TSB Recommendation R22-04

Transport Canada (TC) agrees with recommendation R22-04. The Department has taken concrete steps, in conjunction with government and industry partners, to advance the implementation of physical fail-safe train controls to ensure that signal indications are consistently recognized and followed by train crews.

The Notice of Intent (NOI) published in February of 2022 sent a strong signal of TC’s commitment to the deployment of Enhanced Train Control (ETC) on the Canadian rail network and made clear that the highest risk corridors must be equipped with fail safe, automatic train protection by 2030. Feedback from stakeholders supported the risk-based and corridor-specific implementation which ensures investments in safety improvements on a given corridor are tailored to the safety risk of that corridor.

TC continues to move forward with the necessary building blocks for regulating ETC in Canada, with emphasis on the methodology to assess individual corridor risk and a framework for ensuring interoperable train operations.

As outlined in the NOI, implementing a corridor risk assessment methodology that is robust and consistently applied across Canada will require the principles of the risk-prioritization criteria and methodology to be set out in the regulatory framework and subject to TC approval. To support regulatory development, TC is developing a corridor risk assessment methodology to be completed by September 2023 that will incorporate key risk factors, such as train speed, presence of dangerous goods, passenger traffic, and population density. The factors will serve to identify higher risk corridors and guide priority implementation of ETC across the Canadian rail network.

TC has entered into an agreement with the Standards Council of Canada to have the Canadian Standards Association (CSA) develop a National Technical Specification on Interoperability by September 2023. The CSA, as a standards development organization, has the expertise to bring industry and other stakeholders together to develop this essential building block for ETC. This will ensure that information, such as train position and train speed, can be communicated reliably and securely between railways, notwithstanding the chosen train control technology.

The development and deployment of ETC is a complex and capital-intensive undertaking. As discussed in the NOI, consideration will need to be given to other important elements such as telecommunications needs, access to spectrum, and how to ensure the regulation fosters innovative and evolving technology. TC is working diligently with stakeholders to advance these elements in order to meet our commitment of implementing ETC on the highest risk corridors by 2030.

In parallel with advancing ETC, the department has continued to strengthen the rail safety regulatory regime and has taken measures that address safety risks identified in this investigation report. These measures include new Locomotive Voice and Video Recorder Regulations, which ensures crucial information is available to help determine the cause of an accident and to prevent future accidents. The Duty Rest Rules, informed by the latest fatigue science, will reduce the occurrences of fatigue in railway operations by placing new limits on the length of a duty period and increasing the length of the minimum rest period between shifts. Strengthening of the Track Safety Rules and Key Trains and Key Routes Rules will reduce the likelihood of a derailment of a train carrying dangerous goods.

This recommendation is related to the TSB Watchlist 2022 key safety issue of “Following railway signal indications,” where there is a risk of serious train collision or derailment if railway signals are not consistently recognized and followed. It is also linked to dormant Board Recommendation R00-04 and active Recommendation R13-01.

A review of all TSB rail investigation reports (excluding Class 5 occurrences and including this occurrence) produced since the inception of the TSB in 1990 determined that 80 occurrences may have been prevented had a train control system equivalent to Positive Train Control (i.e., Enhanced Train Control [ETC]) been available.

From 2004 to 2021, there has been an annual average of 35 reported occurrences in which a train crew did not respond appropriately to a signal indication displayed in the field. Although the number of occurrences in 2019 increased to 45, the number of occurrences in 2020 and 2021 returned to the long-run average (34 and 32, respectively).^{Footnote 6}

Transport Canada (TC) agrees with Recommendation R22-04 and has taken steps, in conjunction with government and industry partners, to advance the implementation of physical fail-safe train controls. TC published a Notice of Intent (NOI) in February 2022, identifying that highest risk corridors must be equipped with fail-safe, automatic train protection (i.e., ETC) by 2030.

To identify higher risk corridors, TC is developing a methodology to assess individual corridor risk, to be completed by September 2023; it will incorporate key risk factors, such as train speed, presence of dangerous goods, passenger traffic, and population density.

