Speaking Notes, Operation Lifesaver Gatineau, Quebec
Martin Lacombe

Board Member
Transportation Safety Board of Canada
Gatineau, Quebec
15 September 2010

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Slide 1: Title

Thanks for the opportunity to come and speak with you.

Slide 2: Outline

I'll be keeping today's presentation pretty focused, beginning by outlining what we do at the TSB, then talking extensively about our current safety issues Watchlist.

I'll discuss those issues which are most relevant to the rail industry, and then talk about a few specific accidents to illustrate the points.

Since these issues are based in part on findings and recommendations from our investigations, I'll refer to a few specific TSB recommendations and update you on the progress made.

Slide 3: TSB Mandate

As most of you know, the TSB is an independent government organization. Our mandate is to advance the safety of transportation in the air, marine, rail and pipeline modes.

We do this by�

However, it is not the function of the Board to assign fault or determine civil or criminal liability. It's also important to note that the TSB is independent of federal departments and ministers; therefore, we are not subject to political direction or motivation regarding our accident investigations and the way investigators conduct them.

Also, despite our mandate, the TSB does not "carry a stick." We cannot require that organizations address our concerns, nor can we force them to enact any changes that we recommend. We are Investigators, not Regulators, not Enforcers.

To this end, we are always looking for effective ways to encourage safer transportation for all Canadians. We want to ensure that identified systemic safety deficiencies are addressed and mitigated. So, last March, for example, we took a big step forward and released a safety issues Watchlist�

Slide 4: Watchlist

The Watchlist highlights the nine transportation issues posing the biggest risk to Canadians and the Canadian transportation system based on findings and recommendations from TSB investigations.

Why we did it:

Put simply, these issues weren't getting fixed. They kept reappearing in investigations. To raise public awareness, we decided to highlight them.

So quite frankly, focussing attention - and public pressure - on these issues is our way of shining a spotlight.

What the Watchlist covers:

Three modes: marine, rail and aviation. There are two or three issues unique to each mode, plus two more that are "multi-modal.".

The multi-modal issues, which we'll look at shortly, are the issue of Safety Management Systems and that of Data Recorders. But first, let's look at the two rail-specific issues�

Slide 5: Watchlist (Passenger Trains Colliding with Vehicles)

In the body of the Watchlist, the specific wording is "The risk of passenger trains colliding with vehicles remains too high in busy rail corridors"

Every day, cars and trucks regularly cross Canada's 20 000 railway crossings. What happens is usually straightforward, but 380 times in the last 15 years-on average, once every two weeks-something has gone wrong: 106 Canadians have died nationwide when their vehicle was struck by a passenger train. Warning signs, at both public and private crossings, are the first line of defence, helping to reduce the risk by making drivers aware of approaching trains. Approximately one-third of public crossings also feature flashing lights, a bell, and crossing gates. Yet despite these active warning devices, collisions between vehicles and passenger trains continue to occur. As an aside, about 50% of all crossing accidents occur at locations with automatic protection.

In 1993, prior to authorizing an increase in train speed from 95 mph to 100 mph along the Québec-Windsor corridor, Transport Canada conducted safety assessments to identify crossings that required upgrading. These assessments are nearly 20 years old. They are no longer current. Do they reflect the present and now emerging risks? Given that a third track is being considered along portions of the busy corridor between Montréal and Toronto, the need for action is now!

Here is the problem:

As Canada's population has grown, so has passenger rail traffic along busy rail corridors. Communities are continuing to grow and expand, often resulting in increased vehicle traffic over crossings. Thus, for these reasons the risk of passenger trains colliding with vehicles remains too high in busy rail corridors. In short, though, it boils down to this: are the protections in place appropriate? These are the factors: increased passenger traffic in the corridor, higher speeds, population and community growth, inadequate signage, and increased vehicular traffic. These all lead to a greater risk exposure and potentially greater consequences.

There has been some action to date, but more needs to be done, in our view.

There are several possible solutions: The TSB has repeatedly called for clearer warning signs at steep crossings, and we've pointed out that the design and placement of these signs has been inconsistent. In fact, we have made six recommendations since 1999 about the dangers of vehicles crossing railways in busy corridors.

However, improving the design and placement of signage is just the beginning. New information from safety assessments is required to reduce the risks of collisions at rail crossings. What's needed is for TC and the railways to conduct safety assessments; these will identify high-risk crossings along busy passenger train routes so that the necessary safety improvements can be made.

Slide 6: Watchlist (Operation of Longer Heavier Trains)

The next rail-specific issue on the TSB Watchlist is this: "Inappropriate handling and marshalling can compromise the safe operation of longer, heavier trains."

