Rail Recommendation R00-04
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Reassessment of the Responses from Transport Canada to Rail Safety Recommendation R00–04
Consistent recognition of signals
On 11 August 1998, at approximately 1810 Pacific daylight time, Canadian Pacific Railway (CP) train No. 463-11 (train 463) collided with the rear-end of CP train No. 839-020 (train 839) at Mile 78.0 of CP's Shuswap Subdivision, near Notch Hill, British Columbia. One car on train 463 and two cars on train 839 derailed. There were no injuries.
The Board identified two safety deficiencies related to: the backup safety defences for signal communication and the impact of noise on the communication of safety-critical information between crew members on locomotive cabs.
The Board concluded its investigation and released report R98V0148 on 01 February 2001.
Board recommendation R00-04 (01 February 2001)
The Board recognizes the concerted effort by the railway company and the regulatory body to address the issue related to the communication of signals between crew members. Railway company programs such as the “Rule of the Week” are positive steps towards the reduction of risks associated with the communication of signals. The Board looks forward to the results of TC's review of the current state of compliance to Rule 34, and this program will likely heighten awareness of this issue amongst crews. However, the Board is concerned that the effectiveness of the program will likely be both temporary and incomplete. The current practice suggests that many crews do not consider compliance with Rule 34 to be necessary for safe operation. The widespread practice of not calling signals effectively removes the backup safety defence available from the second crew member in ensuring accurate signal interpretation, thus increasing the risk of accidents.
Various measures could be considered to address this safety deficiency. One option would involve a shift to a non-verbal recordable electronic means of communicating signals which would also provide a record of crew actions, thereby facilitating company or regulatory monitoring. An additional option would involve replacement of the current rule with another more suitable backup defence that could alert crew members if their actions are not consistent with the signal indication. A wide-ranging review of both the extent of the problem and various potential solutions could achieve a significant improvement in rail transportation safety. Therefore, the Board recommends that:
The Department of Transport and the railway industry implement additional backup safety defences to help ensure that signal indications are consistently recognized and followed.
Response to R00-04 (23 April 2001)
TC indicated that they support the intent of this recommendation.
TC responded that they, in conjunction with the Railway Association of Canada (RAC) and the railways, have continued to study new technologies which could provide additional backup safety defences to help ensure that signal indications are consistently recognized and followed by train crews.
TC reported that they monitored studies undertaken by the Canadian Pacific Railway (CP) on improved radio and locomotive cab communication which involved the use of headsets. In addition, TC reported that they monitored technologies such as the Communication-Based Train Control (CBTC), also referred to as Positive Train Control Systems (PTC), which enables communication between trains and could provide the required additional backup to help prevent such accidents from occurring.
Board assessment of response to R00-04 (28 March 2002)
The response indicated that TC, in conjunction with other stakeholders, monitored several new technologies which could provide backup safety defences. Although these efforts were positive, there was an absence of specificity and timing with respect to action to ensure that additional defences were put into place. In consideration that TC continued participation in the studies of new technologies, but had not initiated action to implement additional backup safety defences to ensure that signal indications are consistently recognized and followed, the response to the recommendation was assessed as Satisfactory Intent.
Additional response to R00-04 (11 June 2004)
TC advised that they had no new information at this time. TC considered the recommendation open.
Board reassessment of response to R00-04 (29 September 2005)
TC provided no new information, nor proposed dates, as to when or if a backup safety defence would be implemented to ensure consistent recognition of signal indications. As such, TC's response was reassessed as Unsatisfactory.
Board reassessment of response to R00-04 (25 August 2006)
TC provided no new information, nor proposed dates, as to when or if a backup safety defence would be implemented to ensure consistent recognition of signal indications. As such, TC's response continues to be Unsatisfactory.
Additional response to R00-04 (January 2010)
TC indicated that they are stepping up their vigilance and monitoring of the railways' Performance Monitoring and Rules Compliance (PMRC) program. The results of this monitoring will be forwarded to TC's new Audit/Risk Assessment group for further review.
Additional information from Canadian Pacific Railway (July 2010)
CP has initiated the following Safety Action:
A CTC 1 Signal Record checklist was established as a standard operating procedure to aid in the detection, identification, communication and documentation of signals. The checklist is intended to ensure compliance with the Rules, and reduce the opportunity for crew distraction.
CROR Rule 34 has been enhanced to include: Each signal affecting their movement must be called out by the conductor and must be acknowledged by the person responsible for controlling the locomotive as soon as it is positively identified, but crew members must watch for and promptly communicate and act on any change of indication which may occur.
