Figure 9: Rail occurrences
|Reported incidents (mandatory)||209.00||188.00||233.00||238.00||223.00||217.00|
One indicator of rail transportation safety in Canada is the main-track accident rate (Figure 10). According to data provided by TC, rail activity on main track decreased by 3% from the previous year. The main-track accident rate in 2014 was 2.7 accidents per million main-track train-miles, up from 2.3 in 2013, and up from the five-year average of 2.2.
Figure 10: Main-track accident rate
A total of 16 rail investigations were started in 2014‑2015, and 16 investigations were completed.
A total of 16 rail investigations were started in 2014–2015, and 16 investigations were completed. The average duration of completed investigations was 494 days, up from the 2013–2014 average of 435 days and above the previous five-year average (455 days).
Table 5: Rail Investigations at a glance
of days to complete
|Safety information letters||9||8||18||14||24||5|
Recommendations and progress
There were two new rail safety recommendations issued in 2014–2015.
The Board assessed two responses to new recommendations and reassessed responses to 16 active recommendations of the 139 issued since 1990. The Board’s reassessments were communicated to change agents for information and action.
Of the 18 active rail recommendations at the end of the fiscal year, four were assessed as Satisfactory in Part, four were assessed as having Satisfactory Intent, seven were assessed to be Fully Satisfactory and three remained to be assessed.
Both air brake and hand brake systems are subject to failure, as the technology is not failproof. And, physical defences that protect against the risk of runaway equipment exist. The TSB has pointed out the need for robust defences to prevent runaways since 1996 (TSB Railway Investigation Report R96C0172). From that time, there have been over 120 runaways in Canada that have affected main-track operations. Equipment runaways are low-probability events, but as the 2013 accident in Lac-Mégantic demonstrated, they can have extreme consequences, particularly if they involve dangerous goods. For this reason, the Board recommended that:
The Department of Transport require Canadian railways to put in place additional physical defences to prevent runaway equipment.
TSB Recommendation R14-04
TC response to Recommendation R14-04
TC will fully implement this recommendation.
On 29 October 2014, TC issued an emergency directive pursuant to Section 33 of the Railway Safety Act, requiring railways to improve their operating practices with respect to the securement of railway equipment. TC will be developing monitoring procedures to ensure operators adhere to those requirements.
Also on 29 October 2014, TC issued a ministerial order requiring companies to formulate rules to address the provisions of the emergency directive permanently. The rules are to be filed with TC within 180 days of the issuance of the order.
TC will hire additional specialized staff to strengthen oversight related to train securement and to monitor compliance with these additional levels of defence to prevent runaways.
Furthermore, as of 01 April 2015, enforcement action for any instances of non-compliance will include the option of issuing fines in the event of contraventions to the Railway Safety Act and its rules and regulations.
Recognizing that technological solutions may provide for additional improvements to mitigate risks of runaway trains in the coming years, TC will intensify its collaboration with industry through the Railway Research Advisory Board to help lead the implementation of technologies to enhance railway safety.
Board assessment of TC response to Recommendation R14-04
TC has accepted the TSB recommendation.
The Board is pleased with the safety action taken to date and with the accelerated pace of the proposed safety action. These actions include multiple layers of defence such as clarifying the rules for securement, physical defences and enhanced monitoring. If the proposed measures are fully implemented, the risk of runaway equipment will be significantly reduced. As the proposed rules have not yet been developed, and the changes in regulatory oversight (staffing levels, activities, enforcement, and research) are ongoing, some of which will not take place until 2015 or later, the outcome cannot be known until the process is finalized. Therefore, the Board assesses the response to Recommendation R14-04 as having Satisfactory Intent.
Until Canada’s railways make the cultural shift to Safety Management Systems (SMS), and TC makes sure that they have effectively implemented SMS, the safety benefits from SMS will not be realized. Therefore, the Board recommended that:
The Department of Transport audit the safety management systems of railways in sufficient depth and frequency to confirm that the required processes are effective and that corrective actions are implemented to improve safety.
TSB Recommendation R14-05
TC response to Recommendation R14-05
TC will fully implement this recommendation.
The Railway Operating Certificate Regulations now provide for the suspension or cancellation of the Railway Operating Certificate for non-compliance with safety requirements or the Railway Safety Management Systems Regulations (SMS Regulations).