Interoperability is an essential building block for ETC. TC has stated it will ensure that information, such as train position and train speed, can be communicated reliably and securely between railways, notwithstanding the chosen train control technology. TC has entered into an agreement with the Standards Council of Canada to have the Canadian Standards Association (CSA) develop a National Technical Specification on Interoperability by September 2023.

The Board notes that the development and deployment of ETC is a complex and capital-intensive undertaking, and that consideration will need to be given to other important elements such as telecommunications needs, access to spectrum, and how to ensure the regulation fosters innovative and evolving technology. It also notes that TC has continued to strengthen the rail safety regulatory regime, with the new Locomotive Voice and Video Recorder Regulations and Duty and Rest Period Rules for Railway Operating Employees, and the strengthening of the Railway Track Safety Rules^{Footnote 7} and the Rules Respecting Key Trains and Key Routes.^{Footnote 8}

The Board is encouraged that TC has accepted this recommendation and has committed, in conjunction with government and industry partners, to develop a corridor risk assessment methodology and a National Technical Specification on Interoperability by September 2023. This action is a positive step toward the implementation of physical fail-safe train controls on Canada’s high-speed rail corridors and on all key routes. However, until TC provides further clarification on which corridors will require ETC, the Board considers the response to Recommendation R22-04 to be Satisfactory in Part.

Transport Canada is continually progressing in establishing the essential foundations for regulating enhanced train control (ETC) in Canada, with a particular focus on refining the methodology for evaluating corridor-specific risks. ETC is a complex technology that requires integrating advanced elements such as communication systems, sensors, and automation. Additionally, thorough testing, validation, and training are crucial before full implementation of the technology by the railway industry.^{Footnote 9}

Following the publication of the Notice of Intent in 2022, Transport Canada developed a risk methodology to guide the implementation of ETC in Canada. This approach involves a multi-layered ETC technology application, incorporating automatic train protection for higher-risk track segments and a driver-assist system for medium-risk segments. Lower-risk segments would continue to adhere to existing Canadian Rail Operating Rules.

The risk methodology developed by Transport Canada evaluates various factors, including passenger service, annual gross ton-miles (GTM), and key route status. Key routes, defined as tracks carrying 10 000 or more cars with dangerous goods annually, are a focal point. This risk methodology was shared with the railway industry in May 2023, leading to bi-weekly discussions throughout the summer of 2023 between Transport Canada and the Railway Association of Canada, including representation from freight companies such as the Canadian National Railway Company and the Canadian Pacific Railway Company,^{Footnote 10} as well as passenger companies such as VIA Rail and Metrolinx. Simultaneously, the Canadian Standards Association has finalized and published a set of guidelines for interoperability of enhanced train control applications, marking a significant step toward ensuring the safety and efficiency of railway operations in Canada.

Transport Canada is currently advancing policy and risk analysis work and continues to engage with stakeholders to inform drafting of a future ETC regulation, including defining which rail corridors will require ETC.

The railway industry and TC engaged multiple times throughout 2023, discussing recommendations and supporting information to inform future Enhanced Train Control (“ETC”) regulations in consideration of the NOI. Engagement is planned to continue.

This recommendation is related to the TSB Watchlist 2022 key safety issue of “Following railway signal indications,” where there is a risk of serious train collision or derailment if railway signals are not consistently recognized and followed. It is also linked to dormant Board Recommendation R00-04 and active Recommendation R13-01.

Following the publication of the Notice of Intent (NOI) in February 2022, Transport Canada (TC) developed a risk methodology to guide the implementation of enhanced train control (ETC) in Canada. Such a system would incorporate automatic train protection for higher-risk track segments and a driver-assist system for medium-risk segments. Lower-risk segments would continue to adhere to the existing Canadian Rail Operating Rules.

TC shared the risk methodology with the railway industry in May 2023, leading to bi-weekly discussions throughout the summer of 2023.

The Canadian Standards Association (CSA) finalized and published a set of guidelines for interoperability of ETC applications to ensure the safety and efficiency of railway operations in Canada.

