Communiqués

(For release 04 July 1996)

(Hull, Quebec) - The Transportation Safety Board of Canada (TSB) is concerned that the public is being exposed to risks as a result of operating deficiencies in the emergency window exits on Ontario Northland Railway (ONR) passenger coaches.

On 31 March 1996, an ONR passenger train derailed at a damaged track switch just south of North Bay, Ontario. The train, carrying 54 passengers and a crew of 6, remained upright after the derailment. Three passengers were taken to hospital and treated; seven passengers were treated on the site and released.

Following the derailment, the lead passenger coach began to fill with steam. Some of the passengers in the coach attempted to open the emergency exit windows. Five of the 12 emergency exit windows were tried unsuccessfully before the passenger door at the rear of the coach was opened and the passengers were able to leave.

As a result of the difficulties experienced with the emergency exit windows during the evacuation of the lead coach, the TSB investigation of this occurrence has concentrated on finding the cause of these difficulties. A number of deficiencies in the operation of these emergency exit windows were observed: placards were missing; placards did not provide enough information; 9 of the 12 windows were partially blocked; window size and weight made it difficult to remove; some metal emergency handles were missing and others did not work. Many of these problems would have made exit from the coach extremely difficult if the car had been on its side.

With the investigation evidence to date, the TSB is concerned that, in the event of a more serious accident, particularly one involving coach upset, such non-functional escape routes and inadequate directions on their use could delay or prevent successful emergency escape. Although the investigation into this accident is not yet concluded, as a matter of urgency, corrective action is warranted. The Board has therefore recommended that:

The Ministry of Northern Development and Mines of Ontario ensure that:

• an immediate, one-time, functional test on all emergency window exits on ONR passenger coaches is conducted; and
• a program for regular functional verification of emergency window exits on ONR passenger coaches is established; [R96 - 01]

The Ministry of Northern Development and Mines of Ontario ensure that explicit instructions for use of the emergency window exits on ONR passenger coaches are readily available; [R96 - 02] and

The Ministry of Northern Development and Mines of Ontario ensure that seats and luggage racks do not interfere with the use of the emergency window exits in the passenger coaches. [R96 - 03]

The TSB is also concerned that a significant number of rail passengers would have difficulty lifting one of these emergency exit windows clear of the egress path because of the size and weight of these windows. Because the train crew may not be available to assist in emergency situations, passengers should be able to evacuate the coaches by themselves. The Board has therefore recommended that:

The Ontario Northland Transportation Commission undertake research with an aim to installing, in ONR passenger coaches, emergency exit windows that can be readily removed by able-bodied passengers. [R96 - 04]

These interim safety recommendations do not preclude the possibility of further safety recommendations upon the completion of the TSB investigation into this occurrence.

The Transportation Safety Board of Canada is an independent agency operating under its own Act of Parliament. 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.

-30-

---

INTERIM RAILWAY SAFETY RECOMMENDATIONS

DATE ISSUED: 02 July 1996

FORWARDED TO: The Honourable Chris Hodgson, M.P.P
Minister of Northern Development and Mines of Ontario
Mr. John Wallace, President & CEO
Ontario Northland Transportation Commission
SUBJECT: Adequacy of Emergency Window Exits on Ontario Northland Railway Passenger Coaches

On 31 March 1996, an Ontario Northland Railway (ONR) passenger train derailed at a damaged track switch of the CN North America (CN) Newmarket Subdivision near North Bay, Ontario. The train was travelling at approximately 45 mph when the crew noticed the damaged switch and applied the emergency brake. The train had slowed to an estimated 20 mph at the time of the derailment. All the train cars remained upright. The investigation is ongoing (TSB occurrence No. R96T0111).

The train consisted of a locomotive, a power unit, a kitchen car and three passenger coaches. There were 54 passengers and 6 crew members on board. Three passengers were taken by ambulance to hospital and treated; seven were treated on site and released.

Following the derailment, the lead passenger coach began to fill with steam. Some passengers in the lead coach attempted to open the emergency exit windows. Five of the 12 emergency exit windows were tried unsuccessfully before the passenger door at the rear of the coach was opened and the passengers were able to leave.

As a result of the difficulties experienced with the emergency exit windows during the evacuation of the lead coach, much of the TSB investigation to date has concentrated on identifying the cause of these difficulties.

