Update on derailment of VIA Rail Canada Train 92 (R12T0038) near Burlington, Ontario, in February 2012
This factual update does not list causal factors of the accident or provide
detailed analysis. A full analysis of the accident, along with the findings of the
Board will come when the final report is released.
On 26 February 2012, VIA Rail Canada Inc. passenger train No. 92 (VIA 92) was proceeding eastward from Niagara Falls to Toronto, Ontario, on track 2 of the Canadian National (CN) Oakville Subdivision near Burlington, Ontario. VIA 92, which was operated by 2 locomotive engineers and a locomotive engineer trainee, was carrying 70 passengers and a VIA service manager.
After a stop at the station at Aldershot, Ontario (Mile 34.30), the train departed on track 2. The track switches were lined to route the train from track 2 to track 3, through crossover No.5 at Mile 33.23, which had an authorized speed of 15 mph. At 1525 Eastern Standard Time, VIA 92 entered crossover No. 5 while travelling at about 67 mph.
Subsequently, the locomotive and all 5 coaches derailed. The locomotive rolled onto its side and struck the foundation of a building adjacent to the track. The operating crew was fatally injured, and 45 people (44 passengers and the VIA service manager) sustained various injuries. The locomotive fuel tank was punctured and approximately 4300 litres of diesel fuel was released.
Work completed to date
An extensive site examination was performed at the time of the accident. Downloads from the VIA 92 locomotive event recorder and a number of other sources were obtained and analyzed to gain some understanding of the events surrounding the accident. The locomotive and cars were thoroughly documented and the Transportation Safety Board (TSB) Engineering Laboratory evaluated them against regulatory and industry crashworthiness standards. Extensive testing of the CN signalling system was also performed.
Interviews about this occurrence have been conducted with VIA and CN staff, various passengers, emergency responders, and other witnesses. Additional research and follow-up was conducted with other railways and commuter services in order to identify what physical defences are in place, or being developed, to ensure safe train control. We have also collected and analyzed many documents pertaining to the history of the locomotive, signalling system, track maintenance, personnel training, and the operation of the train.
The TSB has issued two rail safety advisories with regards to this investigation:
- On 18 April 2012, the TSB issued Rail Safety Advisory 02/12 to Transport Canada (TC). The advisory stated that given the serious consequences of a passenger train derailment, TC might wish to review the operating procedures and situations when higher-speed passenger trains were routed through slower speed crossovers with No. 12 turnouts.
- On 16 October 2012, the TSB issued Rail Safety Advisory 04/12 to TC. It identified that, during the accident, the area just above the front nose of the locomotive cab of VIA 6444 struck the foundation of a building adjacent to the track. The locomotive cab roof collapsed resulting in extensive damage to the cab interior; the operating crew was fatally injured. The original cab roof structure and sides were constructed with various configurations of light gauge steel. Although the VIA 6444 was extensively rebuilt recently, there was no structural upgrade of the cab to protect against rollover or impact. Since these locomotives were built prior to the establishment of crashworthiness standards, and given that the Locomotive Safety Rules apply only to new locomotives, there is no regulatory requirement to upgrade the cab structure of these locomotives. The Rail Safety Advisory suggested that TC review the Locomotive Safety Rules to ensure there is clear, consistent crashworthiness criteria for new and rebuilt locomotives.
In Canada, there are voice recorders aboard aircraft and ships, but not yet on trains. As early as 2003, the Board made a recommendation calling for voice recorders on locomotives. Voice recordings allow investigators to understand the environment in which crews operated and the decisions they made leading up to an accident. The lack of this information in rail investigations deprives the TSB of a key tool it needs to help make Canadians safer.
To date, neither TC nor the industry has addressed this significant issue; consequently, this issue remains a priority on the Board's Watchlist. The absence of any in-cab voice recording, forward-facing video recorder, or inward-facing video recorder presents significant challenges to the investigation team.
What we know
Investigators reviewed and assesssed all the information, and this is what we know:
- The train was travelling over 4 times the authorized speed limit at the time of the accident.
- The locomotive and passengers cars were well maintained and their mechanical condition did not play a role in this accident.
- The track structure including the No. 5 crossover was in good condition and did not play a role in this accident.
This investigation is focusing on:
- the operation of the train;
- the operation of the signals; and
- the crashworthiness of the rolling stock.
At the time of the accident, the TSB deployed a team of 10 investigators to the site. The investigation team was led by Investigator-in-Charge (IIC) Tom Griffith. Mr. Griffith is a senior regional investigator working out of the Toronto Regional Office and has been with the TSB since 1990. The team included a number of TSB senior regional investigators, a rail track specialist, a rail operations specialist, engineers from the TSB Engineering Laboratory with specialities in failure analysis, structures and electronics as well as TSB experts in human factors.
The TSB also contracted an independent rail signals expert to assist with the evaluation of the signals testing.
Each investigation consists of three phases: Phase 1 is the Field Phase when accident information is gathered from a number of sources, including the accident site. The team continues its work in Phase 2, which is the Examination and Analysis Phase where information continues to be compiled and the analysis begins. The final phase is the Report Phase. In this phase, after the report is drafted and initially approved by the Board, it is sent out to those who participated in the investigation and is intended to ensure procedural fairness and the accuracy of the Board's final report. It also encourages open and honest comments without the fear of reprisal or harm to reputation. The Board considers all comments and will amend the report where the change will strengthen the scientific accuracy. Once the Board approves the final report, it is released to the public.
This investigation has now entered the final phase. The investigation team has produced an initial draft report, which the TSB does not publish. This initial draft report has been reviewed by the Board and subsequently sent to designated reviewers. The designated reviewers now have the opportunity to respond in writing and comment on any aspect of the report that they believe is incorrect or unfairly prejudicial to their interests.
The list of designated reviewers is confidential. Confidentiality is essential to encourage the fastest possible and most complete accumulation of information affecting public safety, and to provide independent and objective analysis of the deficiencies in the transportation system. The Board has the final decision on the content of the report.
When fatalities occur, responsibility for informing the next of kin falls to the police, the coroner/medical examiner, or the transportation company. However, as it is the policy of the TSB, the investigation team has kept the families of loved ones apprised at every major stage of the investigation and briefs them on the final report before it is released to the public and the media.
The TSB investigation team knows that the survivors and the families who lost loved ones want answers. As we continue our work, our hope is that we will be able to answer the following questions: What happened? Why did it happen? What can we learn so that it does not happen again? We look for these answers to make a safer transportation system for all Canadians.
The Board awaits comments from designated reviewers and will consider them as quickly as possible in order to complete this important investigation. Once done, the report will be released publicly.
The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. 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.
For more information, contact:
Transportation Safety Board of Canada
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