Good morning, Ladies and Gentlemen.
The Transportation Safety Board of Canada is releasing today its final report on the railway accident of December 30, 1999, in Mont-Saint-Hilaire, in which two lives were lost.
Before I go any further, allow me to introduce the investigator-in-charge, Mr. Ed Belkaloul, and Mr. Ian Naish, Director of Rail Investigations. In a few minutes, Mr. Belkaloul will go over the details of this accident with you.
I will then present the recommendations made by the Board to avoid any such accident happening again.
I also wish to remind you, and it is important to bear this in mind, that the role of the Transportation Safety Board is to investigate occurrences such as this one to determine the circumstances surrounding them and to identify any safety deficiencies brought to light by these occurrences. The Board then informs the appropriate authorities of its findings.
It is not the function of the Board to determine civil or criminal liability; this is the role of the courts. The Board investigates, then makes findings and recommendations. It is not up to the Board to point the finger at those who might have played a role in an accident.
Review of the Facts
Let us now review the facts of this accident.
On December 30, 1999, Canadian National train 783, commonly known as the Ultratrain, was travelling westward on the north track of the Saint-Hyacinthe Subdivision. The train was composed entirely of tank cars carrying liquid hydrocarbons from the Ultramar refinery in Saint-Romuald. At approximately 7:00 p.m., near Mont-Saint-Hilaire, cars from the train derailed, fouling the adjacent south track.
Another CN train, number 306, which was travelling eastward at the same time on the south track, collided with the cars as they derailed. An explosion occurred and the locomotives of train 306, engulfed in flames, crashed into the ditch between the two tracks.
Both members of the crew of train 306 lost their lives in the accident. The coroner determined that both had died in the deflagration.
A total of some 60 cars derailed and the majority were destroyed. About 520 metres of track was also destroyed, including a train switch and part of the signal system.
The tank cars of train 783 that derailed were carrying gasoline and heating oil, as well as other liquid hydrocarbons, which are highly flammable, as you know.
Some tank cars exploded and were projected across the road. The hydrocarbons continued burning for four days, creating a column of smoke some 500 metres high.
It is estimated that approximately 2.7 million litres of hydrocarbons were spilled and caught fire, whereas about half a million litres were recovered and transferred into tanker trucks and tank cars by the response teams on the scene.
As a precautionary measure, 350 families were evacuated temporarily and route 116 was closed to traffic for five days.
Naturally, the accident aroused extensive public concern. Shortly after the tragedy in fact, Transportation Safety Board representatives travelled to Mont-Saint-Hilaire and Lévis to meet with municipal authorities and local residents.
Meetings organized jointly with municipal governments provided opportunities for residents to voice their concerns. These meetings also allowed us to explain the role of the Transportation Safety Board as well as our investigation procedures.
Residents in the vicinity of Mont-Saint-Hilaire and Lévis turned out in large numbers and were very appreciative of this initiative.
In a continuing effort to keep the residents informed, I have talked to the mayors of Mont-Saint-Hilaire and Lévis to let them know that our final report was about to be published and to offer to brief them on our findings.
As the families of the victims were understandably troubled by this tragedy, we met them to share with them the findings of our investigation and, more importantly, to answer their questions.
Now, Ed Belkaloul will present the findings of our investigation as to the causes and contributing factors of the accident.
------------Ed Belkaloul technical presentation------------
Thank you, Mr. Belkaloul.
As you can see, our investigation identified a number of safety deficiencies and issues that could compromise railway safety.
Recommendation on the Quality Control of Field Welds
It should be noted that shortly after the accident CN took measures to reduce risks, and also that progress has been made.
But this is not enough.
This was a tragic accident. But imagine, if you will, the magnitude of this disaster if the passenger train that travelled on that same track a few minutes before train 306 had slammed into the derailed tank cars of freight train 783, or if the accident had occurred a few miles further down the track in an urban area.
We acknowledge CN's efforts to reduce the risks associated with field weld defects, but we believe more can be done, particularly on some sections of track, such as main tracks used by high-speed passenger trains, or by trains carrying large quantities of dangerous goods in urban areas.
