The TSB Releases a Safety Recommendation to Improve
Rail Traffic Control Operations
GATINEAU, QUEBEC - The Transportation Safety Board of Canada (TSB) today
released its final report (R04T0008) into the January 14, 2004
derailment of Canadian Pacific Railway (CPR) train 239-13. The
derailment occurred just east of the Garden Street overpass in Whitby,
Ontario. Rail car platforms and containers fell onto the roadway below,
striking a southbound vehicle and fatally injuring the two occupants.
Several safety actions have been taken as a result of the TSB
investigation. Transport Canada issued an order changing the procedures
on how CPR operates when an unidentified track occupancy (UTO) occurs.
The TSB issued two safety communications: the first concerning
inspection and reporting of damaged or broken rail, and the second
concerning shattered rim defects in wheels manufactured by ABC Rail
(formerly Abex Southern Corporation). CPR has instituted procedures to
address both issues. It has also instituted rail traffic control
software enhancements to visually alert the rail traffic controller (RTC)
when a second UTO occurs behind a train, and has improved documentation
procedures to better identify track anomalies.
During its investigation into this fatal accident, the TSB noted that
insufficient measures were in place to address very high workload
situations. In its report, the Board has recommended that Transport
Canada work with the Railway Association of Canada to implement rail
traffic control protocols and training that will recognize periods of
high workload and make safety paramount.
A damaged wheel on the front truck of the 39th car behind the
locomotives of the westbound train fractured the south rail at Mile
178.20 of the Belleville Subdivision, leading to the derailment of the
The TSB is an independent agency that investigates marine, pipeline,
railway and aviation transportation occurrences. Its sole aim is the
advancement of transportation safety. It is not the function of the
Board to assign fault or determine civil or criminal liability.
Click here to read the report