TSB assesses Transport Canada’s response to Lac-Mégantic investigation recommendations: significant progress made, more work required
Gatineau, Quebec, 28 January 2015 – While recognizing significant positive action taken by the regulator, the Transportation Safety Board of Canada (TSB) remains concerned about Transport Canada’s (TC) response to outstanding recommendations stemming from its investigation into the Montreal, Maine & Atlantic Railway (MMA) train that derailed on 6 July 2013 in Lac-Mégantic, Quebec.
“Transport Canada continues to take important steps to address the rail safety deficiencies we identified in our Lac-Mégantic investigation,” said Kathy Fox, Chair of the TSB. “With respect to preventing runaway trains, TC has introduced multiple layers of defences that, if fully implemented, will significantly reduce risks. But with respect to TC auditing and oversight activities, we are concerned that the department has not yet put in place an effective oversight regime that guarantees all railways will be audited in sufficient breadth and frequency to ensure safety issues are addressed in a timely manner.”
Prevention of runaway trains: Unattended equipment (R14-04)
The investigation determined that more robust defences are required to prevent runaways. Even if they have a low probability of occurrence, these events can have extreme consequences, particularly if they involve dangerous goods—as was seen in Lac-Mégantic. For this reason, the Board recommended that TC require Canadian railways to implement additional physical defences to prevent runaway equipment.
In October 2014, TC issued an Emergency Directive (which expires 29 April 2015) that addresses many of the weaknesses in the Canadian Rail Operating Rules pertaining to the securement of equipment. Along with a standardized hand brake chart and explicit instructions for hand brake effectiveness testing, additional physical securement measures must be used. TC also said it will hire additional specialized staff to strengthen oversight related to train securement and to monitor compliance with these additional levels of defence to prevent runaways. If the proposed measures are fully implemented on a permanent basis, the risk of runaway equipment will be significantly reduced; therefore, the Board assesses the response as having Satisfactory Intent.
Safety management systems audits and essential follow-up (R14-05)
Until Canada's railways make the cultural shift to safety management systems (SMS), and TC makes sure they have effectively implemented SMS, the safety benefits will not be fully realized. For this reason, the Board recommended that TC audit the SMS of railways in sufficient depth and frequency to confirm that the required processes are effective, and that corrective actions are implemented to improve safety.
TC has committed to bringing into force additional regulations and enforcement capabilities, hiring more auditors and strengthening its training programs. While significant progress has been made, TC has not yet demonstrated that it has implemented an effective oversight regime to ensure all railways will be adequately audited. Furthermore, TC has not committed to auditing every SMS component within a given time period. As a result, deficiencies within a railway's SMS may not be identified and addressed in a timely manner; therefore, the Board assesses the response as being Satisfactory in Part.
This issue has been identified as one of the key risks to the transportation system and it is included on the TSB's 2014 Watchlist.
“The Minister of Transport and the department have taken strong action to improve rail safety in the wake of the Lac-Mégantic tragedy, but more work needs to be done,” added Ms Fox. “We will continue to monitor the department and rail industry's progress in implementing new regulations and procedures introduced by TC. Canadians deserve no less than the safest transportation system.”
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
- Date modified: