
and are not jacketed. The sides and heads of these tank cars are typically constructed with
7/16-inch-thick steel plate, which is thinner than some other classes of tank cars. When
involved in accidents, these Class 111 tank cars are vulnerable to head and shell damage due to
impacts, as well as fitting damage, which can result in the release of product. Furthermore,
without thermal protection, additional product can be released through excessive venting of the
safety relief device(s), or worse, through a thermal tear, which can result in complete product
loss.

Photo 1. Vulnerability of general-service Class 111 tanks cars to

sustain damage during a railway accident

Previous Recommendations
The TSB has been commenting on the vulnerability of Class 111 cars for about 20 years. In
previous investigations, the TSB identified the risks posed by the release of product from
Class 111 tank cars and the vulnerability of these cars to release product due to accident
damage. The weaknesses of Class 111 tank cars have been acknowledged by the regulator and
industry. Some of the TSB safety messages on Class 111 tank cars are listed in Appendix A.
As a result of an accident involving a petroleum product unit train near Lvis, Quebec, in
August 2004, the Board recommended that:
The Department of Transport extend the safety provisions of the construction
standards applicable to 286 000-pound cars to all new non-pressurized tank cars
carrying dangerous goods.
(R07-04, issued 2007)
Subsequent to this recommendation, an Association of American Railroads (AAR) task force
examined improvements to tank car safety, and the AAR tank car standards were amended to
incorporate a number of enhancements to all new Class 111 tank cars built for the
transportation of crude oil and ethanol in Packing Group (PG) I or PG II. These enhancements

-4include: construction of the tank cars to 286 000-pound standards; protection of the service
equipment on the top shell; use of reclosing pressure relief devices; use of normalized steel for
the tanks and heads; increased minimum thickness for all tank cars not jacketed and insulated;
and at least -inch half-head shields. The AAR petitioned the Canadian and United States
regulators in 2011 to adopt these changes in their respective regulations. After reviewing the
AAR petition, Transport Canada (TC) discussed these modifications during a consultative
meeting with stakeholders in February 2013, and proposed them for adoption in the
Transportation of Dangerous Goods Regulations in Canada Gazette, Part I, in January 2014. TCs
response to this recommendation was assessed as Satisfactory Intent.
However, recent accidents at Cherry Valley, Illinois (June 2009), Lac-Mgantic, Quebec
(July 2013), Aliceville, Alabama (November 2013), Casselton, North Dakota (December 2013),
and Plaster Rock, New Brunswick (January 2014), again highlight the vulnerability of these cars
to accident damage and product release. Following the Cherry Valley investigation, the United
States National Transportation Safety Board (NTSB) recommended that the Pipeline and
Hazardous Materials Safety Administration (PHMSA):
Require that all newly manufactured and existing general service cars authorized
for the transportation of denatured fuel ethanol and crude oil in Packing
Groups I and II have enhanced tank head and shell puncture-resistance systems
and top fittings protection that exceeds existing design requirements for
DOT-111 tank cars (NTSB; R-12-5).
Lac-Mgantic Examination of Class 111 Tank Cars
The examination of the 63 general-service Class 111 tank cars that derailed at Lac-Mgantic
revealed that 60 of the cars (95%) had released product due to tank car damage. The following
types of tank car damage were observed:
Shell punctures:
Head punctures:
Top fittings:
Pressure relief devices:
Bottom outlet valves (operating lever handle):
Thermal tears:
Manways:

33 cars
26 cars
20 cars
12 cars
7 cars
4 cars
2 cars

Tank Car Shells and Heads

Of the 63 derailed cars, the majority were impact-damaged. More than half of the cars
released product due to damage to the shell (33 cars) and/or to the head (26 cars). These
parts of the car structure are often subjected to impacts during a derailment. For the LacMgantic tank cars, the impact damage ranged from small punctures (that is, a few
inches in diameter) to large ruptures (approximately the size of the tank diameter).
The derailed tank cars were subjected to a range of impact speed and forces, depending
on their position in the train. However, it is important to note that the cars at the rear of
the train were travelling at much slower speeds before coming to rest, but still
experienced significant tank shell and head damage as well as product loss. Some of the
product release, especially from the tank cars closer to the end of the train, could have

