'Inconsistent and incomplete maintenance' to blame for Ottawa LRT derailment Sept. 19: TSB concludes

OTTAWA -

Canada's transportation watchdog concludes "inconsistent and incomplete maintenance" is to blame for the O-Train derailment on Sept. 19, which has shutdown the LRT system for nearly seven weeks.

In a Rail Safety Advisory Letter sent to the city of Ottawa this week, the Transportation Safety Board concludes bolts connected to the gearbox were not adequately torqued during maintenance less than a week before the derailment, and there was improper oversight of the maintenance for the LRT system.

"LRV 1121 (derailed car) was repaired and released from a shop only to have a safety-critical component fail and cause a serious accident within 5 days of its release," said the TSB in its letter.

The TSB is recommending the city and Rideau Transit Group conduct an "in-depth" review of all work performed on safety-critical components to confirm procedures are followed, and ensure there is "sufficient oversight" of maintenance work in place.

Ottawa's LRT system has been out of service for nearly seven weeks after an LRT car derailed at Tremblay Station, damaging the car, the track and the transit infrastructure.

In a memo to Council, City Manager Steve Kanellakos said the city received a Rail Safety Advisory letter from the Transportation Safety Board on Tuesday.

"The RSA letter details TSB’s view that the root cause of the derailment was due to inconsistent and incomplete maintenance of the light rail vehicle components by Rideau Transit Maintenance (RTM) at the maintenance facility," said Kanellakos.

"Specifically, that some of the 12 bolts that connect each gearbox to light rail vehicle bogie assemblies were not adequately torqued when they were installed during refurbishment work that took place on nine light rail vehicles in response to the earlier August 8, 2021 derailment near Tunney’s Pasture Station."

Kanellakos says the city agrees with the TSB's finding and recommendations with regards to maintenance processes and the root cause of the Sept. 19 derailment.

City staff told the Transit Commission two weeks ago that improperly torqued bolts caused the gearbox to drop, damaging the train and several hundred metres of tracks before it stopped west of Riverside Drive.

In its report, the Transportation Safety Board says the derailed train (LRV 1121) was held for repairs following the first LRT derailment near Tunney's Pasture on Aug. 8. Car #1121 was one of nine LRT trains identified for additional inspections and maintenance, with three loose cartridge assemblies identified. 

On Sept. 9, work commenced on the vehicle, wtih employees from RTG subcontractor Texelis replacing the cartridge bearing assemblies. Alstom employees then reassembled the trains and torqued the bolts on the train.

"At 2300 on 09 September 2021, the afternoon shop staff finished their shift without realizing that the bolts securing the splined axle stub to the wheel hub in BM2, No. 11 wheel position, had not been adequately torqued or advising the next shift of work that was outstanding," says the TSB.

"On 10 September 2021, the morning shift continued with the refurbishment, completed the torqueing of the disc brake rotors, reinstalled BM2 and BM3 and, then sent LRV 1121 to MSF 1 for final inspection, which included a check of all gearboxes for oil leaks. Subsequently, LRV 1121 was released from MSF 1 on 13 September 2021 and resumed passenger service the next day."

Five days later, the train derailed near Tremblay Station with 12 passengers and a driver onboard.

The report notes the work order for the train was unavailable during the maintenance, "Therefore, staff scanned an old work order and the work was recorded" for another car.  The TSB says Alstom's process requires that all bolts for which a torque is specified are to be identified with a marker/indicator after torqueing.

"A review of some of the overhauled components also revealed a lack of consistency in the 'marking' of torqued bolts," said the TSB in its Rail Safety Advisory Letter.

"At the time the work was performed, it was reported that there was also minimal supervisory and/or quality control personnel oversight of the refurbishment work performed. Although the wheel torques were recorded on a paper, there were no such records for any other component with torqueing requirements and no supervisory or quality control sign-off was required."

The TSB says it conducted a joint examination of the two-car train involved in the derailment with Alstom on Sept. 28, discovering "all 12 bolts from BM2 No. 11 wheel position had failed."

In its conclusion, the TSB said all 12 bolts were not adequately torqued when installed during the maintnenance and the axle failed. 

"LRV 1121 was then allowed to enter service without a complete set of torque data or Alstom verification that all work was complete," said the TSB in its conclusion.

"The lack of applied torque led to the failure of all 12 retaining bolts after only about 800 km of service."

The TSB says disconnected components dropped from the car and contacted the train infrastructure, resulting in the derailment.

"This accident has demonstrated that there can be serious consequences resulting from the inconsistent and incomplete maintenance of safety-critical components on an LRV in commuter passenger service," said the TSB in its report.

"Therefore, OLRT may wish to conduct an in-depth review of all work performed on safety-critical components to confirm that procedures are followed and that there is sufficient oversight in place to prevent a similar occurrence from happening again."

Kanellakos says the findings outlined by the Transportation Safety Board are "aligned with the analysis" from the independent third-party review conducted by TRA Inc., the Philadelphia-based independent agency hired to review the return-to-service plan.

"TSB’s advisory letter also includes recommendations to conduct an in-depth review of all work performed on safety-critical components in order to prevent a similar re-occurrence," said Kanellakos.

"This aligns with the work currently underway by TRA in reviewing RTG’s return to service plan, work procedures and maintenance processes in order to ensure the safety and reliability of the light rail system and to prevent events like the August 8 and September 19 derailments from happening again."

Coun. Catherine McKenney, who has called for a public inquiry into the LRT system, says the public-private partnership is "a failure."

"What we can do today is we can take that maintenance contract back," said McKenney. "For $5 million a month, we can hire somebody who knows how to torque bolts."

In a separate interview with Newstalk 580 CFRA's Ottawa's Now with Kristy Cameron, McKenney said this is "complete and utter incompetence" by Rideau Transit Group and Rideau Transit Maintenance.

"RTG who built the system for $2.1 billion and then walked away and gave us a slew of incompetence maintenance people for $5 million a month," said McKenney.

"This is taking public funds, taking your tax dollars, handing them over to a private consortium who builds a piece of crap, for lack of a better term, and walks away."