Reassessment of the responses to Rail Safety Recommendation R14-04
Physical defences to prevent runaway equipment
On 06 July 2013, shortly before 0100 Eastern Daylight Time, eastward Montreal, Maine & Atlantic Railway freight train MMA-002, which had been parked unattended for the night on the main track at Nantes, Quebec, Mile 7.40 of the Sherbrooke Subdivision, started to roll. The train travelled about 7.2 miles, reaching a speed of 65 mph. At about 0115, while approaching the centre of the town of Lac-Mégantic, Quebec, 63 tank cars carrying petroleum crude oil, UN 1267, and 2 box cars derailed. As a result of the derailment, about 6 million litres of petroleum crude oil spilled. There were fires and explosions, which destroyed 40 buildings, 53 vehicles, and the railway tracks at the west end of Megantic Yard. A total of 47 people were fatally injured, and there was environmental contamination of the downtown area, and the adjacent river and lake.
In this accident, the train was secured at Nantes both with hand brakes and locomotive air brakes. However, a proper hand brake effectiveness test had not been conducted to ensure that the hand brakes alone would hold the train. When the locomotive supplying air pressure to the train was shut down, the air brake system leaked off in less than 1 hour. The force from the hand brakes was not sufficient to secure the train, and the train rolled away.
Both air brake and hand brake systems are subject to failure, as the technology is not fail-proof. For example, air brake systems are prone to leakage and suffer from limitations in maintaining brake cylinder pressure. Furthermore, when brake pressure is low, its ability to generate an emergency brake application is compromised. Hand brake devices also have significant limitations, in that they do not provide feedback to the operator about the force applied, and often do not provide the required braking force due to their design and other mechanical and physical factors.
Within the railway industry, these limitations in technology are addressed with the expectation that there will always be strict compliance with the operating rules. For equipment securement, reliance is placed on Canadian Rail Operating Rules (CROR) 112, company special instructions and training. However, TSB investigations into runaways revealed that the sequence of events very often included a mis-application of the rule, such as an improper hand brake effectiveness test or the application of an insufficient number of hand brakes. This means that no matter how well the rule is worded, it will not always be strictly complied with, thereby introducing vulnerability into the safety system.
Rules are administrative defences and, invariably, there will be instances where practices in the field will deviate from written rules and procedures. Even with clear and comprehensive rules, it has been demonstrated over the years that depending solely on the correct application of rules is not sufficient to maintain safety in a complex transportation system. The concept of "defence in depth" has shaped the thinking in the safety world for many years. Layers of defences, or safety redundancy, have proven to be a successful approach in many industries, to ensure that a single-point failure does not lead to catastrophic consequences.
There are physical defences to protect against the risk of runaway equipment, and these include derails, wheel chocks, mechanical emergency devices, and locomotive auto-start systems to maintain air pressure. New technology is available, such as GPS-equipped devices that can be applied to a hand brake chain, allowing for the remote monitoring of the hand brake status. In addition, some existing technology, such as reset safety controls and sense and braking units, with minor programming changes, can offer additional protection.
Advanced air brake control valves, such as electronically controlled pneumatic (ECP) brakes, can provide added protection by overcoming some of the inherent limitations of the traditional air brake systems. In addition to other operational benefits, ECP brakes protect against brake cylinder leakage, and will monitor brake pipe pressure and automatically generate an emergency brake application if the brake pipe pressure gets low. With ECP brakes, the brake pipe is solely dedicated to continuously supplying air, to keep all of the reservoirs charged on the train.
The National Transportation Safety Board (NTSB) recently made a recommendation to address the need for redundant protection, such as wheel chocks and derails, to protect against runaway trains (NTSB Recommendation R-14-03 Urgent). The recommendation is derived from the NTSB's investigation into the collision between 2 Chicago Transit Authority trains that occurred on 30 September 2013, in Forest Park, Illinois.