-5been reduced had the tank car shells and heads been more impact-resistant. Specifically,
tank cars built with thicker steel, full-head shields, and tank jackets would have been
better protected.
Bottom Outlet Valves
Of the 63 derailed cars, 7 cars exhibited impact damage resulting in an open or partially
open bottom outlet valve (BOV), allowing the release of product. For each, the operating
lever handle for the BOV had been damaged. This issue was highlighted during the
investigation into a 2013 derailment involving Class 111 tank cars in Ontario (TSB
occurrence R13T0060). TSB Rail Safety Advisory (RSA) 15/13 was issued to TC4 to
communicate the risk of product loss through BOV handles that are damaged during
derailments.
Top Fittings
Approximately half of the derailed tank cars were equipped with top fitting
discontinuity protection that met the requirements specified by the AAR for cars
ordered after October 2011. Only 18% of these tank cars released product due to
damage. For the tank cars with top fittings that were not so protected, 66% experienced
product loss due to damage. The majority of the tank cars with damaged top fittings
came to rest on their sides or upside down, allowing the product to flow from the
damaged top fittings to feed the pool fire. Top fitting discontinuity protection provides
an effective means to reduce product release during derailments.
Pressure Relief Devices
Pressure relief devices (PRD) are used to reduce the build-up of excessive internal
pressure. For the Lac-Mgantic tank cars, there was a significant improvement in PRD
survivability when they were protected similarly to the top fittings within a protective
housing. In fact, about half of the PRDs were protected and only 10% of these exhibited
release of product from impact damage. For the unprotected PRDs, 29% exhibited
impact damage resulting in product release. The protective housing around the PRD
provides an effective means to reduce product loss during accidents.
Fire Survivability
Of the 63 derailed cars, 4 cars exhibited thermal tears. At least 2 occurred within
20 minutes of the accident. Simulations for tank car survivability have been conducted
by the AAR. The simulations showed that some of the high-energy events could have
been due to damaged PRDs or structural damage to the tanks. The simulations also
showed that thermal protection, thicker steel, and jacketed tanks can significantly extend
the time a tank car can survive in a pool fire. For example, tank cars equipped with a
thermal protection system and an 11-gauge jacket exhibited fire survivability of up to
1000 minutes. For tank cars equipped with PRDs with a start-to-discharge pressure of no
more than 75 psi and with high flow capacity (27 000 standard cubic feet per minute or
more), the risk of tank cars building up excessive internal pressure during a fire was
reduced.

Awaiting TCs response to RSA 15/13

-6In 2011, the AAR proposed upgraded standards for new tank cars built to transport crude oil
and ethanol meeting the requirements of PG I and PG II. In November 2013, both the AAR and
the American Short Line and Regional Railroad Association (ASLRRA) expressed support for
even more stringent standards for tank cars used to transport these materials. Furthermore, the
AAR and the ASLRRA suggested additional improvements for tank cars transporting
flammable liquids (including PG III flammable liquids), retrofitting existing tank cars in
flammable liquid service, and an aggressive phase-out of tank cars that cannot meet retrofit
requirements. The suggested tank car improvements include modifications such as:
-

Puncture-resistant jackets
Full-height head shields
Thermal protection blanket or coatings in conjunction with jackets
High-capacity PRDs
Reconfiguration of the BOV handles
Possible designation of a new tank car class

Following the Lac-Mgantic accident, federal regulators in the United States and Canada are
accelerating their review and consideration of enhancements to these tank cars. The Board also
recognizes that many tank car owners are voluntarily building new tank cars for crude oil
service that meet the AAR upgraded standards introduced for tank cars transporting PG I and
PG II goods.
However, considering the susceptibility of Class 111 general-service tank cars to product release
during accidents, the large number of general-service Class 111 cars remaining in service, and
the increased movements of large volumes of flammable liquids by rail through many Canadian
and American communities, the Board believes that further action is required immediately.
Design improvements to these types of cars are needed to mitigate the risks of a dangerous
goods release and the consequences as occurred in the Lac-Mgantic accident. These should
include defences such as stronger tank shells, tank car jackets, full-height head shields, thermal
protection and high-capacity PRDs. Given the magnitude of the risks and given that tank car
standards must be set for the North American rail industry, the Board recommends that:
The Department of Transport and the Pipeline and Hazardous Materials Safety
Administration require that all Class 111 tank cars used to transport flammable
liquids meet enhanced protection standards that significantly reduce the risk of
product loss when these cars are involved in accidents.
R14-01

Route Planning and Analysis for Trains Carrying Dangerous Goods

The Lac-Mgantic derailment and other recent rail accidents demonstrate that, when accidents
involving unit trains (or blocks of tank cars) transporting large volumes of flammable materials
occur, there is significant risk for loss of life and damage to communities and the environment.

