Wendy A. Tadros
Transportation Safety Board of Canada
Release of Final Investigation Report (R05V0141) into the
Canadian National Train Derailment near Squamish, British Columbia
on August 5, 2005
Squamish, British Columbia
11 July 2007
Thank you so much for being here. In our investigation of the Cheakamus River derailment, as in all of our investigations, we are here to answer three questions for Canadians: What happened? Why did it happen? And what do government - and industry - need to do to reduce the risk?
Glance at a map of Canada and you will see lakes and rivers flowing across the country. As the country was settled, railways were built along these trading routes and towns and cities followed. Today, we reap the economic benefits of this development, but when there is an accident, we also suffer the costs. For those who make their homes close by, a rail accident can be a disaster.
In the early morning of August 5, 2005 a CN train derailed in extreme mountain territory. It spilled caustic soda into the Cheakamus River. That day, it was the people who lived close by who felt the effects. For them, the river died and an important resource was lost for a time.
I'd like to now show you a short animation of the derailment sequence.
- Short Animation -
- You are looking at the critical curve where the train derailed. However, at just under 10 000 feet, this train was actually snaking along 18 curves when it derailed.
Communities have a strong desire to understand what caused an accident. They also want to know what is being done to prevent future accidents. That is why, at the Transportation Safety Board of Canada, it is our practice to release reports where it matters - close to the communities affected by the accident. Today, we are here in Squamish, British Columbia, to report on the Cheakamus River derailment.
We will tell you about all of the factors that led to this derailment. We will report on the Safety Advisory we issued soon after the accident. We will tell you about the positive response of the Minister of Transport and Canadian National. And we will tell you about what still concerns us - what we think remains to be done to make Canada's railways safer.
How we will proceed
Before I go further, I want to talk about how we will proceed this morning.
Many of you attended our technical briefing and have a firm understanding of what went wrong. So, our collective remarks will take about twenty minutes. This will leave plenty of time for your questions.
- As Chair of the Transportation Safety Board, I will tell you about the mandate of the TSB and what we learned from this derailment.
- Mr. George Fowler, the Investigator in Charge, will provide more details of the accident and our findings.
- I will conclude with how actions taken early as a result of our investigation have improved rail safety on this territory. I will also talk about what we think still needs to be done.
I know the field can become crowded after an accident with different organizations investigating for different purposes. Sometimes, it's hard to understand who does what. That's why I want to clearly explain the role of the Transportation Safety Board of Canada.
A hallmark of the TSB is its independence. In practical terms, this means our work and what we have to say, is not subject to the approval of others. We are free from the influence of the companies we investigate. We are also independent from all other government departments and agencies, both provincial and federal.
We have one purpose and only one purpose. We advance transportation safety by conducting independent investigations into occurrences where we have the most to learn.
It is not the TSB's job to find fault or blame. Rather, we look carefully at the underlying safety issues and bring them to light for regulators and industry to act upon.
As I said before, in this investigation, we answered three important questions: What happened? Why did it happen? And what do government - and industry - need to do to reduce the risk?
I don't need to tell you that Canadians are concerned about rail safety. They want to know their communities will be safe and their lakes and rivers will be protected.
This concern is particularly strong in Western Canada. And it's not surprising given Cheakamus was the first of four similar derailments in this extreme mountain environment in 2005. It's also not surprising given the derailments at Lake Wabamun, Lillooet and Lytton.
Reason dictates we need to examine each occurrence, no matter how many investigations we have ongoing. We need to be meticulous and thorough so government and industry can address the underlying problems. We are reporting today on Cheakamus and in the fall we will release our report on Lake Wabamun and that release will be followed by Lillooet and Lytton.
Railways are a competitive business. They maximize productivity by operating longer and longer trains. They place the cars in the train so they can easily be taken off at destination. This is all well and good when you are operating between Edmonton and Winnipeg or even between Vancouver and Jasper.
But the Squamish Subdivision is one of the most challenging railway lines in Canada and there is no room for error. This is an extreme mountain environment with curves that are twice as sharp and grades more than twice as steep as on other CN main lines.
In our investigation, we found that CN did not pay enough attention to these risks. And we found that the extreme mountain environment was most unforgiving that day.
Now I would like to give Mr. Fowler the opportunity to tell you exactly what happened to train A471 and why it derailed.
Powerpoint presentation by Investigator in Charge
You have now heard about how this train stringlined in the extreme mountain environment. As Mr. Fowler explained, a number of factors lined up, physics kicked in and a serious accident happened.
We cannot change what happened that day on the bridge over the Cheakamus River. We cannot change what happened to the ecosystem and fish that relied on the river. Nor can we change the effect this disaster has had on the people who depend on the river for their livelihood. What we can do is make the case for properly managing all the risks.
I want to talk to you now about some important steps that have been taken to manage the risk and what still needs to be done.
We did not wait until today to bring to light risks we uncovered in our investigation.
Early on, the TSB led the way by issuing an advisory to Transport Canada. The purpose was to make train operations safer over the sharp curves and heavy grades of this extreme mountain territory.
Transport Canada heeded the TSB's warning and imposed restrictions on train length, tonnage and marshalling.
CN took positive actions to develop safer procedures for train operations in this unforgiving territory.
You will find all of this in Section 4 of our report. I must say that I am very pleased about the actions that were taken to manage the risks of operating trains in this extreme mountain environment.
For the Safety Board, when Transport Canada and the company agree with us early on and take action, this is the best possible outcome. It means the system is made safer right away and we do not need to make recommendations in our final report.
Risks to be Managed
Now I want to tell you about two concerns the TSB still has.
We look at the system as a whole to determine what risks remain. We are concerned that the defences in place are not adequate. Let me explain.
Twenty-one years ago, 2 trains collided and 23 people were killed near Hinton, Alberta. The lead locomotive carrying the crew was equipped with the inferior deadman's pedal. A safer system, which might have prevented the accident, was in the second locomotive.
The specifics may differ between Hinton and Cheakamus, but the principle is the same: the safest equipment should be in the lead. That is why in this report we are flagging the importance of marshalling locomotives so the safest technology is in the lead.
The Board is also concerned about cab alarms. We learned that there was no compelling alarm in the cab of this train. An alarm sounded, but it did not specifically identify the problem. Safety is not served when locomotive engineers cannot tell exactly what is wrong and whether it needs immediate attention. That is why we suggest that railways go back to the drawing board to design alarms that will clearly identify the nature of faults.
In summary, we believe safety should be factored in when choices are made about which locomotive will lead. We also believe safety should be paramount in the design of locomotive cabs.
If the people who live along the banks of the Cheakamus and Squamish rivers have paid a high price, so too has Canadian National.
The derailments of recent years have exacted huge costs. There are the more obvious costs of lost equipment and ruined goods, of not being able to use the line and of cleaning it up for use. There are the downstream costs of participating in multiple investigations, of rising insurance premiums, of lawsuits and fish replacement programs.
Then there are those costs that are harder to quantify like lost customers, dissatisfied shareholders, a damaged reputation and growing public concern. I don't believe Canadian National accepts these costs as the cost of doing business and I expect they will want to do everything possible to meet the risks head on.
One way of doing this is for Canadian National to take our safety concerns to heart and adopt our positive suggestions to make the system safer.
That is why we at the Transportation Safety Board of Canada do our work.
In conlusion. . .
You now know what caused this accident. You also know what measures have been put in place to make train operations safer. And you know we still have some safety concerns.
We would now be pleased to take your questions.
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