The TSB has pointed out the need for robust defences to prevent runaways since 1996 (TSB Railway Investigation Report R96C0172). From that time, there have been over 120 runaways in Canada that have affected main-track operations. Equipment runaways are low-probability events, but as this accident demonstrates, they can have extreme consequences, particularly if they involve dangerous goods. As demonstrated in Lac-Mégantic, the cost to human life and our communities can be incalculable. For this reason, the Board recommended that
The Department of Transport require Canadian railways to put in place additional physical defences to prevent runaway equipment.TSB Recommendation R14-04
Transport Canada's response to Recommendation R14-04 (October 2014)
Transport Canada (TC) will fully implement this recommendation.
On 29 October 2014, TC issued an Emergency Directive pursuant to Section 33 of the Railway Safety Act, requiring railways to improve their operating practices with respect to the securement of railway equipment. Specifically, railways were ordered (in part) to
TC will be developing monitoring procedures to ensure operators adhere to the outlined requirements.
Also on 29 October 2014, TC issued a ministerial order, pursuant to section 19(1)(a) of the Railway Safety Act, requiring companies to formulate rules to address the provisions of the Emergency Directive permanently. The rules are to be filed with TC within 180 days of the issuance of the order. TC will continue to work with the railway industry to identify and address any possible residual risks well in advance of the rule submission deadline. Should any unforeseen vulnerabilities be identified that are not addressed sufficiently in the Rule proposed by industry, TC would issue an amended Emergency Directive to immediately address any such issues.
TC 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. Rail Safety personnel will
Furthermore, as of 01 April 2015, enforcement action for any instances of non-compliance will include the option of issuing fines in the event of contraventions to the Railway Safety Act, and its rules and regulations.
Recognizing that technological solutions may provide for additional improvements to mitigate risks of runaway trains in the coming years, TC will intensify its collaboration with industry through the Railway Research Advisory Board to help lead the implementation of technologies to enhance railway safety. In July 2014, TC signed a Memorandum of Cooperation with the United States Federal Railroad Administration to facilitate further information exchange, and to help in identifying technical cooperation projects. TC will also initiate a strategic research initiative program to investigate alternatives that would enhance brake system performance, focusing on braking systems and train securement technologies. Such technologies will be developed under, but not limited to, the following themes: remote brake application systems, wayside temperature detectors, and hand brake monitoring devices.
Through these measures, TC will provide for multiple layers of defence for securement to prevent runaway trains.
TSB assessment of response to Recommendation R14-04 (November 2014)
Transport Canada (TC) has accepted the TSB recommendation.
The Emergency Directive issued in October 2014 (expiring 29 April 2015) addresses many of the weaknesses in the CROR rules pertaining to the securement of equipment. For example, the Emergency Directive mandates the use of a hand brake chart specifying the minimum number of hand brakes required, taking into consideration the tonnage of the train and the grade of the track. In addition, train securement must be confirmed by a hand brake effectiveness test, followed by the application of the hand brakes on the lead locomotives and air brakes on the entire train, adding additional levels of defense. Moreover, the required use of both air brakes and hand brakes on standing equipment while switching, and verification of its status every 2 hours, further reduces the risk of runaway equipment in those situations. The Emergency Directive also mandates the use of additional physical defenses, such as derails, mechanical emergency devices, and mechanical lock parking brakes in addition to the existing defences. These additional measures strengthen the existing rules for securement of equipment.
The Ministerial Order issued in October 2014 requires railways to submit for approval new rules respecting the securement of railway equipment. The new rules are intended to address the provisions of the Emergency Directive on a permanent basis. It is anticipated that further improvements will be made during the final rule making process to ensure it is clearly written to enhance correct application and to ensure that any gaps identified in the current hand brake chart are addressed. It is clear that TC requires any rules submitted to contain specific provisions to enhance safety, such as enhanced securement practices and the use of additional physical defenses.