-7The Lac-Mgantic investigation has identified these issues relating to the operation of trains
transporting dangerous goods:

Securement of unattended trains

Trains secured on a descending grade
Rail conditions
Trains left unattended and accessible for extended periods of time
Effect of speed on the severity of the derailment

In July 2013, the TSB issued two safety advisories on the securement of trains (RSA 08/13 and
RSA 09/13). Further attention is required to address the remaining issues in order to reduce the
frequency of derailments and their severity. To this end, the industry has charged the AAR
Tank Car Operations Working Group with evaluating alternative operational options. Some of
the operational options include speed reduction, rail integrity, braking systems and emergency
response. These options should be considered as part of a comprehensive strategy to identify
and reduce the safety risks along the entire route used by trains carrying dangerous goods.
Relation Between Speed, Rail Breaks and Derailments
The severity and consequences of a derailment are related to speed because the energy
dissipated during a derailment depends on the kinetic energy of the train in movement, thus its
speed and mass. Analysis conducted on Federal Railroad Administration (FRA) data5 for mainline freight train derailments over the period from 1992 to 2001 shows that the number of cars
derailed, an indicator of accident severity, is highly correlated with speed (see Appendix B,
Figure 1) and with dangerous goods being released. TSB data on main-track derailments from
2003 to 2012 also indicate that higher derailment speeds are significantly associated with a
higher number of derailed cars. Interestingly, FRA data from 1997 to 2001 indicate that the rate
of accidents (main-line derailments per million train-miles) is higher on short lines than on
major railways despite a slower operating speed.6
FRA accident data segregated by cause show that broken rail is the factor most likely to pose the
greatest risk to train operations because accidents due to broken rails are more frequent and
more severe than average (see Appendix B, Figure 2). Broken rails were the cause of major
derailments involving dangerous goods both in the United States (New Brighton and Arcadia)
and in Canada (Mont-Saint-Hilaire [TSB report R99H0010] and Wabamun [TSB report
R05E0059]). Consequently, a reduction in broken rails is essential to any strategy to improve the
safety of dangerous goods transportation by rail.
Speed reduction has the potential to reduce the severity and consequences of derailments but
would not necessarily result in a reduction of the number of derailments on lower classes of
track due to the fact that track maintenance standards are less stringent for lower classes of
track. Unless the track is maintained at a level higher than Class 2, the full benefits of speed
reduction of key trains will not materialize.

C.P.L. Barkan, C.T. Dick and R. Anderson, Analysis of Railroad Derailment Factors Affecting
Hazardous Materials Transportation Risk, Transportation Research Board Annual Meeting, 2003.
The rate of derailment was 1.4 derailments per million train-miles for major railways, compared
to 6.09 for short lines.

-8Route Planning and Circular OT-55

Route planning and analysis involves a comprehensive system-wide review of all operational
changes, infrastructure modifications, traffic adjustments, and other changes affecting the safety
of train movements. Safety assessments of potential routes used for the transportation of
dangerous goods will help ensure that the route selected is the one presenting the fewest overall
safety risks. Factors to be considered include hazards related to the nature of the product, the
volume being transported, the handling of the product, speed of train operations, passenger
traffic along the route (that is, shared track), railway infrastructure characteristics (for example,
signaling, track class, crossings, wayside systems, traffic density), geography, environmentally
sensitive areas, population density along the route, and emergency response capability along
the route. In the absence of alternative routes, an assessment of the safety risks along the route
is critical to enhancing rail transportation safety as the identified vulnerabilities can be
proactively addressed.
Additional safety benefits can be achieved when route planning and analysis is complemented
by tighter operating measures. These measures can include a maximum allowable speed for
trains carrying dangerous goods and a minimum level for class of track. Although speed
reduction reduces the capacity of the route, the impacts can be minimized if the speed reduction
is applied selectively to the trains that present the higher risks. This practice has been in place
for over 20 years in the United States for some specific dangerous goods. Based on
recommendations of the Inter-Industry Task Force on the Safe Transportation of Hazardous
Materials by Rail, in January 1990, the AAR issued Circular OT-55, Recommended Railroad
Operating Practices for Transportation of Hazardous Materials. Circular OT-55 gave the rail industry
routing guidance for selected dangerous goods, including poisonous by inhalation (PIH) or
toxic by inhalation (TIH) products and radioactive materials. It defined a list of TIH products
(over 200, including chlorine and anhydrous ammonia). Furthermore, it identified technical and
handling requirements for key trains and key routes. Following the Lac-Mgantic accident,
the definition of a key train was expanded in Circular OT-55-N (see Appendix C).
The essential elements of Circular OT-55-N are:

