BURLINGTON, ON, June 11, 2013 /CNW/ - The Transportation Safety Board of Canada (TSB) is calling for fundamental changes aimed at improving the country's rail network—beginning with an automatic, fail-safe way to slow or stop trains when a signal is missed. This is one of three recommendations emerging from a TSB investigation report (R12T0038), released today, into a fatal 2012 VIA Rail derailment near Burlington, Ontario.
On 26 February 2012, three locomotive engineers were killed and dozens of passengers were injured when VIA 92 derailed at a crossover en route from Niagara Falls to Toronto. Investigators determined within days that the train had been travelling at more than four times the allowable speed, and that the locomotive crew had not properly responded to signals requiring a slowdown to 15 mph.
The frequency of misperceived signals—approximately one per month in Canada—is a driving force behind the Board's recommendation. "Every day, hundreds of passenger and freight trains encounter thousands of signals all over Canada," said Wendy Tadros, Chair of the TSB. "Missed signals are a real risk, and we need to drive that risk down. That's why we're calling for an automatic, fail-safe way to stop trains."
The TSB investigation concluded that the signals were misperceived by the crew and that several factors could have been responsible, including the unexpected presence of a work crew on the tracks. The report adds that the accident occurred at a point in the route where, 99% of the time, the crew would go straight ahead at track speed, and that such an expectation may have strongly influenced their actions.
The Board is making two further recommendations, including the installation of in-cab video cameras in all lead locomotives in mainline operations. To prevent these kinds of accidents, the TSB needs to better understand why they happen, and recordings are the key to that understanding. Finally, the Board recommends improving crew survivability by applying crashworthiness standards for new locomotives to rebuilt passenger and freight locomotives.
"We think Canadians deserve safer railways," added Tadros. "And that is why the TSB is recommending fundamental changes. We want railways where trains will automatically slow down and stop when they are supposed to, where what happens in the locomotive cab gets recorded, and where crews are given a better chance of surviving an accident."
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.
BACKGROUNDER
RECOMMENDATIONS for VIA RAIL 92 CRASH (R12T0038)
NEAR BURLINGTON, ONTARIO in FEBRUARY 2012
Occurrence
On 26 February 2012, VIA Rail passenger train 92, en route from Niagara Falls to Toronto, Ontario proceeding eastward entered a crossover near Burlington, Ontario, and derailed the locomotive and 5 coaches. The locomotive struck a building after it derailed and the locomotive cab was destroyed. Many passengers were injured, and the 3 crew members in the cab of the locomotive were fatally injured.
Recommendations
1) The Department of Transport require major Canadian passenger and freight railways to implement physical fail-safe train controls, beginning with Canada's high speed rail corridors.
R13-01
- Currently, Canada's major passenger and freight railways rely solely on administrative defences (rules, procedures) to prevent this kind of accident. These defences alone are inadequate for situations where the train crew misperceives, misinterprets or does not follow a signal indication. The Board is calling for physical defences so that if a signal is missed, the train will be stopped automatically.
2) The Department of Transport require that all controlling locomotives in main line operation be equipped with in-cab video cameras.
R13-02
- The absence of valuable information from in-cab voice and video recorders means there will always be unanswered questions, and represents a lost opportunity. Understanding the environment and interaction between the crew is vital. In order to prevent accidents in the future, we need to understand why the accidents happen.
3) The Department of Transport require that crashworthiness standards for new locomotives also apply to rebuilt passenger and freight locomotives.
R13-03
- Currently, there is no requirement for rebuilt locomotives to meet standards for crashworthiness—only new locomotives. Many locomotives may be susceptible to cab structural, fuel tank and other failures during derailments. This includes over 90% of freight and passenger locomotives in Canada.
Process
Under the Canadian Transportation Accident Investigation and Safety Board Act , federal ministers must formally respond to TSB recommendations and explain how they have addressed or will address the safety deficiencies. As of 11 June 2013, the Minister of Transport has 90 days to respond to recommendations put forth in investigation R12T0038.
Using an Assessment Rating Guide (which includes definitions for the status of recommendations), the Board evaluates the responses and their overall effectiveness. Each response is assessed as Fully Satisfactory, Satisfactory Intent, Satisfactory in Part or Unsatisfactory. Progress made to address TSB recommendations is assessed by the Board on an ongoing basis.
SOURCE: Transportation Safety Board of Canada
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