2000 TSB Recommendations & TC Responses
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R98T0042 - Main Track Derailment - Canadian National Freight Train No. Q-107-11-28 - Mile 127.54, Kingston Subdivision - Lyn, Ontario - 01 March 1998 (R00-01)
TSB Full Text Report (R98T0042):
TSB Recommendation R00-01
Assessment of CN's Track and Turnout Inspection Reporting - (Action Required, as presented in the TSB Report)
The Board recommends that:
A system-wide assessment of Canadian National's track and turnout inspection reporting and supervisory review procedures be conducted by either Transport Canada or the railway. (R00-01)
Transport Canada's Response (R00-01)
(signed by Minister on July 17, 2000)
Following the accident the department requested all its regional infrastructure inspectors to give particular attention to the switches in their respective regions. The regional offices reported back that they did not observe any similar situations where the railway supervisor had not taken appropriate action to ensure safe switch conditions.
Departmental officials have discussed the inspection of turnouts with CN Headquarters' engineering management to ensure that the Railway's inspection staff across the CN system understand and take appropriate action to guarantee safe turnout conditions.
As the Board is aware, the Track Safety Rules do not specify the amount of allowable chipping or wearing of switch points that can occur before remedial action is taken. Qualified Railway track inspectors must first evaluate the immediate circumstances to determine whether switch points are "unusually chipped or worn".
With respect to the use of subjective terms, such as "good", "fair" and "poor", by CN track inspectors when assessing track or turnout conditions, CN issued instructions on May 3, 2000, advising their track inspectors that they should avoid using subjective terms such as poor, fair, good, etc. which may have a different interpretation by different individuals. When possible, quantitative terms should be used and correct inspection processes are to be constantly monitored.
In addition, CN is reviewing its Standard Practice Circular (SPC) entitled "Turnout Installation, Inspection and Maintenance" (SPC 3500). The review will primarily target the standardization of practices between CN and Illinois Central (IC) lines. Also, to ensure universal applicability, references to specific track-work components will be made more generic.
Transport Canada will follow-up with CN at the next semi-annual meeting to ensure that the Railway has followed through with clearer instructions.
Considering the initiatives taken by both the Railway and Transport Canada, the department is satisfied that the Board's recommendation has been adequately addressed.
R98C0022 - Rear-end Train Collision - Canadian National Freight Trains A-447-51-01 and C-771-51-28 - Mile 165.4, Edson Subdivision - Obed, Alberta - 01 March 1998 (R00-02)(R00-03)
TSB Full Text Report (R98C0022):
TSB Recommendation R00-02
Safe Movement of Railway Rolling Stock - (Action Required, as presented in the TSB Report)
The Board recommends that:
The Department of Transport ensure that an assessment is made of the technologies designed for the safe separation of railway rolling stock movements, with the intent of establishing a minimum safety standard. (R00-02)
Transport Canada's Response (R00-02)
(signed by Minister July 27, 2000)
Transport Canada accepts the recommendation. The Board may wish to know that technological development in the areas of safe separation of railway rolling stock have been ongoing for some years in both Canada and United States (U.S.). Transport Canada is conducting a research project/program on new train control technologies in three phases. The first phase of the project was completed and the results are published in a TC report, titled "A Review of State-of-the-Art Train Control Systems Technology", TP13105E, March 1998 (copy enclosed). The study provided a comprehensive review and analysis of current technological development and implementation in Canada and worldwide. The report also discusses key issues including: current and new methods of train control; key functional requirements; design challenges, techniques and methodologies used in system engineering, integration and testing; and identifies issues regarding current and future developments. The second phase of the project is focused on assessing those identified technologies and their impact on the safety of railway operations, and the third phase will focus on the impact of technology on existing standards, rules and regulations with the intent of establishing a minimum safety standard for the new technology.
