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Rail Transportation Safety Investigation Report R19c0002

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Rail Transportation Safety Investigation Report R19c0002 RAIL TRANSPORTATION SAFETY INVESTIGATION REPORT R19C0002 NON–MAIN-TRACK COLLISION AND DERAILMENT Canadian Pacific Railway Yard Assignment CW11-06 Alyth Classification Yard Calgary, Alberta 06 January 2019 ii | TRANSPORTATION SAFETY BOARD OF CANADA ABOUT THIS INVESTIGATION REPORT This report is the result of an investigation into a class 3 occurrence. For more information, see the Policy on Occurrence Classification at www.tsb.gc.ca 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. TERMS OF USE Use in legal, disciplinary or other proceedings The Canadian Transportation Accident Investigation and Safety Board Act states the following: • 7(3) No finding of the Board shall be construed as assigning fault or determining civil or criminal liability. • 7(4) The findings of the Board are not binding on the parties to any legal, disciplinary or other proceedings. Therefore, the TSB’s investigations and the resulting reports are not created for use in the context of legal, disciplinary or other proceedings. Notify the TSB in writing if this report is being used or might be used in such proceedings. Non-commercial reproduction Unless otherwise specified, you may reproduce this investigation report in whole or in part for non-commercial purposes, and in any format, without charge or further permission, provided you do the following: • Exercise due diligence in ensuring the accuracy of the materials reproduced. • Indicate the complete title of the materials reproduced and name the Transportation Safety Board of Canada as the author. • Indicate that the reproduction is a copy of the version available at [URL where original document is available]. Commercial reproduction Unless otherwise specified, you may not reproduce this investigation report, in whole or in part, for the purposes of commercial redistribution without prior written permission from the TSB. Materials under the copyright of another party Some of the content in this investigation report (notably images on which a source other than the TSB is named) is subject to the copyright of another party and is protected under the Copyright Act and international agreements. For information concerning copyright ownership and restrictions, please contact the TSB. Citation Transportation Safety Board of Canada, Rail Transportation Safety Investigation Report R19C0002 (released 09 July 2021). Transportation Safety Board of Canada 200 Promenade du Portage, 4th floor Gatineau QC K1A 1K8 819-994-3741; 1-800-387-3557 www.tsb.gc.ca [email protected] © Her Majesty the Queen in Right of Canada, as represented by the Transportation Safety Board of Canada, 2021 Rail transportation safety investigation report R19C0002 Cat. No. TU3-11/19-0002E-PDF ISBN: 978-0-660-39376-6 This report is available on the website of the Transportation Safety Board of Canada at www.tsb.gc.ca Le présent rapport est également disponible en français. RAIL TRANSPORTATION SAFETY INVESTIGATION REPORT R19C0002 | iii Table of contents 1.0 Factual information ................................................................................................. 1 1.1 The occurrence ............................................................................................................................................ 1 1.2 Sequence of events ................................................................................................................................... 3 1.3 Site examination ......................................................................................................................................... 3 1.4 Emergency response ................................................................................................................................. 4 1.5 Alyth C-Yard information ........................................................................................................................ 6 1.6 Car kicking operations in Alyth C-Yard .............................................................................................. 7 1.7 Remote control locomotive system operations ............................................................................. 9 1.8 Coupler assembly .....................................................................................................................................10 1.9 Inspection of freight car knuckles ......................................................................................................10 1.10 Car repair history for CP 429137 ........................................................................................................11 1.11 Laboratory examination of the broken knuckle ...........................................................................12 1.12 Experimental couplers and parts ........................................................................................................14 1.13 Coupler and knuckle force ....................................................................................................................15 1.14 Train dynamics simulation of the uncontrolled movement ....................................................16 1.15 Other occurrences in Alyth C-Yard between the commencement of operations on 22 December 2018 and 06 January 2019 ..............................................................................................17 1.16 Risk assessment.........................................................................................................................................18 1.18.1 TSB Watchlist .............................................................................................................................22 1.19 Reporting marks on tank car SRIX 33958 .......................................................................................23 1.20 TSB laboratory reports............................................................................................................................23 2.0 Analysis ................................................................................................................... 24 2.1 The accident ...............................................................................................................................................24 2.1.1 The uncontrolled movement ...............................................................................................24 2.1.2 Coupler knuckle fracture on car CP 429137 ..................................................................25 2.2 Coupler knuckle inspection requirements ......................................................................................25 2.3 Risk assessment.........................................................................................................................................26 2.5 Reporting marks on tank car SRIX 33958 .......................................................................................28 3.0 Findings ................................................................................................................... 29 3.1 Findings as to causes and contributing factors ............................................................................29 3.2 Findings as to risk .....................................................................................................................................29 3.3 Other findings ............................................................................................................................................30 4.0 Safety action ........................................................................................................... 31 4.1 Safety action taken ..................................................................................................................................31 4.1.1 Transportation Safety Board of Canada ..........................................................................31 4.1.2 Canadian Pacific Railway .......................................................................................................31 4.1.3 Transport Canada .....................................................................................................................32 Appendices....................................................................................................................... 34 RAIL TRANSPORTATION SAFETY INVESTIGATION REPORT R19C0002 | 1 RAIL TRANSPORTATION SAFETY INVESTIGATION REPORT R19C0002 NON–MAIN-TRACK COLLISION AND DERAILMENT Canadian Pacific Railway Yard Assignment CW11-06 Alyth Classification Yard Calgary, Alberta 06 January 2019 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. This report is not created for use in the context of legal, disciplinary or other proceedings. See the Terms of use on page ii. Summary On 06 January 2019, at approximately 0655 Mountain Standard Time, the crew of Canadian Pacific Railway Yard Assignment CW11-06 was switching cars eastward into the classification tracks at Alyth C-Yard in Calgary, Alberta, when 56 cars disconnected from the movement and ran uncontrolled down the lead track into the designated emergency track, contacting a cut of stationary loaded hopper cars. As a result of the collision, a total of 22 cars derailed. No injuries
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