The Board acknowledges that the development and deployment of ETC is a complex and capital-intensive undertaking, and that consideration will need to be given to other important elements such as telecommunications needs, access to spectrum, and how to ensure the regulation fosters innovative and evolving technology. However, TC and the railway industry have been discussing the framework needed to address the safety issue of “Following railway signal indications” since 2013 and, while TC has taken positive steps toward identifying a solution for physical fail-safe defences in the form of ETC, the pace of development is slow.

At the time of this assessment, there were 3 active TSB investigations related to occurrences in which trains were operating on key routes and passed Stop signals. While the preliminary investigation into these occurrences indicates that each of the trains involved received appropriate advance warning of the requirement to stop, the existing administrative defences were inadequate to ensure that these trains respected their limits of authority:

• R23H0006: On 13 April 2023, a Canadian National Railway Company (CN) freight train was proceeding eastward while a VIA Rail Canada Inc. (VIA) passenger train was proceeding westward on the same track on the CN Kingston Subdivision. The CN train went past a Stop signal at Wesco near Cornwall, Ontario, and the crew applied the brakes in emergency shortly therafter. The train came to a controlled stop approximately 20 car lengths east of the VIA train. There were no injuries reported. The VIA passenger train was transporting 168 passengers. Before encountering the Stop signal, the CN train had been provided with a progression of signals requiring preparation to bring the train to a stop.
• R23E0079: On 08 August 2023, CN freight train Z11531-06 (train 115), travelling westbound on the south main track of the CN Wainwright Subdivision, passed a Stop signal in Wainwright, Alberta, and side-collided with CN freight train S77181-04 (train 771) that was departing the Wainwright Yard onto the south main track. Train 115 went past the Stop signal at 32 mph and, after an emergency application of the train brakes, side-collided with train 771 at about 20 mph. As a result of the collision, the 2 locomotives on train 115 derailed, as well as several rail cars on both trains. No one was injured. Before encountering the Stop signal, train 115 had been provided with a progression of signals requiring preparation to bring the train to a stop.
• R23V0205: On 19 November 2023, northbound Burlington Northern Santa Fe (BNSF) freight train RNWE-804117 (train 804) collided with the side of southbound BNSF manifest freight train VBCEVE-118 (train 118) on the BNSF New Westminster Subdivision. Train 118 was entering the siding at Oliver in Delta, British Columbia, and its tail end had not yet cleared the main track when the collision occurred. Two intermodal cars on train 118 derailed. Two locomotives and 5 cars on train 804 derailed upright, including 3 tank cars containing liquefied petroleum gas (UN1075)—2 loaded and 1 residue. The fuel tank on the lead locomotive of train 804 was punctured, resulting in the release of about 5700 litres of diesel fuel (UN1202). There was no other product release. The crew members on train 804 did not sustain any injuries. Train 804 had encountered a progression of signal indications requiring that the train be stopped clear of the north siding switch at Oliver. It went past the Stop signal at 34 mph and into the side of train 118. In this occurrence, train 804, coming from the United States, had been afforded the protection of positive train control (PTC) up to the Canadian border, where PTC protection terminates for trains entering Canada.

Despite the calls from the TSB for additional physical fail-safe defences in signalled territory since 2000 and the implementation of such solution in the United States since 2020 (i.e., PTC), the Canadian railway system continues to rely on administrative defences centred on compliance with rules by train crews. However, human factors science shows, and the TSB has demonstrated in multiple investigation reports, that even well-trained, well-meaning train crews will occasionally misinterpret or misapply signals and that administrative defences alone are not effective to prevent adverse outcomes.

The Board is encouraged that TC has developed a corridor risk methodology and that the CSA has published a set of guidelines for interoperability of ETC applications. This action is a positive step toward the implementation of physical fail-safe train controls on Canada’s high-speed rail corridors and on all key routes by 2030. However, given the risks to train crews and the travelling public, TC and the railway industry are urged to accelerate the implementation of physical fail-safe train controls on Canada’s high-speed rail corridors and all key routes in Canada. The Board considers the response to Recommendation R22-04 to show Satisfactory Intent.