In addition, as part of the Rail Safety Advisory Committee (RSAC) of the Federal Railroad Administration (FRA) in the U.S., Transport Canada participates in a number of working groups examining the implications of such technologies and participates in the development of the new Standard for Positive Train Control (PTC) Systems. Transport Canada also participates in the development of new industry standards on Communications-Based Train Control (CBTC) Systems, and the Software-Systems Safety Verification Standards, which are undertaken by the Rail Transit Vehicle Interface Standards (RTVIS) Committee of the Institute of Electrical and Electronics Engineers (IEEE).
TSB Recommendation R00-03
Reporting Delays to Operations - (Action Required, as presented in the TSB Report)
The Board recommends that:
The Department of Transport ensure that an assessment is made of the suitability of current Canadian Rail Operating Rules and railway instructions concerning the immediate reporting of operating delays to all concerned when there is a safety risk. (R00-03)
Transport Canada's Response (R00-03)
(signed by Minister on July 27, 2000)
Transport Canada accepts the recommendation. The Department continues to work with the Railway Association of Canada (RAC) to ensure that the requirements of the CROR provide the highest level of safety and clarity for the railway industry. In this regard, the Department will ensure that the RAC is aware of the Board's recommendation and that it is brought to the attention of its membership to ensure train crews comply with the rules. In addition, the Department will correspond with the RAC requesting a review of the wording of Rule 85.
CROR rule 85 on Reporting Delays states "The conductor of each train will ensure that the RTC is promptly advised of any known condition which may delay the train." It is noted that the TSB does not feel the word "promptly" is specific enough; however, the department's interpretation of the word "promptly" is the immediate notification of any train delay.
Protection Against Secondary Impacts (Safety Concern) - (Action Required, as presented in the TSB Report)
The Board recognizes that current locomotive cabs are designed with cab crashworthiness and crew injury prevention as a primary concern as it pertains to collisions and derailments. In addition, personal injuries in the locomotive cab can result from train action, such as slack in the train running in or out, unexpected emergency stopping, or sudden lurching of the train. For a person in a locomotive cab, these situations often result in a person losing his or her balance, falling, and in the process, striking any of the sharp metal objects permanently fixed in the cab. For example, abdominal and chest injuries can result when the body torso strikes the edges of the control stand or the conductor's table. Other examples include the water cooler or hot plate bracket which, if fallen upon, could result in a laceration or a blunt trauma injury.
There are a number of approaches that could be employed to reduce secondary impact injuries. A direct approach would be to relocate the hazardous structures, or use personal restraining devices. However, given that there is always a trade-off between safety and operational considerations, it may not be practical to relocate fixed objects. In this case, risk of personal injury may be reduced by applying a number of engineering design techniques, such as smoothing sharp edges, adding padding to distribute the contact force, or using more energy-absorbing materials for construction. Designing the interior of the cab with an ergonomic view of eliminating these situations and introducing the use of personal restraining devices would reduce personal injuries within the locomotive cab. The Board is concerned that, without ergonomically modifying the interior of the locomotive cab to provide protection against secondary impact, the risk of the inherent hazards within the locomotive cab will continue to contribute to injury severity.
Transport Canada's Response (Safety Concern)
(Signed by Minister on July 27th, 2000)
With regard to the use of personal restraining devices, the department has little evidence available from accident statistics that the lack of such devices in locomotive cabs has increased the severity of employee injuries sustained during accidents.
However, as the TSB may be aware, in the late 1960s a "clean cab" committee comprising the rail industry, relevant unions and the Canadian Transport Commission, was set up as a result of accidents related to locomotive cabs. The committee addressed questions of cab components, including protection against sharp objects and what could be done to minimize injury in the case of an accident. As a result, the design of the locomotive cab was changed to what is now known as the "comfort cab", which has addressed many of the identified major problem areas in the cab.
