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Final report on Buckskin Derailment
Published: August 8, 2008
Source: Transportation Safety Board of Canada

Related story from June 5th 2008
TSB Report R06T0022
Emergency Directive

July 29, 2008

Ms. Wendy A. Tadros
Transportation Safety Board of Canada
200 Promenade du Portage
Place du Centre, 4th Floor
Gatineau, Quebec
K1A 1K8

Dear Ms. Tadros:


I am writing in response to your letter of June 2, 2008, which contained Transportation Safety Board recommendations R08-01 and R08-02. These recommendations were made as a result of the investigation into the derailment of a Canadian Pacific Railway freight train 230-30 at mile 114.65 of the MacTier Subdivision in Buckskin, Ontario on January 31, 2006.

I am pleased to provide you with a response as required under subsection 24(6) of the Canadian Transportation Accident Investigation Safety Board Act.

Yours truly,

Original signed by

The Honorable Lawrence Cannon, P.C., M.P.



From the TSB Final Report – Removal of Suspect Transcona Wheel Shop Wheel Sets:

In 2000, loose wheels began to occur on CN's coal rail car fleet. By fall 2001, CN had traced the problem to a modified wheel boring process that had been used in the assembly of 36-inch wheel sets at its Transcona wheel shop between April 1998 and February 2001. The modified boring process resulted in wheel sets with reduced contact area between the wheel bore and axle wheel seat. Under normal service conditions, the reduced contact area led to higher stresses in the remaining areas of contact that initiated fretting at the tips of the bore spirals when the car was negotiating a curve. This resulted in brinell indentations occurring on the axle wheel seat that progressively loosened the interference fit. All of the wheel sets that were produced using the modified wheel boring process (approximately 43 800) have a high susceptibility to loosen, particularly in heavy-curvature territory.

Since loose wheels were first detected, CN and the Association of American Railroads (AAR) initiated an industry recall that included issuing AAR Early Warning letter (EW) 5183 and AAR Maintenance Advisory (MA) 74. However, due to shortfalls in the recall process, the risk has not yet been completely mitigated. Consequently, at least 25 per cent (10 000 to 12 000) of these wheel sets remain in service six years after the initial recall and loose wheel derailments continue to occur.

To date, at least 15 derailments in Canada have been attributed to suspect Transcona wheel shop loose wheels, 12 of which occurred after the recall process had been initiated. Since most of these two-wear wheel sets have an extended service life and the mode of failure takes time to develop, the risk of failure for these remaining wheel sets continues to increase the longer they remain in service.

Therefore, the Board recommends that:

“The Department of Transport ensure that all 36-inch Canadian National Transcona wheel shop wheel sets assembled between April 1998 and February 2001 be removed from cars operating in Canada.” (R08-01)

Transport Canada (TC) accepts the Recommendation R08-01. On June 13, 2008, TC issued an Emergency Directive (copy attached) to Canadian National (CN) pursuant to Section 33 of the Railway Safety Act (RSA) whereby CN is to identify and remove the said wheelsets from Canadian Services, by no later than, October 15, 2008.

From the TSB Final Report - Tracking Wheel Set Components

There were gaps in the initial industry recalls of EW 5183 and MA 74 that did not include approximately 17 000 suspect Transcona wheel shop wheel sets assembled between January 2000 and February 2001. Aside from CN, the industry as a whole did not target the full population of suspect wheel sets for removal until July 2006. As a result, many wheel sets were permitted to remain in service or, as in this occurrence, removed from the original car, reconditioned and placed under a second car.

This was not the first time that a wheel population with a known manufacturing defect had caused multiple derailments and been subjected to an industry recall. In 2004, a Southern wheel failure on a Canadian Pacific Railway train resulted in two fatalities in Whitby, Ontario (TSB investigation report R04T0008). The AAR had previously issued recalls of wheels that contained known manufacturing defects produced by Southern Wheel, by Mafersa, and by Edgewater. In each of these cases, industry was aware of these wheels' susceptibility to failure, and had initiated recalls, but had been unable to track, locate, and remove all of them before failure.

When wheel sets are installed under freight cars, wheel set information such as month and year of manufacture, manufacturer code, heat treatment class, wheel flange and tread thickness is recorded. However, there is no requirement to record wheel mount date and wheel serial numbers even though the information is readily available. The absence of wheel serial numbers and mounting dates presented fundamental difficulties during the Transcona wheel shop wheel set recall process. Had this information been available, it would have provided an alternate method for locating the defective wheel sets. An industry-wide search of databases would have located the suspect Transcona wheel shop wheel sets, regardless of which car they were under at the time of the recall. In addition, databases could have been flagged to produce a warning before the installation of suspect Transcona wheel shop wheel sets.

The testing of radio frequency identification tags to track rail car components is a positive step towards solving the tracking problem. However, when compared to the aviation industry, the rail industry falls short in its ability to locate and remove defective components. Specifically, the Canadian Aviation Regulations require that, whenever components are installed into an airframe, the components and the procedures used for their installation are uniquely identified and permanently recorded. In this manner, components can be easily located if a problem develops at a later date with either the component or the installation procedure. With the transition to a more global supply network for the North American rail industry, the need for a system that has the ability to effectively and quickly locate potentially defective wheel set components in freight cars is essential.

Because the industry has no effective way to track wheel sets once they are removed from their original car, wheel sets with potentially defective components cannot be easily located and removed from service before failure. The inability to quickly locate defective wheel set components increases the risk of a failure, which can lead to a derailment.

Therefore, the Board recommends that:

“The Department of Transport ensure that railways adopt procedures and technologies to track all wheel sets.” (R08-02)

TC accepts the Recommendation R08-02. On June 13, 2008, TC issued an Emergency Directive to CN pursuant to Section 33 of the RSA, whereby CN has been directed to put in place a system to record and track major components such as, but not limited to, wheels, wheel sets, axles, roller bearings, draft gears, and couplers throughout their service life, by no later than
December 13, 2008.

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