Notes For Remarks
MR. Benoît BouchardChairman Transportation Safety Board of Canada
Release of the final report April 5, 2001
Into the derailment/collision of
Via Rail Canada Inc. Passenger Train no. 74
On 23 April 1999
Good afternoon, ladies and gentlemen:
Two years ago, on a stretch of CN track not far from where we sit today, a human error and an outdated system of rail traffic control resulted in tragedy. Two men, employees of VIA, lost their lives. Seventy-seven other people were hurt, several of them seriously.
All of us__and especially the families of the victims__wish that this accident had never happened. But it did.
As a society that cares about safety, we must work together to ensure that we learn from this tragedy, and do whatever is necessary to prevent such a catastrophe in the future.
And so it was the Transportation Safety Board of Canada's duty to investigate this accident. Today, we make our findings and recommendations public, so that regulatory authorities and the rail industry can take all reasonable steps to enhance public safety.
In a moment, Mr. Dan Holbrook, the Transportation Safety Board investigator-in-charge of this accident investigation, will take you through the technical details of what we found.
Permit me first, however, to set the scene.
On April 23rd, 1999, VIA passenger train No. 74, with 186 persons on board, was travelling east on the CN Chatham Subdivision in south-western Ontario. Unknown to the locomotive crew, a switch was set in the wrong position, causing the train to be directed onto another track.
Train No. 74, not expecting this situation, could not slow down enough to move safely to the other track, and derailed. In the process, it rolled over and collided with stationary hopper cars on a nearby siding. Four of these hopper cars contained ammonium nitrate.
Now, first and foremost, I want to acknowledge that the quick actions of the two crew members in the VIA train's locomotive probably saved many lives.
For one thing, when they recognized the danger of the improperly set switch, they quickly activated the train's emergency brakes to slow it down.
They then shut down the engine. That action removed a source of ignition, thereby lessening the chance of fire or explosion of the ammonium nitrate that was released in the collision with the hopper cars.
And, with just seconds to act, the crew members radioed a warning to another passenger train approaching from the other direction. As a result, the westbound train was stopped in time.
So, I say to the families of these two individuals, Canadians owe these men a lot of gratitude. Their actions helped avoid potential death and/or injury to almost 300 people on the two trains.
I would also like to commend the quick actions of all the emergency response crews in Chatham-Kent. They arrived on the scene within a few minutes of the accident and had the survivors out of the train, the most seriously injured people on the way to the hospital, and they stabilized the leaking fuel oil, all within 50 minutes.
So, how did this accident come to pass?
In the simplest terms, it was caused by a track switch being locked in the wrong position. Instead of continuing straight down the main track, train No. 74 hit the switch and veered off towards a different track. A train, travelling at posted track speeds, cannot successfully navigate such an abrupt change in direction.
Our investigation found that the switch was left in the wrong position__a result of simple human error.
I think it is important to underline here that the role of the TSB is not to assign blame or fault. That is the role of the court. Our role is to investigate transportation accidents, to determine what happened, why it happened, and to identify safety deficiencies.
Those deficiencies may in fact have contributed to the particular accident under investigation, or they may represent a risk__a future accident waiting to happen.
Whenever we find a safety deficiency, we bring it to the attention of the appropriate authorities which could be the regulator, the train operator, the manufacturer, and so on. They are the ones who can fix the problems; our job is to bring them to light.
Which brings me to the main area of concern highlighted by this accident. And that is, the control of the switches, and how train crews are alerted to improperly positioned switches.
In this instance, the train was travelling through what we refer to as "dark territory." What that means is that there is no illuminated or electronic signal to tell a locomotive engineer who is approaching a switch what position the switch is in.
The locomotive engineer has to proceed with the expectation that all switches have been properly positioned by other railway personnel who are responsible for handling those switches.
Clearly, in such circumstances, human mistakes can easily go undetected. By the time a locomotive engineer spots the small red sign that indicates a reverse switch, it can be too late.
From the standpoint of the TSB, this is simply not good enough.
And I suggest to you that this is not a minor problem. In Canada, we have 47 hundred kilometres of track where passenger trains operate through "dark territory," 47 hundred kilometres of track where there is no advance warning of the position of the switches available to train crews.