The Board acknowledges the industry concerns with using additional physical defences on main track, including the possibility of introducing new risks. However, the TSB recommendation does not prescribe a specific solution. We believe that a one-size-fits-all approach may not be suitable and that different solutions may be required in different operating environments (e.g. main track, sidings, rail yards, etc.). As part of the rule making process, it is up to industry, in collaboration with TC, to consider potential risks and to determine the most appropriate solutions to be used under different circumstances.
TC has also committed to taking a number of additional measures, such as hiring more staff to enhance monitoring and inspection activities, and using administrative monetary penalties to strengthen enforcement activities when there is non-compliance. Through the Railway Research Advisory Board, TC stated it will also help lead the implementation of technologies to enhance railway safety, and will initiate a strategic research initiative program to investigate alternatives that would enhance brake system performance, focusing on braking systems and train securement technologies.
The Board is pleased with the safety action taken to date and with the accelerated pace of the proposed safety action. These actions include multiple layers of defence such as clarifying the rules for securement, physical defences and enhanced monitoring. If the proposed measures are fully implemented, the risk of runaway equipment will be significantly reduced. As the proposed rules have not yet been developed, and the changes in regulatory oversight (staffing levels, activities, enforcement, and research) are ongoing, some of which will not take place until 2015 or later, the outcome cannot be known until the process is finalized. Therefore, the Board assesses the response to Recommendation R14-04 as having Satisfactory Intent.
Railway Association of Canada's Response to Recommendation R14-04 (February 2015)
The Emergency Directive (ED) that was issued on 29 October 2014 requires additional physical defences. Under Section 19 of the Railway Safety Act (RSA), the RAC prepared a new securement rule for railway equipment and has circulated the rule for consultation. Under Section 20 of the RSA, the RAC will file a change to the Railway Locomotive Inspection and Safety Rules regarding the Reset Safety Control (RSC) and its use relating to train securement.
Additional response from Transport Canada to Recommendation R14-04 (February 2015)
TC requires railway companies to meet standardized requirements for hand brake application and has put into effect additional physical defences to secure trains.
TSB reassessment of response to Recommendation R14-04 (March 2015)
The RAC is preparing to submit new rules for train securement on behalf of the member railways as required by TC's Order, dated 29 October 2014. As the proposed rules have not yet been finalized and must be approved by TC, the outcome cannot be known until the process is completed. Therefore, the Board considers the response to the recommendation as having Satisfactory Intent.
Additional response from Transport Canada to Recommendation R14-04 (January 2016)
Transport Canada (TC) issued a Ministerial Order, pursuant to section 19(1)(a) of the Railway Safety Act, requiring railway companies to formulate rules to address the securement of railway equipment. Following extensive consultations with the industry, the newly revised Canadian Rail Operating Rules - Rule 112 was approved by the Minister of Transport and came into effect on 15 October 2015. With respect to Rule 112(c)Footnote 1, Rail Safety Inspectors will be asked to note if they see any instances where industry is unclear on this section of the rule.
In conjunction with the new rule, railway special instructions will contain additional detail for employees regarding these requirements.
With respect to safety control equipment on locomotives, the Railway Locomotive Inspection and Safety Rules, which were updated on 03 July 2015, contain the following requirement:
Section 29. Safety Control Equipment
29.4 It must be communicated to affected railway employees when a locomotive is equipped with a safety control system with roll-away protection.
Companies are able to determine the most effective way to communicate with their employees whether it be, for example, by written instruction, by equipping the locomotives with stickers or both.
Railway Association of Canada's response to Recommendation R14-04 (January 2016)
A new securement rule came into effect as of 15 October 2015. The rule requires additional physical defences for equipment securement. The RAC submitted a change to the Locomotive Inspection and Safety Rule with regards to RSC improvement and the change was approved by TC.