A key train is any train containing one or more cars of PIH or TIH material,
anhydrous ammonia, ammonia solutions, spent nuclear fuel or high-level radioactive
waste, or 20 car loads or intermodal portable tank loads of any combination of other
hazardous materials.

Key trains are limited to a maximum speed of 50 mph and consist of cars that must meet
certain technical standards.

In the event that a wayside device detects an abnormal condition in a key train, further
speed restrictions and car handling requirements are imposed.

A key route is any route that carries more than 10 000 car loads or intermodal portable
tank loads of hazardous materials, or a combination of 4000 car loads of PIH or TIH
material, anhydrous ammonia, flammable gas, Class 1.1 or 1.2 explosives,
environmentally sensitive chemicals, spent nuclear fuel, and high-level radioactive
waste over a period of one year.

Track on key routes must be rated Class 2 or higher.

-9

Key routes must have wayside defective bearing sensors spaced not more than 40 miles
apart.

On key routes, all main tracks must be inspected at least twice per year and all sidings at
least once per year using rail flaw detection and geometry cars. All tracks must have
periodic track inspections between rail defect and geometry car inspections to detect
cracks and breaks in rail joint bars.

AAR member railroads are responsible for tracking the location of PIH or TIH
shipments from shipper to consignee, and ensuring the timely delivery of the material in
accordance with United States Department of Transportation guidelines. They are also
required to provide, on request, a list of the top 25 hazardous materials that are
transported through the jurisdiction.

The requirement for a key route to have main tracks inspected at least twice per year and all
sidings at least once per year using rail flaw detection and geometry cars would have a positive
impact. It would mitigate risks associated with wide gauge and rail breaks, which are the major
causes for derailments. This in turn would reduce the risk of damage to Class 111 tank cars and
the release of dangerous goods.
A primary safety concern related to the transportation of dangerous goods by rail is the
prevention of a catastrophic release or explosion in a densely populated area or in an
environmentally sensitive area. The Lac-Mgantic accident has heightened the publics
awareness of the risks associated with the transportation of dangerous goods. Canadian
municipalities are now demanding better communications about dangerous goods travelling
through their territory.
Circular OT-55-N or similar operating restrictions are necessary to alleviate many of the
shortcomings identified during the Lac-Mgantic investigation and other investigations
involving the release of dangerous goods. However, these measures need to be complemented
by a more comprehensive, proactive approach. Although Circular OT-55-N is not applicable in
Canada, in October 2013, Canadian National (CN) indicated that these measures have been
extended to its Canadian operations. An approach based on Circular OT-55-N, strengthened
with a requirement to conduct route planning and analysis, would be a positive step to improve
the safety of transporting dangerous goods by rail. Therefore, the Board recommends that:
The Department of Transport set stringent criteria for the operation of trains
carrying dangerous goods, and require railway companies to conduct route
planning and analysis as well as perform periodic risk assessments to ensure that
risk control measures work.
R14-02

Requirements for Emergency Response Assistance Plans

An Emergency Response Assistance Plan (ERAP) is required by the Transportation of Dangerous
Goods Regulations for certain goods that pose a higher-than-average risk when transported in
certain quantities. When there is an accident, the handling of these dangerous goods requires
special expertise, resources, supplies and equipment. An approved ERAP will describe the