In our view, it is essential to implement effective quality controls that take into account local conditions, tonnage, speed and traffic density. It is clear that the rate of weld defects has declined; however, some residual risk remains, and this risk must be considered as quite high on some tracks. In this particular instance, the weld defect was never detected. Therefore, this problem must be addressed to avoid another similar tragedy.
The Federal Railroad Administration (FRA) has adopted such a risk management approach, and new US standards call for field welds on high-speed track to be inspected for internal defects.
The Board therefore recommends that Transport Canada review the requirements for the inspection and quality control of thermite field welds to ensure that an adequate level of safety is maintained on all types of tracks.
Recommendation on Emergency Response Plans
The transportation of such large quantities of liquid hydrocarbons in urban areas obviously entails risks. It is equally obvious, in our view, that steps should be taken to reduce such risks and eliminate accidents and their consequences.
It is therefore surprising to note that no emergency response plan is required when handling over six million litres of hydrocarbons, as was the case with train 783.
Indeed, according to existing regulations, neither CN nor Ultramar was required to have emergency response plans in place, because liquid hydrocarbons are not listed as dangerous goods in Schedule I of the regulations. Nonetheless, CN did have an emergency response plan; however, this plan was not designed for such a serious accident.
Let me quickly emphasize the excellent work done by the emergency response teams in this instance. The steps taken to ensure public safety were both appropriate and well executed. The intermunicipal mutual assistance agreement worked as intended and the firefighters performed their duties properly.
However, the lack of an appropriate emergency response plan undoubtedly hindered and delayed the actions of these response teams. Such a plan would have defined in advance the roles of the individual players, determined the appropriate response methods and identified the equipment that was available in the region.
The Board therefore recommends 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.
Recommendation on Locomotive Event Recorders
The Board also recommends that Transport Canada ensure that the design specifications for locomotive event recorders include provisions regarding the survivability of data.
Event recorders are those so-called "black boxes" that record and supply vital data in case of an accident. This information enables us to better understand the circumstances leading to an accident.
This information is also very valuable in improving railway safety.
The problem in this particular accident, however, is that we were unable to recover the event recorders. They failed to withstand the impact of the crash and the high temperatures that followed for the plain and simple reason that they were not designed or built to withstand such forces.
Yet such resistance requirements are in force for other modes of transportation.
Safety Concern Regarding Train Consists
This investigation also revealed weaknesses in the electronic data interchange (EDI) system with respect to train consists. Errors in documentation that occurred could have had disastrous consequences.
The data transmitted electronically indicated that one of the cars in train 306 was empty when in fact it was loaded with sodium chlorate; a highly hazardous substance that can explode when exposed to hydrocarbons.
Contact with this substance or its vapours is potentially fatal. It was only on January 1, during cleanup operations after the fire had been brought under control, that the emergency response teams discovered the car and were surprised to find out what it contained. Fortunately, the contents of the car never came in contact with any hydrocarbons, and a very serious explosion was averted.
This points out the critical need to ensure the accuracy of the information supplied concerning the nature and quantities of goods being transported by train.
In closing and before answering your questions, I would like to say a few words directly to the families of the victims of this terrible tragedy, to the many people who had to be evacuated from the area, and to the Canadian public at large.
More than two and a half years have elapsed since this accident occurred, and the Board is only now publishing its final report on this investigation.
Obviously, it could not be expected for such a complex investigation to be completed and the results announced to the public overnight. After all, this is one of the most serious railway accidents to have occurred in Canada. Many technical tests had to be performed, but there is no denying that more than two years is a long time.
Immediately following an accident, safety measures are often taken as a result of information uncovered by the TSB's ongoing investigation. In this instance, corrective measures were implemented before the publication of the report. Nonetheless, I consider that it took too long to make our findings public.
I am therefore pledging here today to do everything I possibly can, as the new Chairperson of the Transportation Safety Board, to accelerate our processes and to further advance transportation safety through our investigations.
Safety is our priority.
I imagine you have a number of questions. Please go ahead, we will be happy to answer them now.
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