TSB reassessment of response to Recommendation R14-04 (March 2016)
TC issued a Ministerial Order resulting in new Canadian Railway Operating Rules (CROR) relating to the securement of railway equipment, which came into effect on 15 October 2015. TC's Rail Safety Inspectors have been instructed to take note of any instances where industry is unclear on the new rules. The RAC submitted a change to the Locomotive Inspection and Safety Rule with regards to RSC improvement and the change was approved by TC.
The recommendation asked TC and industry to put in place additional physical defences to prevent runaway equipment. The Board acknowledges the effort that has gone into revising CROR Rule 112. In addition, as the new rule is sufficiently complex, any instances where a railway is unclear on the new rules will need to be addressed. However, despite these actions, the number of occurrences involving runaway equipment has increased in the past year (i.e., 42 occurrences in 2015 compared to 30 occurrences in 2014 and a 5-year average of 36). More needs to be done to ensure that the risk of runaway equipment is reduced and appropriately mitigated.
These physical defences should not rely on air brakes due to their lack of reliability. As air brakes are known to leak and the rate of leakage is generally unpredictable, this defence would not be a sufficient back-up to the hand brakes. Until an assessment of the effectiveness of the new rules is conducted, it will not be known if they are achieving the desired outcome. The Board considers the response to the recommendation as being
Satisfactory In Part.
Transport Canada's response to Recommendation R14-04 (February 2017)
Transport Canada has put in place a significant number of measures to improve railway safety including more stringent requirements for the securement of unattended railway equipment, regulations prescribing fines for contraventions to the Railway Safety Act, and a new liability and compensation regime for federally regulated railways.
TC imposed stricter requirements for securing unattended trains by issuing an Emergency Directive under the Railway Safety Act requiring railway companies to meet standardized requirements for handbrake application and requiring additional physical defences to secure trains.
In October 2015, Transport Canada approved a strengthened Rule 112 of the Canadian Rail Operating Rules respecting train securement. Handbrakes are the first line of defense in preventing equipment from rolling away. Sufficient handbrakes will prevent equipment movement in all weather conditions and over virtually unlimited periods of time. The revised rules provides industry with a comprehensive handbrake application chart to respond to various operating situations, which once applied, must be confirmed by another employee with the appropriate level of knowledge. For example, the rules would require a train weighing between 10,000 and 14,000 tons on a grade of 1% to be secured with 26 handbrakes, in addition to handbrakes on all leading locomotives on the train. In addition to handbrakes, railway equipment must be secured by additional physical means listed in the rules when unattended on main track, siding track, subdivision track and high risk locations. The revised rules provide the additional requirements that have to be met when air brakes are used as the additional means of securement.
Additional funding to increase the safety of the movement of dangerous goods by rail has been allocated to support increased inspection capacity and improved training for stronger and more consistent oversight across the country; enhanced systems for testing, classifying, registering and mapping dangerous goods and their movements, and to support better risk management; increased federal contributions for local investments in safer railway crossings to help prevent accidents; and additional support for first responders to provide better tools and the information required to better protect communities.
TC's oversight activities include monitoring the safety of railway companies' operations, as well as compliance with rules, regulations and standards through audits and inspections, and taking appropriate enforcement action as required. Oversight of the new rules has been integrated into the oversight plan and continues to be an area of priority. While the new rules are more comprehensive than their predecessors, Railway Safety Inspectors have not found that industry is unclear on the application of the rule. When non-compliance is found, appropriate action is taken.
On 01 April 2015, new Administrative Monetary Penalty Regulations came into force under the Railway Safety Act. Administrative Monetary Penalties are fines issued by Transport Canada to corporations or individuals for contraventions to the Railway Safety Act, or regulations and rules made under the Act.
In its reassessment of March 2016, the Transportation Safety Board stated that the number of occurrences involving uncontrolled movement of railway equipment had increased (i.e., 42 occurrences in 2015 versus 30 occurrences in 2014). However, it is important to note that these occurrences covered numerous operational scenarios such as unintentional movement of equipment in railway yards while employees were actively assembling trains, or when railway equipment moved uncontrolled and was stopped by a derail (a device placed on the track to act as an additional means of defence as permitted in Rule 112).