- 10 specialized response capabilities, equipment and procedures that will be available to local
emergency responders and will assist emergency responders in addressing the consequences of
the accident.
The risks posed by specific dangerous goods are determined based on the properties,
characteristics and quantities of the dangerous goods being transported. Importers, as well as
persons who offer for transport a dangerous good that requires an ERAP, must have an ERAP
approved by TC.
Previous Recommendation
Following the TSB investigation into the 1999 derailment, collision and subsequent fire of a CN
unit train carrying flammable liquid hydrocarbons in tank cars near Mont-Saint-Hilaire, Quebec
(TSB report R99H0010), the Board determined that a comprehensive emergency response plan,
where roles, resources and priorities for emergency response are defined ahead of time, would
enhance the emergency response and alleviate post-accident risks. The Board recommended
that:
Transport Canada review the provisions of Schedule I and the requirements for
emergency response plans to ensure that the transportation of liquid
hydrocarbons is consistent with the risks posed to the public.
(R02-03, issued June 2002)
The Transportation of Dangerous Goods Regulations were amended to require an approved ERAP
for 3 flammable liquids (UN 1202, diesel fuel; UN 1203, gasoline; and UN 1863, aviation fuel)
when offered for transport or imported in a specific configuration of 17 or more interconnected
rail tank cars that are each at least 70% full.
As part of its assessment of Recommendation R02-03, the Board noted that the updated ERAP
application criteria, as implemented by TC, did mitigate the risks to the public posed by the
transportation of large volumes of liquid hydrocarbons that were, at that time, regularly
transported between Qubec and Montral in interconnected tank cars. The Board therefore
assessed Recommendation R02-03 as Fully Satisfactory in August 2008.
Emergency Response Assistance Plans
In the Lac-Mgantic accident, following confirmation that the dangerous goods involved in the
fire consisted of petroleum crude oil, the emergency responders assessed the situation and
estimated that approximately 33 000 litres of foam concentrate would be required to allow a
continuous uninterrupted production of foam to be applied to the fire. As that quantity of
supply was not available locally, the Lac-Mgantic Fire Department arranged to transport the
foam concentrate from a refinery in Lvis, Quebec, about 180 km away.
In this accident, the relative proximity of the refinery, the availability of the required type and
quantity of foam concentrate and the capability to deliver it to Lac-Mgantic in a timely manner
provided the firefighters with one of the critical materials to successfully fight the large
hydrocarbon fire. However, if this accident had occurred in a community in Canada where
supplies and other specialized resources were not available in a timely manner, the emergency
response efforts would have been jeopardized.

- 11 The transportation of large volumes of flammable liquids, such as petroleum crude oil, does not
currently require an ERAP. However, approved ERAPs would consistently ensure that first
responders have access, in a timely manner, to the required resources and assistance in the
event of an accident involving significant quantities of flammable hydrocarbons.
In November 2013, an Emergency Response Working Group (Working Group) was established
by the Transportation of Dangerous Goods General Policy Advisory Council. The Working
Group is chaired by the Canadian Association of Fire Chiefs and is tasked to examine the
possibility of extending the ERAP program to include flammable liquids such as crude oil or to
recommend other viable emergency response solutions to accomplish a similar goal of ensuring
access to appropriate response capability and specialized supplies. The Working Groups
recommendations are expected to address short-term or longer-term solutions or actions that
TC can take to enhance emergency response.
The Board acknowledges this TC initiative. Given the significant increase in the quantities of
crude oil being transported by rail in Canada, and the potential for a large spill with the risks it
would pose to the public and the environment, the Board recommends that, at a minimum:
The Department of Transport require emergency response assistance plans for
the transportation of large volumes of liquid hydrocarbons.
R14-03

Next Steps Lac-Mgantic Investigation

The TSB investigation into the Lac-Mgantic derailment is ongoing. Further analysis of the
information collected continues and more work needs to be done before a final report is
published. However, as the investigation proceeds, should the Board identify additional safety
deficiencies in need of urgent attention, it will make further rail safety recommendations.

Wendy A. Tadros
Chair
cc:

Mr. Michael Bourque

President and Chief Executive Officer
Railway Association of Canada
Mr. Joseph C. Szabo
Administrator
Federal Railroad Administration
The Honorable Deborah A.P. Hersman
Chairman
National Transportation Safety Board
Mr. Edward R. Hamberger
President and Chief Executive Officer
Association of American Railroads

- 12 -

Appendix A
TSB Investigations and Safety Messages on Class 111 Tank Cars (1992 to Present)
Report
Number
R10T0020

Occurrence
Date
09-Feb-2010

Location
MacMillan Yard,
Toronto, Ontario

Summary
During switching operations, tank
car ACFX 73936
(DOT-111A100W5) on a Canadian
National (CN) yard assignment
failed catastrophically and
derailed. The tank car broke into
2 sections, and released its entire
load of approximately 57 000 litres
of ferric sulphate (UN 3264) along
the roadway and adjacent tracks.
A total of 2 cars derailed and
3 additional cars were damaged.
There were no injuries.

