OHS Canada Magazine

Crew misread signals in deadly VIA derailment

June 17, 2013

Health & Safety Workplace accident -- fatality

FEDERAL (Canadian OH&S News)

FEDERAL (Canadian OH&S News)

Canada’s rail safety watchdog has revealed the cause behind last year’s deadly VIA train derailment — but because of a lack of information, they cannot be entirely positive.

On June 11, the Transportation Safety Board of Canada (TSB) came out with their investigative report into the VIA Rail train accident in Burlington, Ont., which killed three locomotive engineers and injured dozens of riders.

According to the report, the VIA train derailment was likely caused by a misinterpretation of the signals, causing the VIA 92 train travelling east from Niagara Falls to Toronto to derail in February of 2012. At Aldershot station, the track switches were supposed to route track two to track three, requiring the train to proceed at 15 miles per hour. Instead, the train entered the crossover at 67 miles per hour, causing the locomotive and five coaches to go off the rails.

However, the TSB cannot determine for certain why the signals were misperceived, as there were no voice and video recorders, explained TSB manager for central region and lead investigator on the case, Rob Johnston.


“Whenever we have these kinds of cases where there’s no survivors, it’s very difficult to know exactly what went on in the cab. In this particular case, it still left a lot of unanswered questions. We don’t know whether the crew called the signals, we don’t know who called them, who responded, we don’t know what signal they recognized, we don’t know if there was a distraction in the cab,” Johnston explained. “These are things that are really important in order to prevent them from happening in the future and identifying them as risks to the industry. It’s really important that we’re able to get down to that level to understand what really happened. Without that, it’s hard to prevent another accident like this from happening.”

In Canada, Johnston estimates that once a month, a crew member misreads a signal. For a decade now, the TSB has recommended that trains implement mandatory voice and video recorders, that will help them to determine everything that happens in the cabins. In this case, the crew had about 80 years of experience between them, and were highly trained on signal recognition.

“We keep seeing these kinds of accidents over and over again, and if we don’t address this, it’ll happen again,” Johnston added.

The latest report made three major recommendations regarding rail safety. First, that major Canadian passenger and freight railways implement physical fail-safe controls, beginning with Canada’s high-speed rail corridors. Second, the report went on to say, all controlling locomotives in main line operation be equipped with in-cab video cameras. Finally, the TSB recommended that crashworthiness standards for new locomotives apply to rebuilt passenger and freight locomotives.

Mark Hallman, the director of communications and public affairs at Canadian National Rail Company (CN) said that they will be working with Transport Canada regarding physical fail-safe train controls.

“CN’s focus on safety is unwavering — it understands the importance of safe train operations for its customers, including VIA Rail, its employees and the community it serves. In 2012, CN had the fewest main track accidents and employee injuries in its history,” Hallman said in an email statement.

When it comes to physical fail-safe controls, Hallman pointed to positive train control (PTC), the collision avoidance technology intended to override locomotive controls and slow or stop a train before an accident. However, he explained that such a system would not be compatible with the CN system.

“PTC, as currently being implemented, is a technologically complex system that as of yet has not been proven in any large scale industry implementation,” he said. “In CN’s view, further deployment of PTC beyond the existing mandated rollout should not be pursued until we can fully validate the reliability and operability of the system. CN is concerned that other available automatic train control technologies may not be compatible with the interoperable PTC system currently under development.”

As for voice and video recorders, Transport Canada released its final report on June 7, encouraging the Railway Association of Canada and independent companies to install recorders on all rail systems. The release also noted that VIA Rail has made the voluntary commitment to put voice recorders on all of its trains.

Earlier this spring, the government also announced amendments to the Railway Safety Act. That included tougher monetary penalties and increased judicial penalties for rule breakers, whistleblower protection for employees who raise safety concerns, and the requirement that each railway have an executive legally responsible for safety.



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