A System Special Instruction to Rule 34(b) has been developed, stating: In CTC (or at any other signal which is an advance signal to a signal in CTC), except as otherwise indicated in special instruction, the conductor must complete the applicable portions of the CTC Signal Record form immediately after the leading end of the movement has passed each signal. The checklist requires:
- signal location, signal name, time, other than signal restrictions verification, radio broadcast confirmation, and job briefing confirmation.
- signal detection and identification.
- intra-cab communications.
- inter-cab communications.
Additional Crew Resource Management principles have been developed to improve intra-cab communications. New requirements in the Rules have been integrated and communicated to crews with the intent of allowing the person controlling the Locomotive to focus on the task of doing so safely.
An on board checklist process has been developed that requires (in part) conductors to record the number of axles communicated to the crew by a hot box detector after passing each hot box detector location. This process is intended to provide a conductor with a running written record of a train's axle count and any defects that may be communicated by the detector.
System Special Instruction to CROR Rule 142(b) has been enhanced, stating: Crew members within physical hearing range are required to remind one another of the restrictions contained in GBO and clearances in sufficient time to ensure compliance. This communication must be initiated by the conductor and must be acknowledged by the person responsible for controlling the locomotive.
CROR Rule 121 Positive Identification has been enhanced, stating: The person initiating a radio communication and the responding party must establish positive identification. The initial call must commence with the railway company initials of the person being called. When calling a movement, other than when specifically required by the rule, the initial call must be directed to the Conductor of the movement.
Board reassessment of response to R00-04 (September 2010)
Between 2007 and July 2010, the Board has investigated five collisions (3 CP and 2 CN) and a main track train derailment (VIA) in CTC territory. In 5 of these cases, signal identification and response were causal elements in the accidents. This clearly demonstrates that consistent signal recognition by train crews continues to be problematic which increases the risk for these types of accidents to occur.
TC has stepped up its compliance monitoring of activities surrounding signal recognition, and has indicated that its Audit/Risk Assessment Group will assess the results of the monitoring activities to determine possible further action. This action on its own does not constitute an additional backup safety defence to ensure consistent recognition of signal indications as contemplated by the recommendation. However, it does make reference to possible further action.
CP has implemented a number of new administrative defences to help ensure that signal indications are consistently recognized and followed. While these steps may be positive, the administrative nature of the defences may also add to the cognitive workload of train crews and create additional distraction. Furthermore, these defences only apply to CP and are not utilized throughout the industry. While no additional physical safety defences have been engineered into CTC to ensure consistent recognition and response to signal indications, the administrative changes made by CP demonstrate development in this area and may have a positive result. Therefore, the Board reassesses the response to Recommendation R00-04 as Satisfactory In Part.
Additional response to R00-04 (October 2011)
TC advises that the industry is exploring the use of positive train control technology which would help protect against human factors type issues with signal recognition and/or distractions.
Board reassessment of response to R00-04 (February 2012)
The additional information does not reveal sufficient safety action to change the assessment category. The underlying deficiency which needs to be addressed still remains, as is evidenced by TSB occurrences R12T0038, R11Q0011, R10V0038, R09V0230 and R11E0063. Therefore, while some action has been taken, more is required. The Board reassesses the response to Recommendation R00-04 to remain as Satisfactory In Part.
Additional response to R00-04 (January 2013)
Transport Canada (TC) has discussed with industry the possibility of adapting existing on-board computer systems to assist in train control. Since then, TC has been advised that General Electric (GE) and some of the railways have met to discuss a “wish list” of programming changes to GE's Trip Optimizer computer system. CN has mentioned that they have discussed with GE the possibility of adding work zones (Track Occupancy Permit (TOP), CROR Rule 42 etc.) as well as air brake control and signal recognition to the future capabilities of the Trip Optimizer. TC is following up on these issues with CP and CN.
Board reassessment of response to R00-04 (February 2013)
The issue of signal recognition was added to the TSB Watchlist in 2012, highlighting those issues that pose the greatest risk to Canadians.Transport Canada and the railways are exploring the potential for current locomotive fleet computer systems to include signal recognition and air brake control capabilities. However, to date there has been no formal strategy developed to adapt either emerging technology or existing on-board computer systems to provide fail-safe physical train control defences. Therefore the Board reassesses the response to Recommendation R00-04 to remain Satisfactory In Part.
Next TSB action
The TSB will monitor progress to determine what action will be implemented.
This deficiency file is assigned an Active status.
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