Safety Message
Rail Safety Advisory (RSA) 05/11 on the
application of re-pads to non-pressure,
non-jacketed tank cars constructed prior
to September 1990.
RSA 06/11 on applicable standards for
non-pressure tank cars and fracture
toughness criteria for material used in
their construction.
RSA 07/11 on suitability of existing
visual method for inspecting welds that
secure partial stub sill re-pads to nonpressure tanks.

Response or
Action Taken
- Issue discussed at the
Association of American
Railroads (AAR) Tank Car
Committee (TCC) and
Transport Canadas (TC)
Transportation of
Dangerous Goods (TDG)
Directorate to publish
additional changes to
standard.
- TDG Directorate requested
the Task Force to extend
the inclusion of all safety
enhancements to all new
non-pressure tank cars.
- TDG Directorate officials to
closely monitor
performance of structural
integrity inspections at
tank car facilities in
Canada.
- The Federal Railroad
Administration (FRA) will
work with the AAR to
advise tank car owners to
verify fillet weld gauge
and AAR to ensure that a
fracture toughness
requirement is considered
in specifications.

- 13 Report
Number
R04Q0040

R00T0067

Occurrence
Date
17-Aug-2004

14-Mar-2000

Location
Saint-Henri-deLvis, Quebec

Temagami,
Ontario

Summary
A CN petroleum product unit
train derailed 18 tank cars.
Approximately 200 000 litres of
gasoline (UN 1203) and diesel fuel
(UN 1202) spilled into the marshy
area from 3 DOT-111A100W1 tank
cars, but the spilled product was
recovered. There were no injuries.

Safety Message
RECOMMENDATION
The Board believes that further attention
is required to address the issue of
puncture resistance of cars of lower
weight and recommends that:

An Ontario Northland Railway

(ONR) freight train derailed
29 cars; 25 of these were tank cars
containing sulphuric acid
(UN 1830). Approximately 386 000
litres of sulphuric acid was spilled
from 12 DOT-111A100W2 tank
cars. There was minimal mortality
to organisms and fish in Martin
Creek and Hornet Lake. There
were no injuries.

The TSB investigation revealed that the

failure of the top fitting on Class 111
tank cars caused sulphuric acid to leak,
resulting in environmental impact.

The Department of Transport extend

the safety provisions of the
construction standards applicable to
286 000-pound cars to all new nonpressurized tank cars carrying
dangerous goods. (R07-04)

The TSB also found that the absence of a

standard requiring that Class 111 tank
cars used in the transportation of
sulphuric acid be equipped with top
fitting protection designed to minimize
loss of product during rollover presents
a continuing risk to the public and the
environment.

Response or
Action Taken
- The AAR Tank Car Task
Force petitioned the
Canadian and United
States regulators to adopt
mandatory use of
normalized steel when
carbon or low-alloy steels
are used in the
construction of the tank car
shell and heads in their
respective regulations. TC
is addressing this petition
in consultation with
stakeholders. (Rating:
Satisfactory Intent)
- An AAR TCC Task Force
was formed, and
specifications for fittings
for acid cars will be
revised. An
implementation period of
10 years is proposed with
the requirement that 50%
of existing cars be
completed within five
years.
- TC initiated a program to
identify the most
vulnerable cars in
Canadian service and
expedite modification to
the new top fitting
protection level.

- 14 Report
Number
R99D0159

Occurrence
Date
27-Aug-1999

R95D0016

21-Jan-1995

Location
Cornwall, Ontario

Summary
During switching operations,
6 tank cars from a CN yard
assignment ran away. The cars
struck the stop block at the end of
the track. STEX 20520, a
Class 111A tank car, derailed and
its tank was punctured.
Approximately 5000 gallons of a
class 3 combustible liquid
(NA 1993) was released but was
almost all recovered. There were
no injuries.

Safety Message
In its investigation, the TSB concluded
that, in general, Class 111A tank cars do
not have sufficient protection against
punctures, even in a low-speed impact
due to the thinness of the tank shell and
the absence of a head shield.

