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) Rule 112, company special instructions and training. However, TSB investigations into runaways revealed that the sequence of events very often included a misapplication 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.
Board assessment of the 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 Canadian Railway Operating 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 defence. Moreover, the required use of both air brakes and hand brakes on standing equipment while switching, and verification of its status every two hours, further reduces the risk of runaway equipment in those situations. The Emergency Directive also mandates the use of additional physical defences, 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 defences.
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. TC stated that, through the Railway Research Advisory Board, 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.
Response from the Railway Association of Canada 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 Railway Association of Canada (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.
Transport Canada's response 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.
Board reassessment of the response to Recommendation R14-04 (March 2015)
The Railway Association of Canada (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 Recommendation R14-04 as having Satisfactory Intent.
Transport Canada's response 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 (CROR) 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.
Response from the Railway Association of Canada 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 Railway Association of Canada (RAC) submitted a change to the Railway Locomotive Inspection and Safety Rules with regards to the reset safety control (RSC) improvement, and the change was approved by TC.
Board reassessment of the response to Recommendation R14-04 (March 2016)
Transport Canada (TC) issued a ministerial order resulting in a new Canadian Railway Operating Rules (CROR) rule 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 Railway Association of Canada (RAC) submitted a change to the Railway Locomotive Inspection and Safety Rules with regards to the reset safety control (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 five-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.
Therefore, the Board considers the response to Recommendation R14-04 as being Satisfactory in Part.
Next TSB action
The TSB will monitor TC's and the rail industry's progress on the implementation of new rules and procedures to prevent runaway equipment.
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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