Communiqués

TSB # R 11/98

(For release 01 September 1998)

(Hull, Quebec) - The Transportation Safety Board (TSB) has determined that the lead axle on the trailing locomotive of VIA Rail train No. 2 fractured in the early morning of 03 September 1997 near Biggar, Saskatchewan, as a result of a bearing failure. The bearing in the suspension system for one of the traction motors had overheated and failed due to a lack of lubrication.

The broken axle spread the track apart, thereby derailing the train. At the time, the VIA Rail train was travelling eastward at 67 mph. Thirteen of 19 cars and the two locomotives derailed. Seventy-nine of the 198 passengers and on-board crew were injured, 1 fatally and 13 seriously.

Twenty-nine hours before the derailment, an on-board monitoring system had detected an overheated bearing and sounded an alarm. Various operating and maintenance personnel attempted to diagnose the warning, but inadequate knowledge and training, coupled with miscommunication, led to the erroneous conclusion that the failure was in the warning system. The crew then disconnected the monitoring system approximately 27 hours before the bearing failure.

Several passenger safety issues, previously identified by the TSB, had not been fully addressed by either Transport Canada (TC) or VIA Rail. As a result, the Board issued an Interim Rail Safety Recommendation (R97-07) on 01 October 1997, calling on the Minister of Transport to have VIA Rail complete, within 30 days, the implementation of a number of short-term measures necessary to improve rail passenger safety.

Both TC and VIA Rail worked to reduce these risks within the recommended time frame. This included such items as: improving emergency signage for passengers, increasing the intensity of emergency lighting in the area where emergency equipment is located, including more megaphones to facilitate giving emergency directions to passengers, placing trauma kits in all coach and sleeper cars, and equipping those kits with highly reflective bands for easy identification.

Since the accident, VIA Rail has initiated a number of other actions for improving passenger safety on its trains such as: improving crew communications with respect to equipment problems, providing better instructions and training for crews regarding the bearing monitoring system, committing to installing suspension bearing monitoring devices on all its locomotives, and setting up a more stringent quality control program for the work on wheel sets.

The regulator, Transport Canada, has also carried out a number of actions including reviewing proposed amendments to the Railway Safety Act to see if changes are needed to improve rail safety. The Minister of Transport requested the Department to proceed with safety measures that do not require legislative changes. A project team commenced work earlier this year to develop regulatory initiatives for key safety areas.

In view of the number of significant safety risks to passengers travelling on the VIA Rail system identified in this investigation (many of which had been identified in previous investigations), the Board is concerned that VIA Rail does not yet have an effective system for safety management in place. Subsequent to the accident, much has been undertaken by VIA Rail to mitigate these risks. However, the Board believes that the requirement for many of these actions could have been identified before the accident through a more effective safety management system. VIA Rail has received 27 recommendations from its safety consultants that, if implemented in full, should result in a more responsive safety management system. However, without an implementation program with clear deadlines, the effectiveness of this program cannot be evaluated.

TC reacted quickly, ensuring that required equipment modifications were implemented and took enforcement action under provisions of Part II of the Canada Labour Code and the Railway Safety Act. At the same time, TC was working towards developing and implementing policies and procedures for a national audit program in response to a Board recommendation following a fatal main track collision near Edson, Alberta, on 12 August 1996 (TSB Report R96C0172). The Board recognizes that this work, along with the development of passenger safety handling and evacuation standards, is ongoing. The implementation of effective audit procedures, along with these standards, will significantly enhance the potential for identifying risks to passenger safety in a proactive manner.

Notwithstanding these actions, there is a continuing absence of appropriate regulatory mechanisms governing passenger safety. This reduces the ability of TC to identify the safety risks posed. Following are some gaps in the current regulatory system:

Although passenger safety handling and evacuation standards are under development, there is currently no base for an audit program in this area.

Although there is a program to audit the extent to which passenger safety improvements were implemented and maintained in VIA Rail's corridor service, no such program is in place for VIA Rail's transcontinental service and other passenger-carrying operations.

There are no standards and audit mechanism to ensure that locomotive engineers in passenger service are aware of the unique aspects of passenger locomotive operations.

The Board is encouraged that the Department commenced work in June 1998 on six initiatives to improve the effectiveness of regulatory oversight in Canadian rail operations. However, until the project team's detailed planning has been completed, it will be unclear when and to what extent the above-mentioned safety risks will be addressed. Therefore, the Board has recommended that:

The Department of Transport clarify the scope and timing of its current initiatives related to rail passenger safety and release a public statement outlining the implementation program for these initiatives at the earliest practicable date. [R98-01]

The Transportation Safety Board of Canada is an independent agency operating under its own Act of Parliament. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

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