Freight trains cross the country every day. As you know, their length, mass, as well as the manner in which cars are marshaled, affects the in-train forces. Since 2000, the TSB has investigated at least 12 derailments where these in-train forces have been a causal or contributing factor. Not only are trains involved in main-track derailments heavier than ever, they are longer, too-over 25 per cent from just 15 years ago. Some of today's trains stretch over three kilometres in length and contain 150 cars or more. Such trains are in more common use across Canada, including in the busiest traffic corridors.

The consequences of a derailment, therefore, can be magnified, and it is important that those who identify and monitor the risks be able to mitigate them.

Following the 2007 derailment of this freight train near Cobourg, Ontario, the TSB once again drew attention to train configuration and braking, expressing concern that effective measures had not been taken to reduce the continued risks of derailment. The accident took place when a westward CN freight train, travelling at 46 mph, derailed following excessive dynamic breaking and a subsequent run-in of train slack.

In addition, the TSB has issued four other safety communications since 2001, all dealing with the safe operation of longer, heavier trains. Although industry has taken some measures to address this issue, more needs to be done.

What's needed is for railways to take further steps to ensure the appropriate handling and marshalling of longer, heavier trains. Detailed risk assessments are required whenever operating practices change.

Slide 7: Watchlist (SMS)

Those were the two rail-specific issues on the Watchlist. Of the two "multi-modal" issues, the first is SMS. "Through audits and inspections, TC must proactively monitor SMS practices to ensure they are effectively applied by railways."

Safety is a key component of any healthy industry, and an effective SMS enables operators to identify operational hazards, assess risks, and identify potential mitigation strategies. Although SMS has been required in the rail industry since 2001, recent investigations have shown that railways' SMS are at different levels of maturity, and, in certain cases, effective action to identify and mitigate risk had not occurred. The TSB has also found that regulatory audits have not always been effective and have not consistently produced the expected benefits.

This is a picture of a derailment near Lillooet, BC, in 2006. A CN freight train derailed a locomotive and a loaded car of lumber while descending a steep grade. Two of the three crew members died. The investigation revealed the failure to identify and mitigate risks through effective SMS as a safety deficiency and led to a TSB Board recommendation (R09-03).

Implemented properly, safety management systems (SMS) allow transportation companies to identify hazards, manage risks, and develop and follow effective safety processes. However, Transport Canada (TC) has not always provided effective oversight of transportation companies transitioning to SMS.

At the TSB, we've had six separate Board investigations that examined the issue of SMS. The Board has also issued four safety communications dealing with this issue, as well as a formal recommendation calling for the identification and mitigation of risks to safety as required by a railway's safety management system. Efforts within the industry aimed at addressing SMS maturity are ongoing, and this is positive. However, more needs to be done in respect of addressing shortcomings in the implementation and oversight of SMS.

Slide 8: Watchlist (Data Recorders)

The picture here is of a derailment near McBride, British Columbia, in 2003.

Following the occurrence, the two locomotive event recorders (LERs) were sent to the TSB Engineering Laboratory for analysis, but the data could not be recovered because the LERs had been severely damaged by fire and heat.

The TSB has previously emphasized the survivability of recorded data on trains, and we have made multiple calls for improved crashworthiness standards to better preserve data. This in fact is the Watchlist's second multi-modal issue:

"Industry needs to expand adoption of recently improved recorder standards to prevent the loss of data following collisions and derailments."

Following any accident, investigators have a long list of questions, starting with "what happened," and "why." A prime source for information is a locomotive's LER. These devices contain valuable information that can help pinpoint what happened. Recorders, however, can be lost or damaged in accidents.

Lost locomotive data in the rail industry has impeded TSB investigation efforts in six fatal railway accidents in the last 18 years. Without a secure, retrievable information record, the search for hard evidence becomes more difficult. This can translate into longer investigations. With objective data, however, it is easier to pinpoint safety deficiencies which, when corrected, will make the system safer.

To give credit where it's due, new crashworthy recorders are slowly being phased in. However, given the 20-30 year lifespan of locomotives, successful replacement of all recorders may take a long time.

Slide 9: Pincourt

OK, I mentioned earlier a pair of accidents that the TSB investigated in 2007 and 2008: Pincourt and Mallorytown. I'd now like to take a closer look at what happened there, as well as what has transpired since, particularly with regard to the TSB's subsequent investigations, the recommendations we made, and what progress has been made. I am focusing on these two occurrences because they are particularly relevant in light of the Watchlist and the issues it addresses.

On 17 December 2007, a VIA Rail passenger train, travelling westward at 62 mph, struck an empty tractor-trailer that was immobilized on a level public crossing near Pincourt, Quebec. The tractor-trailer was destroyed; the locomotive was damaged and was unable to continue. Subsequently, 76 passengers were transferred to another VIA train, and rail traffic was delayed for up to 3 ½ hours. The truck driver sustained minor injuries. There was no derailment and no track damage.

Following the accident, the TSB report highlighted two key safety issues:

  • The risk of truck/train collisions at level crossings on the Québec-Windsor rail corridor.