TC also proposed changes to the SMS Regulations and published them in the Canada Gazette, Part I, on 05 July 2014. The changes improve how railway companies develop, implement, and assess their SMS.
TC is in the process of bringing into force additional enforcement capabilities where it will be able to fine railways for contraventions of the Act, or regulations or rules made under the Act.
TC has also reassessed the required number of inspections and audits. Audits will now be completed on at least a three- to five-year cycle, based on risk. Additional auditors with specialized training will be recruited by June 2015. As well, TC has developed, and is implementing, a management action plan to improve its oversight of railway safety, including SMS. A national review process to closely monitor all operators with compliance or on-going safety issues has also been established. Audits will now involve more rigorous review and timely follow up tied to enforceable penalties for non-compliance.
TC indicated that it did not intend to increase the scope of audits conducted every three to five years. As a result, the Board assessed TC’s response as Satisfactory in Part.
Subsequently, following the Board’s initial assessment, TC indicated it would audit every component of a railway’s SMS on at least a three- to five-year cycle.
Board re-assessment of TC response to Recommendation R14-05
As the railway industry continues to make progress towards improved safety culture, TC must demonstrate that its oversight regime will ensure that all railways are audited with sufficient scope and at a frequency to confirm that the required processes are effective and that corrective actions are being implemented.
The Board is pleased that TC has now made a clear commitment to auditing every component of a railway’s SMS on at least a three- to five-year cycle. The amended SMS Regulations were to come into effect on 01 April 2015, requiring railway companies to implement a formal framework that integrates safety into their day-to-day operations. In addition, proposed amendments to the Railway Safety Act will give the Minister the power to order corrective measures if it is believed that a company is applying its safety management system in a way that compromises railway safety. Therefore, the Board considers the response to the recommendation to have Satisfactory Intent.
The year 2014 will be regarded as a critical year for the advancement of rail safety in Canada and in North America. In August 2014, the TSB released its much-anticipated investigation report into the July 2013 tragic runaway and main-track derailment of the Montreal, Maine & Atlantic Railway freight train in Lac-Mégantic, Quebec. That comprehensive report identified a host of safety deficiencies, which spurred action on the part of industry and the regulator to improve safety for the transportation of flammable liquids. It also contributed to two issues being added to the TSB Watchlist.
Lac-Mégantic and the transportation of flammable liquids (R13D0054) (Watchlist)
The Lac-Mégantic investigation uncovered a diverse set of issues ranging from tank car standards, characteristics of petroleum products, train securement, emergency response, route planning for the transportation of dangerous goods, and the regulatory oversight of SMS. By the end of the investigation, the TSB made a total of five recommendations to TC, one of which was also addressed to the U.S. Pipeline and Hazardous Materials Safety Administration. Additional related recommendations to the Federal Railroad Administration were made by the U.S. National Transportation Safety Board.
Furthermore, the TSB found the railway company had a weak safety culture and did not have a functioning safety management system to manage risks. TC did not audit the railway often and thoroughly enough to ensure it was effectively managing the risks in its operations.
While there has been positive response on the part of the rail industry, shippers, and regulators, a number of serious derailments involving crude oil unit trains have continued to occur in Canada and in the U.S. The TSB will continue to press for required changes and to make public any urgent safety information determined during the course of its investigations.
The transportation of flammable liquids by rail, as well as safety management and regulatory oversight, have been identified as two of the key risks to the transportation system and are included on the TSB’s 2014 Watchlist.
Failure of the Bonnybrook Bridge (R13C0069)
Nature played a large role in another train derailment in 2013. In its investigation, the TSB identified intense and unprecedented flooding as the major factor contributing to the failure of the Bonnybrook Bridge in Calgary, Alberta, in June 2013. A Canadian Pacific Railway (CP) freight train derailed six tank cars. The TSB conducted a comprehensive examination of the bridge failure. The investigation determined that, although CP inspections of the bridge before the accident met TC requirements, scouring action of the flooding Bow River on the downstream end of Pier No. 2 resulted in a loss of foundation support to the pier. The flood water flow had attacked the shale bedrock/clay pier foundation, eroding and undermining it.
Following the accident, TC issued a number of safety communications regarding bridge inspections to all railway companies. In addition, CP revised its bridge inspection practices, its inspector training program and is investing in research for the early detection of scour and erosion at railway bridges.