Recommendation R13-01

Reassessment of the responses to Rail Safety Recommendation R13–01

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Physical fail-safe train controls

Background

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 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 1525:43 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 service manager) sustained various injuries. The locomotive fuel tank was punctured and approximately 4300 litres of diesel fuel was released.

The Board concluded its investigation and released report R12T0038 on 10 June 2013.

TSB Recommendation R13-01 (June 2013)

In order to assure safety, modern transportation systems need robust defences to effectively prevent accidents. Defences can be administrative or physical. Administrative defences for example are regulations, operating procedures, supervision and training. Physical defences could include alarms and warnings in the cab, or a physical means of stopping the train.

The concept of “defence in depth” has been prevalent in the safety world for many years. Layers of defences or redundancy have proven to be a successful approach in many industries, including the nuclear industry, to ensure a single-point failure does not lead to catastrophic consequences. In the rail industry, in addition to administrative defences and wayside signals in centralized traffic control (CTC) territory, some railways have long since been equipped with additional physical fail-safe train control defences. These additional defences have the ability to alert the operating crew members if they do not correctly read or respond appropriately to a signal or other restriction, and some can intervene to slow or stop the train.

Transport Canada (TC) and industry should move forward with a strategy that will prevent accidents like the one at Aldershot, Ontario, by ensuring signals, operating speeds and operating limits will always be followed. Therefore, the Board recommends that:

The Department of Transport require major Canadian passenger and freight railways implement physical fail-safe train controls, beginning with Canada’s high-speed rail corridors.

TSB Recommendation R13-01

Transport Canada's response to Recommendation R13-01 (September 2013)

Transport Canada (TC) accepts the recommendation. TC proposes that the Advisory Council on Rail Safety (ACRS) establish a working group with representatives from the railways, the unions and TC to study the issue of fail-safe train control systems for Canada's railways, with a special focus on the high-speed rail corridors and to provide TC with options and recommendations as to how to address this issue in a written report by April 30, 2014.

TSB assessment of Transport Canada's response to Recommendation R13-01 (October 2013)

This recommendation is related to the TSB Watchlist issue of “Following railway signal indications” which sets out the risk of serious train collision or derailment if railway signals are not consistently recognized and followed.

TC has accepted the recommendation and will request a study and a written report by the Advisory Council on Rail Safety (ACRS). TC has indicated that the ACRS will be given a very specific mandate and timeline. The Board expects that the Department will provide a strong mandate with clear outcomes so that this process will guide the railway industry towards action to mitigate this deficiency.

However, the effect of TC's initiative cannot be fully known until the ACRS report has been filed, the options and recommendations are made public, and a decision to move forward with concrete actions is announced by TC . At this time, TC's response does not provide a clear plan to mitigate the safety deficiency. Therefore, the Board assesses the response to Recommendation R13-01 as Satisfactory in Part.

Transport Canada has accepted the recommendation and requested a written report on a proposed study by the Advisory Council on Rail Safety (ACRS). TC has commenced a process that may help steer the railway industry into positive action to mitigate this deficiency. However, this response falls short of providing any prompt action or having a plan to mitigate the safety deficiency. Therefore, the Board assesses the response to Recommendation R13-01 as Satisfactory in Part.

Transport Canada's response to Recommendation R13-01 (March 2014)

TC has formed a working group under the auspices of ACRS to focus on options with regard to train control systems. The first meeting of the working group was held on 15 January 2014 to review the draft terms of reference for the project.

The working group held another meeting at the end of February to discuss the scope of work, including a research component with TC's Railway Research Advisory Board (RRAB). This work will include an environmental scan of existing technologies. A progress report, including a work plan with timelines, will be presented at ACRS in spring 2014.

TSB reassessment of Transport Canada's response to Recommendation R13-01 (April 2014)

This recommendation is related to the TSB Watchlist issue of “Following railway signal indications”, where there is a risk of serious train collision or derailment if railway signals are not consistently recognized and followed. It is also linked to Recommendation R00-04, in which the Board recommended that the railway industry implement additional backup safety defences to help ensure that signal indications are followed.

The working group has begun a process that may lead to positive safety action. However, the process may take significant time to produce any positive results. The original response called for options and recommendations in a written report by 30 April 2014, and the latest response only undertakes to provide a work plan with timelines and gives no projected date for further action. The risk of a serious train collision or derailment occurring in the absence of physical fail-safe train controls continues. Therefore, the Board reassesses the response to Recommendation R13-01 to remain as Satisfactory in Part.

Railway Association of Canada's response to Recommendation R13-01 (February 2015)

A framework for working groups must be established by ACRS for the Train Control Working Group to address confidentiality concerns. Nonetheless, RAC and industry are actively working with this working group. The RAC and industry are also active in research to advance technology in this area, including research by the Railway Research Advisory Board. VIA is moving forward on various initiatives with its rail and union partners and continues to develop and implement its technological support and controls for its GPS Train Safety System program.

