An investment in safety: On the ground of the VIA train derailment in Burlington
11 June 2013
Posted by: Julie Leroux
Arriving on the scene of the VIA train derailment in Burlington
The day VIA train 92 derailed in Burlington one I will never forget. The call came in late on Sunday afternoon, and within a few hours I had packed my bag, flown to Pearson International, and was making my way along the 407 to Burlington. When I arrived at my hotel just after 1 a.m., I joined two TSB investigators who were drawing up a plan for later that morning. With a heavy heart and very little sleep, we arrived at the accident site at 9 a.m. where an army of journalists awaited, anxious for answers.
One of the first things we confirmed was that the locomotive event recorder had been found. Similar to a black box on an aircraft, this recorder captures valuable data, including the exact speed the train was travelling. But what it wouldn’t tell us is what the three crewmembers said in the cab—something we’ve been calling for since 2003.
As the investigation progressed in the following months, our team worked incredibly hard to piece together what happened. We examined the locomotive and cars, conducted interviews, and analyzed many documents about railway signals, track maintenance and employee training. At every major stage of the investigation, we also kept the families and loved ones up-to-date and briefed them on the final report this past Sunday.
Today, we are releasing the results of our investigation, and again I’m on the ground in Burlington to make our findings public. But to understand what happened, you need to know what railway signals are and how they work.
How railway signals work
Similar to traffic lights, railway signals have green, yellow and red lights. They tell drivers and train operators when to go ahead, when to slow down and when to stop. What’s different about railway signals is that they also tell crews how fast to go and how to approach the next signal. This additional information is communicated through the flashing and position of the lights, and the combination of which ones are lit up together. That's a lot to take in!
Investigation into the VIA train derailment in Burlington
Very early on, we knew the train was travelling much faster than it was supposed to. The railway signals that day called for a maximum speed of 15 mph, but the train was clocked at 67 mph as it approached the crossover in Aldershot.
In the weeks that followed, our investigators confirmed that the signals were working exactly as intended and that they told the crew to slow down. So why didn’t they? The answer was difficult to find, and the truth is, we will never know for sure. We can’t—not without concrete proof from voice or video recordings.
But that didn’t stop our human factors experts. They were quite sure the crew had seen the signals. So the question became: did they misunderstand them? There are several possible theories, one of which centers around the crew’s familiarity with the route.
One theory into the VIA train derailment in Burlington
Train crews travel the same routes over and over. They become incredibly familiar with what to expect. The same thing happens when you drive your car on the same roads, to the same places every single day. Your brain becomes hardwired. Now consider when a Canadian, who has driven on the right side of the road for their entire life, drives for the first time in England or Australia. They have to constantly remind themselves to stay to the left.
People are creatures of habit, and we do what we expect to do. It takes something very strong to change that expectation. For train crews, it’s no different. On the track where VIA train 92 was traveling, crews were used to going straight through at the same speed. In fact, this was the case 99% of the time. But on this day, the train was redirected through a crossover onto another track, which is why the signals had told the train to slow down.
In Canada, our busiest rail corridor from Quebec City to Windsor is run by a kind of choreography. The rail traffic controllers determine how trains will move and then direct the system to show the crews the appropriate signals. The problem is that about once a month, somewhere in Canada, there is a disconnect between what the signal displays and how the crew perceives it. Something fundamental needs to change so this won’t happen again—something to defend against our natural human behaviour.
TSB recommendations from the VIA train derailment in Burlington
In recommending an automatic fail-safe way of slowing down or stopping trains, the TSB is calling for big change. And we also want voice and video recorders on trains so that the next time, we can better understand why the crew did what they did. Finally, we also want tougher standards that will give crews a better chance of surviving an accident.
I think this investigation is going to be a game-changer, and I am proud to have been a part of it, on the ground in Burlington.
Julie has always been passionate about communications. She began her career as a Communications Advisor in the Government of Canada in 1999. Since 2007, Julie has worked at the TSB as a Media Relations Specialist and has spearheaded a number of major news conferences. Julie loves to travel, read and go shopping!
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