The result? Since 1993, 79 trains__an average of 10 per year__have come across unexpectedly reversed main track switches. Two-thirds of these occurrences took place in "dark territory."
Many of these trains carried passengers; others carried potentially hazardous freight. The potential for disaster, clearly, is great.
So, with so many occurrences, why are we calling for change only now?
In point of fact, the problem of hand operated switches and switch signalling through dark territory is something the TSB has commented on many times before.
It is true that certain improvements are being made. But the Board considers that those changes are not coming fast enough. Much still needs to be done.
In a moment, I will speak about some of the measures that have been taken to address the safety deficiencies outlined in this report. But first, I will turn the microphone over to Mr. Holbrook, to take you through the conclusions of our investigation.
[Dan Holbrook presents investigation findings]
Thank you Dan.
In the past, the TSB has recommended better strategies to protect against the unauthorized reversal of main track switches. We have felt that many of the systems in place lack safeguards to help lessen the impact of errors.
For example, if somebody makes a mistake in setting the switch, there ought to be backup measures in place that will catch the mistake in time to avert disaster.
Fortunately, some important actions along those lines are already being taken.
Canadian National, for example, is giving its employees more training on how to safely manage rail switches.
The company is also increasing the size and visibility of its main track switch targets which tell the locomotive engineer the position of switches up ahead when they are required to use them.
At the same time, CN is field-testing a system that uses radio signals to indicate the switch position__well beyond the maximum distance the train needs to brake.
And, as a significant response to the Thamesville accident, CN last year upgraded all its train control systems in "dark territory" on all tracks used by passenger trains throughout the Québec-Windsor corridor to include wayside signals that provide advance warning of reversed switches and other track conditions.
Transport Canada, which regulates the rail system, has also taken action.
Last November, for instance, the Department issued a six-month directive requiring passenger trains to slow to 50 miles per hour or less in non-signalled territory until the crew can confirm the proper positioning of the switches. Freight trains must not exceed 45 miles per hour, while trains carrying special dangerous goods are restricted to 40 miles per hour.
Also, workers who have changed the setting of a switch are now obliged to confirm with another employee that the switch is in the correct position.
The Transportation Safety Board of Canada believes that Transport Canada's emergency directive acknowledges the risk of train operations in "dark territory." We also believe that the steps taken by the rail industry will help mitigate some of the risk.
We cannot, however, be satisfied with the initiatives already underway. We need to be sure that these improvements won't expire at the end of Transport Canada's six-month directive. Not only must they be extended, they must be made permanent.
Even while these improvements were being put in place, trains were encountering reversed switches in Canada. In fact, since the Thamesville accident, there have been 14 instances where trains, 4 of which were passenger trains, have come across reversed switches in "dark territory".
There is a need to ensure some form of permanent measures to protect against trains encountering reversed switches in "dark territory." That is the intent of the Board's first recommendation.
Ladies and gentlemen, let me be clear: no one will ever be able to regulate human error out of existence. We humans are not perfect; accidents, sadly, will always happen.
But what we can do, and what we must do, is reduce the likelihood of mistakes, especially those that can have catastrophic consequences.
This is why the TSB has also recommended that the train control system that was in use at Thamesville and remains in use on a great deal of track in Canada be reviewed, in detail, with a view to ensuring that it is designed with sufficient regard to human error.
At Thamesville, the dangerous goods cars had been stored immediately adjacent to a high-speed main track for an extended period of time. In addition, there was some debate as to whether these cars were still within the transportation system or delivered to destination.
While we acknowledge the safe record Canada's rail carriers have in handling dangerous goods, we believe that, where possible, such cars should not be stored so close to main tracks, particularly where passenger trains are operated. Therefore, our third recommendation calls upon Transport Canada and the Canadian rail industry to review the current safety framework for storage and handling of dangerous goods by rail.
Finally, the Board has observed some passenger safety concerns that still need addressing__particularly on passenger coaches where unsecured luggage and tool boxes still pose a problem in the event of an accident. A lot has been done in the field of passenger safety, but this problem needs to be looked after in a more timely fashion.
We have the technologies and the know-how to address all of the preceding issues. All we need now is the will.
I thank you for your attention. And now we are available to answer any questions you may have.
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