Industry believes that Locomotive Voice and Video Recorders (LVVR) will provide an important safety defence with regards to this issue and is actively working with the TSB and TC to have them remove the hurdles that would prevent this from being used effectively. RAC has completed consultation on a rule addressing the handling of LVVR if the system is used by industry. 

Transport Canada's response to Recommendation R13-01 (February 2015)

The ACRS Working Group will study the issue of fail-safe train control systems for Canada's railways, with a special focus on the high-speed rail corridors and will provide TC with options and recommendations as to how to address this issue in a written report.

Three research projects were initiated in 2014: an evaluation of the cognitive and human factors aspects of signal recognition and following, including cognitive vulnerabilities of the task and an overview of mitigating strategies and their effectiveness; a literature review of existing technologies including their capabilities, vitality and miles of use in revenue service; and a literature review of the human factors considerations of train control automation in the cab including an analysis of accidents where train control technology did not successfully prevent the occurrence.

The findings from these studies will be included in the final Working Group's report, which is expected to be presented to ACRS in the fall of 2015.

TSB reassessment of response to Recommendation R13-01 (March 2015)

This recommendation is related to the TSB Watchlist issue of “Following railway signal indications”, where there is a risk of serious train collision or derailment if railway signals are not consistently recognized and followed. It is also linked to Recommendation R00-04, in which the Board recommended that the railway industry implement additional backup safety defences to help ensure that signal indications are followed.

The ACRS Working Group will provide TC with a written report on options and recommendations to address this issue by the fall of 2015. Action has been initiated to study the deficiency which could yield an appropriate solution in the long term. However, while the issue is being studied, there are no short term plans to address the risk of serious train collision or derailment in the absence of physical fail-safe train controls.

The Railway Association of Canada indicates that locomotive voice and video recorders will provide an important safety defence with regards to this issue. Although there will be safety benefits with these recorders, the Board cautions that the defense in-depth concept of system safety design cannot be satisfied solely through additional layers of crew monitoring. It is only through the use of additional layers of physical defenses that the risk of serious train collision or derailment can be effectively mitigated. Therefore, the Board considers the response to the recommendation to be Satisfactory in Part.

Transport Canada's response to Recommendation R13-01 (January 2016)

In 2014, 3 research projects had been initiated by the working group under the auspices of the Advisory Council on Railway Safety (ACRS) to focus on options with regard to train control systems: 1) An evaluation of the cognitive and human factors aspects of signal recognition and following including cognitive vulnerabilities of the task and an overview of mitigating strategies and their effectiveness; 2) A literature review of existing technologies including their capabilities, reliability and miles of use in revenue service; and 3) A literature review of the human factors considerations of train control automation in the cab including an analysis of accidents where train control technology did not successfully prevent the occurrence.

In 2015, the working group completed the first two phases of its work plan which consisted of a field study of missed signals by rail crews and two literature reviews (i.e., Technical Overview of Existing Technologies and Human Factors Literature Review). The third phase (i.e., Generating and evaluating options) and the fourth phase (i.e., Preparing recommendations and the final report) are underway. The final report from the working group will be presented to ACRS in spring 2016.

Railway Association of Canada's response to Recommendation R13-01 (January 2016)

The RAC and industry are actively working with the ACRS working group. The RAC and industry are also active in research to advance technology in this area, including research by the Railway Research Advisory Board. VIA is moving forward on various initiatives with its rail and union partners and continues to develop and implement its technological support and controls for its GPS Train Safety System program. Industry believes that LVVR will provide important information on why such incidents occur, as well as, serve as a safety defence with regards to this issue. Industry is actively working with the TSB and TC on the LVVR Safety Study.

TSB reassessment of response to Recommendation R13-01 (March 2016)

This recommendation is related to the TSB Watchlist issue of “Following railway signal indications”, where there is a risk of serious train collision or derailment if railway signals are not consistently recognized and followed. It is also linked to Recommendation R00-04, in which the Board recommended that the railway industry implement additional backup safety defences to help ensure that signal indications are followed.

The ACRS Working Group will provide TC with a written report on options and recommendations to address this issue. This work is now scheduled to be completed by spring 2016. Although action has been initiated to study the deficiency which could yield an appropriate solution in the long term, there still remains no short term plans to address the risk of train collision or derailment in the absence of additional backup safety defences.

The Railway Association of Canada (RAC) indicates that locomotive voice and video recorders will provide a safety defense with regards to this issue. Although there may be safety benefits from the use of these recorders relating to following signal indications, the Board cautions that any defense in-depth concept of system safety design cannot be satisfied solely through additional layers of crew monitoring. Additional layers of physical defenses are still required so that the risk of serious train collisions or derailments can be effectively mitigated.