In correspondence dated 20 December 2016 to Transport Canada, the Transportation Safety Board identified a malfunction of the reset safety control with rollaway protection system on certain locomotives. Specifically, there was an occurrence reported to the TSB (R16W0242) whereby the rollaway protection on one locomotive did not function as expected and resulted in a train moving for about 1 minute at a speed of about 1 mile per hour for approximately 80 feet. The existence of this defect condition in other locomotives of the same series was confirmed through additional testing. Given that this defect condition could exist with other locomotive models and could reasonably be expected to result in a situation where a person could be injured and constitutes a threat to safe railway operations, Transport Canada took immediate action and, on 22 December 2016, TC issued an Order pursuant to section 32.01 of the Railway Safety Act requiring railway companies to implement certain safety measures regarding the use of reset safety control with rollaway protection.
Additionally, and pursuant to section 36 of the Railway Safety Act, railway companies were ordered to file with the Minister of Transport certain information regarding locomotive models in service and results of testing on locomotives equipped with rollaway protection. The department is reviewing the data which has been submitted by railway companies and will take any necessary actions in the interest of safe railway operations based on the findings of this review.
Transport Canada has taken meaningful actions to address Recommendation R14-04. The department continues to monitor implementation of the rule and to monitor companies for compliance.
Railway Association of Canada's response to Recommendation R14-04 (March 2017)
A new securement rule came into effect as of 15 October 2015. The rule requires additional physical defences for equipment securement.
The industry continues to work with TC to improve these rules.
TSB reassessment of response to Recommendation R14-04 (March 2017)
In October 2015, Transport Canada approved a strengthened Rule 112 of the Canadian Rail Operating Rules respecting train securement. The revised rules provide industry with a comprehensive handbrake application chart to respond to various operating situations, which, once applied, must be confirmed by another employee with the appropriate level of knowledge. In addition to handbrakes, railway equipment must be secured by additional physical means listed in the rules when unattended on main track, siding track, subdivision track and high risk locations.
Oversight of the new rules has been integrated into TC's oversight plan and continues to be an area of priority. TC has allocated additional funding to support increased inspection capacity and improved training for stronger and more consistent oversight of the movement of dangerous goods by rail across the country. While the new Rule 112 is more comprehensive, TC's Railway Safety Inspectors have not found that industry is unclear on the application of the rule. However, when non-compliance is found, appropriate action is taken.
The total number of occurrences involving uncontrolled movements has remained unchanged in the past year (i.e., 42 occurrences in 2016 compared to 42 occurrences in 2015 and a 5-year average of 39). The Board recognizes that uncontrolled movements cover numerous operational scenarios, including situations when employees are actively assembling trains. Of the 42 occurrences in 2016, 27 of these involved uncontrolled movements where the securement was inadequate. This was a decrease of 6 as compared to 2015 when there were 33 similar occurrences. However, the number of these occurrences in 2016 was slightly higher than the 5‑year average of about 26.
Situations where inadequate securement has resulted in uncontrolled movements include
These situations must continue to be monitored and addressed on a priority basis as part of TC's oversight for the strengthened Rule 112. In addition, as air brakes are known to leak and the rate of leakage is generally unpredictable, this defence should not be considered a sufficient back-up to hand brakes.
The Board is encouraged that TC has implemented a number of initiatives, including a strengthened rule and a comprehensive oversight plan for the new rule. However, as the desired outcome of significantly reducing the number of uncontrolled movements has not yet been achieved, the Board considers the response to the recommendation as being Satisfactory In Part.
Next TSB action
The TSB will monitor progress on the implementation of new rules and the related procedures to prevent uncontrolled movements.
This deficiency file is Active.
- Footnote 1
When equipment is left unattended in a yard, at least one physical securement or mechanical device must be utilized.
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