Gouin, Quebec
(Petit lac
Masketsi)

A CN train derailed 28 loaded cars

of sulphuric acid (UN 1830).
Approximately 230 000 litres of
sulphuric acid was released from
11 DOT/CTC-111A tank cars,
causing environmental damage.
There were no injuries.

The TSB found that the tank cars that lost

product were all Class 111A cars, a class
known to be susceptible to product loss
at derailment.

Response or
Action Taken
- Efforts are being made by
TC, through the AAR TCC,
to change the design of
new Class 111 tank cars
and to increase the top
fitting protection level of
the most vulnerable nonpressure tank cars in the
North American fleet.
- A full head shield will be a
future requirement for new
Class 111A aluminum and
nickel tank cars carrying
dangerous goods.
- TC determined that a
retrofit of the top fittings of
all Class 111A cars would
be cost-prohibitive (in
excess of one billion
dollars), especially given
the age and remaining life
of the cars. TC is
examining thousands of
other products that are
transported in order to
categorize them with
respect to adverse
characteristics and to
update the list of products
prohibited from being
transported in Class 111A
cars (further to the
80 products already
prohibited by the
standard).

- 15 Report
Number
R94C0137

R94T0029

Occurrence
Date
17-Oct-1994

30-Jan-1994

Location
Lethbridge,
Alberta

Near Westree,
Ontario

Summary
A Canadian Pacific Railway (CPR)
train derailed 6 tank cars
containing methanol (UN 1230);
4 DOT/CTC-111A tank cars lost
product and approximately
230 700 litres of methanol was
released. A 20-square block area of
the city was evacuated and
secured by police until the spilled
and remaining methanol was
removed from the site. There were
no injuries as a result of the
accident or the product spill.

A CN train derailed 23 freight cars

as the train passed through a
curve. Three Class 111A tank cars
containing dangerous goods
(2 cars containing vinyl acetate
[UN 1301] and 1 car containing
methanol [UN 1230]) released
product. There were no injuries.

Safety Message
RECOMMENDATION
The risks could be mitigated by reducing
the probability of product release
through design improvements for
protecting the cars, especially the top
fittings, and/or by reducing the
consequences of accidents by further
limiting the types of products that can be
carried in minimum specification
Class 111A tank cars. The Board
recommends that:
The Department of Transport take
immediate action to further reduce
the potential for the accidental
release of the most toxic and volatile
dangerous goods transported in
Class 111A tank carsfor example,
require design changes to improve
tank car integrity in crashes or
further restrict the products that can
be carried in them. (R96-13)
The TSB investigation revealed that,
even though the susceptibility of
Class 111A tank cars to release product
at derailment and impact is well
documented, the transportation of a
variety of the most hazardous products
in such cars continues.

Response or
Action Taken
- Certain halogenated
compounds have recently
been added to the
prohibited list and will
only be authorized in
pressure tank cars by
01 July 2006. Dow
Chemical of Fort
Saskatchewan has already
replaced its fleet of
Class 111 tank cars in that
service with Class 112 tank
cars. All aluminum
Class 111A cars are being
retrofitted with head
shields. (Rating: Fully
Satisfactory)

- Amendment Schedule
No. 21 to the Transportation
of Dangerous Goods
Regulations makes
mandatory the use of
revised tank car standard
CAN/CGSB 43.147-94
(restricting the use of
Class 111A tank cars, and
prohibiting over
80 dangerous goods for
transportation in Class 111
cars).

- 16 Report
Number
R94D0033

Occurrence
Date
27-Jan-1994

Location
Montral, Quebec

Summary
During switching operations, a CN
yard crew detected a strong odour
of gasoline. The train crew
determined that PROX 47917, a
CTC-111A tank car loaded with
gasoline (UN 1203), was leaking
from a crack in the tank shell at the
B end of the car. The tank shell
fractured as a result of being
subjected to impact forces that
were higher than the anticipated
limits of the car design. An
estimated 1125 litres (250 gallons)
of product leaked from the car.