As it is too early to assess the results of the working group study on options and recommendations, the Board considers the response to the recommendation to be Satisfactory in Part.

Transport Canada's response to Recommendation R13-01 (February 2017)

This recommendation is linked to TSB Recommendation R00-04.

Transport Canada established a Train Control Working Group under the auspices of the Advisory Council on Railway Safety (ACRS) to study train control technologies and their suitability for Canada's railway operations with a special focus on the high-speed rail corridors. The impetus for the establishment of the Working Group was the TSB's recommendation that TC “require major Canadian passenger and freight railways implement physical fail-safe train controls, beginning with Canada's high-speed rail corridors” (R13-01).

The Working Group concluded its mandate and presented its findings to the Advisory Council on Railway Safety (ACRS) on 20 September 2016. The final report of the Working Group recommends a targeted, risk-based and corridor-specific implementation of enhanced train control (ETC) technologies as the best option for Canada.

To build on this recommendation, Transport Canada and the Railway Association of Canada hosted a workshop on 25 January 2017 entitled “Understanding Enhanced Train Control Systems and the State of the Art for existing Enhanced Train Control Systems Implementations”. The workshop brought together experts from Canada and the United States.

Coming from the workshop was an agreement that Transport Canada will continue working with stakeholders in industry and labour to further study options to define an enhanced train control application and implementation concept for Canada, taking into consideration the conclusions and recommendations of the working group report.

The next phase of work will be conducted by the Canadian Rail Research Laboratory (CaRRL) for Transport Canada. Building upon the output of the Working Group, CaRRL will:

  • Conduct a more-in depth analysis of RODS data to determine the number of occurrences where the likelihood or impact of the occurrence could have been reduced had existing ETC technology or ETC technologies under development, been in place. CaRRL will seek further information from the individual railway companies in order to clarify the occurrences where data is not supported with sufficient detail.
  • Develop risk-prioritization criteria and a recommended application methodology which can be applied to risk rank corridors in the Canadian Rail Network.
  • Develop a methodology for conducting a cost-benefit analysis.
  • Apply these methodologies to conduct a case study of a particular Canadian rail corridor and produce a corridor-specific analysis.
  • Prepare a final report summarizing the results of the data analysis conducted and the conclusions drawn from the corridor-specific case study.

Railway Association of Canada's response to Recommendation R13-01 (March 2017)

The RAC and industry worked with the ACRS train control working group providing written reports and recommendations to Transport Canada. As a result of the recommendations, a task force has been established. The RAC and industry are actively working with this new task force.

The RAC and industry are also active in research to advance technology in this area; by individual companies, by the Railway Research Advisory Board, and with academic institutions such as CaRRL.

VIA has completed the proof of concept of a GPStrain in Q4 2016 which demonstrated that the system was effective to mitigate human factors. 

Industry believes that locomotive voice and video recorders (LVVR) will provide an important safety defence with regards to this issue.

TSB reassessment of response to Recommendation R13-01 (March 2017)

This recommendation is related to the TSB Watchlist issue of “Following railway signal indications,” where there is a risk of serious train collision or derailment if railway signals are not consistently recognized and followed. It is also linked to Recommendation R00-04, in which the Board recommended 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.

The Working Group concluded its mandate and presented its findings on train control technologies to the Advisory Council on Railway Safety (ACRS) on 20 September 2016. The final report of the Working Group recommended a targeted, risk-based and corridor-specific implementation of enhanced train control (ETC) technologies as the best option for Canada. On 25 January 2017, TC and the RAC hosted a workshop that was focused on understanding ETC systems and on the status of existing ETC implementations. The workshop brought together experts from Canada and the United States.

Building on the output of the Working Group, TC has scoped out the next phase of work which will be conducted by the Canadian Rail Research Laboratory (CaRRL). This work will include more in-depth analysis of relevant occurrence data, development of a methodology for risk priorization and ranking corridors in the Canadian rail network and a case study to apply the methodology on a particular rail corridor.

The Board is encouraged that VIA has successfully completed a proof of concept system (GPStrain) that demonstrates the effectiveness of this technology to mitigate human factors. In addition, the Board is encouraged that TC will continue working with stakeholders in industry and labour to further study options to define an ETC implementation concept for Canada, taking into consideration the conclusions and recommendations of the Working Group report. However, despite the significant work on these research initiatives, there still remains no short‑term plan to address the risk of train collision or derailment in the absence of additional backup safety defences.

With respect to LVVR technology, the Board cautions that any defence in-depth concept of system safety design cannot be satisfied solely through additional layers of crew monitoring. Additional layers of physical defences are still required so that the risk of serious train collision or derailment can be effectively mitigated.

The Board considers the response to the recommendation to be Satisfactory in Part.

Next TSB action

The TSB will continue to monitor progress on the development and implementation of additional backup safety defences, including the need for a short-term plan to address the risk of train collision or derailment.

This deficiency file is Active.