  • The adequacy of Emergency Contact Information signage posted at railway crossings.

As you know, that risk of collisions between vehicles and passenger trains is now a part of our TSB safety Watchlist.

But the TSB's final report on the Pincourt crash (R07D0111) also contained two Board recommendations:

  • "That Transport Canada conduct safety assessments of level crossings on the high-speed passenger rail Québec-Windsor corridor and ensure that defences are adequate to mitigate the risk of truck/train collisions." (R09-01)


  • "That Transport Canada implement standards to improve the visibility of emergency contact signage at railway crossings in Canada." (R09-02)

Currently, here's where things stand�

Slide 10: Pincourt - Update


With respect to the safety assessments that we recommended TC conduct along the Québec-Windsor corridor, Transport Canada agrees with us. TC has acknowledged the deficiency and followed up with the stakeholders, whereby the involved railways have conducted some safety assessments of crossings on the corridor and more are planned.

TC has described action which, if fully implemented, will substantially reduce or eliminate the safety deficiency. However, at present, the assessments are still ongoing. As a result, the TSB has assessed this response Satisfactory Intent.

What we plan to do: The TSB will continue to monitor action taken in this respect, as well as any additional targeted crossing safety programs by TC.


With respect to the standards that would improve the visibility of emergency contact signage at railway crossings, TC accepts the recommendation and is working at mitigating the deficiency. (They are currently investigating the implementation of special signage for emergency contact numbers and, based on the results, TC will work at having them incorporated into its technical requirements.) If fully implemented, this action will substantially reduce or eliminate the safety deficiency. However, at present, the action has not been sufficiently advanced. As a result, the TSB has assessed this response Satisfactory Intent.

The TSB will continue to monitor the industry as it progresses on the issue.

Slide 11: Mallorytown

On 15 July 2008, a passenger train derailed on the busy railway corridor between Toronto and Montréal after striking a loaded tractor-trailer immobilized at a crossing in Mallorytown, Ontario. The trailer and the equipment it was carrying were destroyed. The driver of the truck, which had low ground clearance, escaped unharmed. The operating locomotive engineer and four train passengers suffered minor injuries.

Rail Investigation Video for Windows Media


The TSB's subsequent report (R08T0158) highlighted two safety issues:

  • With more than 10 000 low-ground-clearance trailers on Canadian highways, collisions between trains and immobilized vehicles will continue-in the absence of high-visibility signage that alerts drivers to steep crossing profiles.


  • Current driver training does not ensure that truck drivers will always promptly alert the railway if their vehicle is immobilized on a railway crossing.

Following the accident, the The TSB report into the occurrence also made the following recommendation: expressed concern that, unless trucking companies and drivers operating low ground clearance vehicles are educated on grade crossing emergency situations, including when and how to alert railway authorities, grade crossing collisions involving trains and immobilized vehicles will continue to occur.

The TSB report into the occurrence also made the following recommendation:

That TC work with the provincial governments to expedite the implementation of a national standard for low ground clearance advance warning signs at railway crossings. (R09-04)

Currently, here's where things stand�

Slide 12: Mallorytown - Update


TC is working with the appropriate authorities to develop such a sign.

As a result, the TSB has assessed this response satisfactory intent.

Slide 13: Other TSB Recommendations

As I have noted earlier in this presentation, the TSB has made a number of recommendations related to the issues on the Watchlist. Here's a quick look at some of the key ones we're following.

With regard to Recommendation R09-03, "that CN take effective action to identify and mitigate risks to safety as required by its safety management system, and that TC require CN to do so"

Given the initiatives that have been taken to date, the TSB has assessed this response as satisfactory intent.

With regard to Recommendation R02-04, "that TC ensure that the design specifications for locomotive event recorders include provisions regarding the survivability of data�"

TC has approved revised locomotive inspection and safety rules, which include design specifications for LERs-including provisions for survivability of data.

The Board has therefore assessed the response to this recommendation as Fully Satisfactory.

Slide 14: Summary

In summary, the Watchlist highlights nine key transportation issues posing the biggest risk to Canadians. Two of these are rail specific:

  • the operation of longer, heavier trains
  • passenger trains colliding with vehicles

Two other issues are multi-modal but are of importance to the rail industry:

  • SMS
  • Data recorders

They've proven to be challenging issues, and they keep re-appearing in investigations. It is our intent that, by identifying these issues, and in some cases proposing solutions, we can shine a spotlight on them, and generate momentum towards getting them solved. Some progress has clearly been made, as evidenced by the movement on the recommendations I just mentioned. However, there are other recommendations and safety concerns underpinning the Watchlist, and we are working to make sure these too get a passing grade.

With regard to the two occurrences I described today, Pincourt and Mallorytown, progress is being made and we look forward to the day when we can assess them as fully satisfactory.

Slide 15: Questions

Slide 16: End