More recently, the Railroad Safety Advisory Committee (RSAC) Working Group, comprised of the Association of American Railroads (AAR), the Federal Railroad Administration (FRA), manufacturers (including GM of Canada), operators and unions, have been working to revise the Association of American Railroads Manual of Standards and Recommended Practices (S-580) to enhance the level of crashworthiness protection. Although still in the draft stage, the revisions will incorporate a comprehensive update of AAR S-580, which includes such items as stronger collision posts on short hoods; the addition of corner and window posts; interior configuration (sharp edges, protruding parts, corners); underframe strength; anti-climbers, etc. When finalized, these requirements will update the current S-580. As the Board may be aware, under Part II - Locomotives Design Requirements of the Railway Locomotive Inspection and Safety Rules, section 10.2 requires new locomotives to be designed and constructed as a minimum in accordance with the S-580 or to an equivalent standard to provide for safe operation and for the protection of operating crews, and property from accidents caused by functional failure of locomotives.
R98V0148 - Rear-end Train Collision Canadian Pacific Railway - Train No. 839-020 and Train No. 463-11 Mile 78.0, Shuswap Subdivision - Notch Hill, British Columbia - 11 August 1998 (R00-04)(R00-05)
TSB Full Text Report (R98V0148):
TSB Recommendation R00-04
Signal Communication - (Action Required, as presented in the TSB Report)
The Board recommends that:
The Department of Transport and the railway industry implement additional backup safety defences to help ensure that signal indications are consistently recognized and followed. (R00-04)
Transport Canada's Response (R00-04)
(signed by Minister on April 19, 2001)
Transport Canada supports the intent of this recommendation. As indicated in the TSB Press release, the Board believes that a wide-ranging review of both the extent of the problem and various potential solutions could achieve a significant improvement in rail transportation safety.
The Department will continue to study new technologies, in association with the Railway Association of Canada and the railways which could provide additional backup safety defences to help ensure that signal indications are consistently recognized and followed by train crews.
For this purpose, Transport Canada is monitoring studies currently being undertaken by the Canadian Pacific (CP) Railway on improved radio and locomotive cab communication which involves the use of headsets. In addition, the Department is monitoring technologies such as the Communication-Based Train Control (CBTC), also referred to as Positive Train Control Systems (PTC), which enables communication between trains, and could provide the required additional backup to help prevent such accidents from occurring.
TSB Recommendation R00-05
Locomotive Environment - (Action Required, as presented in the TSB Report)
The Board recommends that:
The Department of Transport assess the impact of noise on voice communication in locomotive cabs and ensure that crew members can effectively communicate safety-critical information. (R00-05)
Transport Canada's Response (R00-05)
(signed by Minister on April 19, 2001)
Transport Canada accepts this recommendation. The Department participated in an assessment of noise levels in locomotive cabs, in conjunction with Human Resources Development Canada in November 1999. Noise measurements in locomotive cabs were carried out from November 1999 to August 2000, and the results of these measurements were presented to CP and Canadian National (CN) on January 10, 2001. The results indicate that noise levels meet the Canada Labour Code requirements with respect to hearing loss.
Transport Canada has noted the Board's concern regarding the current state of compliance with the Canadian Rail Operating Rules (CROR), Rule 34 (the identification and calling of the signals by the crew). The Department's Rail Safety Inspectors monitor for compliance to Rule 34 by conducting on-board inspections while riding in locomotive cabs. In addition, crew compliance with Rule 34 is also monitored by the railway companies, through proficiency tests that are audited by Transport Canada.
Further to these enforcement measures, Transport Canada has undertaken concentrated efforts across Canada during the monitoring of Rule 34 to make qualitative assessments on the ease of communications, and audit railway records and Operational Safety and Health (OSH) minutes for complaints concerning communication problems, and will take remedial action if necessary.
In addition, the Railway Safety Management Systems Regulations, which came into effect March 31, 2001, will further improve railway safety by promoting a safety culture within the railway industry, enabling railways to demonstrate their commitment to safety, and their compliance with regulatory requirements.
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