Safety Message
RECOMMENDATIONS
To further reduce the risk of a stub sill
structural failure or sill cracks
propagating into the tank shell on tank
cars carrying dangerous goods, the
Board recommends that:
The Department of Transport
require that federally regulated
Canadian railways:
a) implement an awareness program
on the susceptibility of stub sill tank
cars to cracking, especially if
subjected to abnormal impact loads
and stresses in cold temperatures,
for all employees engaged in the
movement of freight cars;
b) establish a procedure which
would allow employees to report
stub sill tank cars suspected of
having been subjected to abnormal
impact loads and stresses; and
c) perform a special inspection on
those stub sill tank cars reported as
having been subjected to abnormal
loads and stresses before the cars are
allowed to continue in service.
(R97-03)

Response or
Action Taken
- TC incorporated
section 10.7 in the
Transportation of Dangerous
Goods Regulations (an
offence to couple tank cars
containing DGs at 7.5 mph
at ambient temperatures
above -25C or 6 mph at
lower temperatures).
(Rating: Fully Satisfactory)
- Section 180.509(b) in
United States Code of
Federal Regulations (CFR)
Title 49 contains a clause
that achieves this goal.
(Rating: Fully Satisfactory)

- 17 Report
Number

R92W0300

Occurrence
Date

18-Dec-1992

Location

Oakville,
Manitoba

Summary

A CN train derailed 3 diesel

locomotives and 29 cars; 24 of the
derailed cars were tank cars
transporting dangerous goods and
5 DOT/CTC-111A tank cars were
ruptured. A total of 345 tonnes of
product was spilled from these
5 cars (vinyl acetate [UN 1301]
from 1 car, acetic anhydride
[UN 1715] from 1 car, sodium
hydroxide [UN 1823] from 1 car
and sulphuric acid [UN 1830] from
2 cars). A total of 410 residents
were evacuated. There were no
injuries.

Safety Message
Given that stub sill tank cars are
interchanged extensively between
United States and Canadian railways,
the Board recommends that:
The Department of Transport, in
consultation with the United States
Federal Railroad Administration,
encourage the adoption, by
American railway companies, of
special inspections of stub sill tank
cars suspected of being subjected to
abnormal impact loads and stresses.
(R97-04)
In its investigation, the TSB revealed that
the regulated products escaped only
from Class 111A tank cars. These cars
have a high incidence of failure when
involved in accidents, and frequently
transport highly flammable, toxic and
environmentally dangerous materials
even though better protected cars are
available.

Response or
Action Taken

- TC is revising tank car

standards to deal with the
construction, maintenance
and use of Class 111A tank
cars for carrying certain
dangerous goods.
- The United States National
Transportation Safety
Board (NTSB) Safety Study
(NTSB/SS-91/01) into the
Transport of Hazardous
Materials by Rail
questioned the safety of
Class 111A tank cars. The
NTSB recommended
improved packaging of the
more dangerous products
and the development of a
list of hazardous materials
that should be transported
only in pressure tank cars

- 18 Report
Number

Occurrence
Date

R92D0065

R92C0021

Location

Summary

Safety Message

30-Apr-1992

Montral, Quebec

The TSB found that experience has

revealed that, due to their construction,
Class 111A tank cars have a reduced
ability to maintain tank integrity, and
reduced ability to provide a degree of
protection against loss of product, when
compared to the Class 112 and 114 cars.

17-Mar-1992

Calgary, Alberta

During humping operations, tank

cars containing sulphuric acid
(UN 1830) rolled free and struck
33 stationary tank cars.
PROX 60066, a CTC-111A tank car,
was punctured, releasing
2360 gallons of product. There
were no injuries.
NATX 13950, a DOT-111A100W3
tank car loaded with molten
sulphur (UN 2448), caught fire
around the safety relief vent on top
of the car. The fire extinguished
itself before the fire department
arrived. There were no injuries.

SAFETY CONCERN
The Board is concerned that undetected
corrosion in molten sulphur tank cars
may continue to create sulphur fires or
other safety-related operating problems.
Additionally, the Board is concerned that
many cars in service may not meet the
minimum tank shell plate thickness
requirement of 7/16 inch.

Response or
Action Taken
with head shield protection
and thermal protection.
- TC is addressing tank car
standards dealing with the
construction, maintenance,
selection, and use of
Class 111A tank cars for
carrying certain dangerous
goods.

- 19 -

Appendix B
Severity of Derailments

Figure 1. Correlation between speed and derailed cars (source: Analysis of Railroad Derailment
Factors Affecting Hazardous Material Transportation Risk, op. cit.)

Figure 2. Frequency and severity of freight train derailments by cause (source: Association of
American Railroads)

- 20 -

Appendix C
Association of American Railroads Circular OT-55-N

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