ONR Passenger Coaches

The ONR is currently using 14 coaches similar to the lead coach in this occurrence; six others are in storage. Each passenger coach has a maximum seating capacity of 54, and the ONR passenger service runs a return train using this type of coach six days per week. The coaches were originally used in the Toronto GO Transit system for commuter service and were modified for the ONR passenger service. The modifications included higher seatbacks, overhead luggage racks and a permanent luggage rack at the end of each coach. Apparently, no modifications were incorporated to make the emergency egress exits more suitable to travel in non-urban or wilderness areas, remote from first responders.

Operation of Emergency Window Exits

Placards, using pictograms and located on each emergency exit window above the red emergency pull handle, show how to operate the emergency exits (see photographs in Appendix A). The intended operation of the emergency exit windows is as follows:

1. The rubber weatherstripping from around the window is removed by pulling the red emergency handle.
2. Once the red emergency handle is pulled, a metal handle is exposed; after removing the weatherstripping completely, the metal handle is pulled in an upward and inward motion to loosen the window from the frame.
3. The window is then lifted out of the frame and placed so as not to obstruct the egress route.

Preliminary Investigation Observations

During on-site examination and operating tests of the emergency exit windows of the lead coach, the TSB noted the following:

1. The placards on two of the emergency exit windows were missing.
2. The placards gave the impression that the emergency window was hinged at the top; they did not indicate that the window must be removed and stowed out of the way.
3. The placards do not depict passenger egress out of the coach via the window.
4. Nine of the 12 emergency window exits were partially obstructed by the higher modified seatbacks, and one was partially obstructed by the permanent luggage rack at the end of the coach.
5. The effort required to pull the rubber weatherstripping from around the windows varied from very little to considerable (see Appendix A).
6. The window frame has a lip against which the metal handle can become jammed if the handle is pulled inward before the bottom edge of the window has cleared the lip.
7. The metal handle to remove the window is small, limiting the force that can be applied to loosen and remove the window (see Appendix A).
8. The window size (31 inches by 50.5 inches) and weight (approximately 60 pounds) makes removal and subsequent manoeuvring difficult (hence conducive to jamming between the seats and the coach wall and to obstructing the egress route).
9. Of the five window exits tried by the passengers during the occurrence, one was missing a metal handle, two could not be loosened in their frames, and the remaining two had the metal handles jammed against the lip of the frame.
10. Many of these problems would have been exacerbated if the coach had been on its side and the only safe egress route had been overhead through the emergency exit windows.

The Board understands that the emergency window exits are not regularly tested to verify that they function as intended. Apparently, the windows are only removed as required for repair or maintenance.

Action Required

Given the investigation evidence to date, the Board is concerned that the public is being unnecessarily exposed to risks as a result of operating deficiencies inherent in the emergency exit windows on ONR passenger coaches. In the event of a more serious accident, particularly one involving coach upset, such non-functional escape routes and inadequate directions on their use could delay or prevent successful emergency egress. Although the investigation into this accident is not yet concluded, as a matter of urgency, corrective action is warranted. Therefore, the Board recommends that:

The Ministry of Northern Development and Mines of Ontario ensure that:

• an immediate, one-time, functional test on all emergency window exits on ONR passenger coaches is conducted; and
• a program for regular functional verification of emergency window exits on ONR passenger coaches is established;

R96-01

The Ministry of Northern Development and Mines of Ontario ensure that explicit instructions for use of the emergency window exits on ONR passenger coaches are readily available; and

R96-02

The Ministry of Northern Development and Mines of Ontario ensure that seats and luggage racks do not interfere with the use of the emergency window exits in the passenger coaches.

R96-03

Furthermore, the Board is concerned that a significant proportion of rail passengers would have difficulty lifting one of these emergency exit windows clear of the egress path because of the size and weight of these windows. Considering that the train crew may not be available to assist in emergency situations, passengers should have a means to evacuate the coaches by themselves. Therefore, the Board also recommends that:

The Ontario Northland Transportation Commission undertake research with an aim to installing, in ONR passenger coaches, emergency exit windows that can be readily removed by able-bodied passengers.

R96-04

The foregoing recommendations do not preclude the possibility of further TSB safety recommendations upon completion of the referenced investigation.

John W. Stants
Chairman
On behalf of the Board

APPENDIX A - PHOTOGRAPHS