Rail transportation safety recommendation R03-05
Reassessment of the response to rail safety recommendation R03-05
Transport Canada's monitoring program
On 14 May 2003, a Canadian National (CN) train derailed on a timber bridge at Mile 79 on the Fraser Subdivision near McBride, British Columbia The bridge, two locomotives, and five cars were destroyed by fire The two crew members in the lead locomotive were fatally injured The investigation uncovered deficiencies with the potential to degrade rail safety A number of bridge components were identified as defective and were not repaired by CN because of shortcomings in inspection and maintenance practices.
TC's inspectors determine compliance with guidelines, rules, and regulations by conducting cursory inspections to identify visible defects However, TC's visual inspections were not referenced to railway inspection records for bridges Moreover, there was no examination of railway inspection procedures and maintenance practices for timber bridges.
TC inspected infrastructure on the Fraser Subdivision in 2000 and 2002 and made cursory inspections of timber bridges However, the shortcomings documented by the railway, such as those contained in the 1999 detailed inspection, were not considered In addition, there was no comparison of working procedures and practices with railway inspection and maintenance requirements to ensure that the SPCs were being met.
Board Recommendation R03-05 (November 2003)
When there are no secondary defences to ensure the integrity of railway processes, unsafe conditions remain undetected and uncorrected The Board noted that, because all available information was not being utilized, there were deficiencies in TC's compliance review program.
The Board recommended that:
The Department of Transport incorporate in its compliance reviews a comparison of railway working procedures and practices with railway inspection and maintenance records.
Transportation Safety Recommendation R03-05
Response to R03-05 (16 March 2004)
A response from the Minister advised that TC was revising its traditional inspection and monitoring programs to integrate monitoring and inspection activities of railway infrastructure, equipment and operations with a "Safety Management System" (SMS) approach. This approach is encompassed in the Safety Management System Regulations for railway companies, which had come into effect in March 2001.
The SMS approach requires an examination by TC of each railway company's standards and practices with respect to safety management of its infrastructure, as well as auditing of company inspection and maintenance records.
By incorporating compliance reviews with the comparison of working procedures and practices and by examining railway records, TC will have a better opportunity of discovering gaps in railway management of bridge condition assessment and repair. TC is aggressively developing an audit program that focuses on all railway structures. The track program will also continue to be carried out and any concerns will be flagged for TC follow-up audit activities.
Board Assessment of Response to R03-05 (April 2004)
The response from TC indicates that the SMS audit program is being aggressively developed and it will give TC a better opportunity of discovering gaps in the railway company's standards and practices, with respect to safety management of its bridge structures. TC states that the SMS audit approach will provide a comparison of the company's procedures with practices relating to bridge infrastructure.
It is very likely that the SMS audit approach will successfully incorporate this comparison in TC's compliance reviews, however, there are no specified time lines provided in which this audit will take place, therefore, the response to R03-05 is assessed as having Satisfactory Intent.
Board Reassessment of Response to R03-05 (December 2005)
No further information has been received from TC, so the Board maintains the assessment of response to this recommendation as Satisfactory Intent.
Additional Response to R03-05 (July 2006)
In TC's update in July 2006, TC advises that the structures component of the Rail Safety Program is completed and being administered using the Safety Management System (SMS) philosophy auditing.
Board Reassessment of Response to R03-05 (September 2006)
As TC's new auditing process incorporates in its compliance reviews a comparison of railway working procedures and practices with railway inspection and maintenance records, the reassesses the response to Recommendation R03-05 as Fully Satisfactory.
Next TSB Action
This file is assigned an Inactive status.
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