Rail transportation safety recommendation R14-04

Reassessment of the response to TSB Recommendation R14-04

Physical defences to prevent runaway equipment

 Recommendation R14-04 in PDF [283 KB]

Background

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.
Transportation Safety Recommendation R14-04

Response from Transport Canada (29 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

  • use standardized hand brake charts;
  • ensure the adequacy of hand brake applications through hand brake effectiveness testing;
  • use additional physical securement mechanisms/measures (a list was provided);
  • apply hand brakes to the locomotive(s) in addition to those on the cars;
  • use air brakes in addition to hand brakes on trains or equipment left unattended on the main track; and
  • verify every 2 hours by a qualified employee the securement of cars left unattended on the main track during switching, picking up or setting off enroute.

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

  • develop and implement targeted oversight requirements related to new rule(s) focused directly on securing trains; and
  • identify and challenge any technical gaps in railways' risk assessments and provide technical advice/direction on new securement rules, special instructions, and daily bulletins/safety issues identified by inspectors in the field.

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 U.S. 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 response to R14-04 (November 2014)

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 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, contains 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

  • no handbrakes applied or insufficient number of handbrakes applied;
  • air bleeds off of cars left standing with an emergency air brake application and the train air brakes subsequently release; and
  • faulty or ineffective handbrake(s).

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.

Transport Canada's response to Recommendation R14-04 (February 2018)

Since the tragic accident in Lac-Mégantic, 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, improved regulations regarding companies' safety management systems, regulations prescribing fines for contraventions to the Railway Safety Act, improved tank car standards, emergency response plans, and a new liability and compensation regime for federally regulated railways. A detailed list of measures can be found at http://www.tc.gc.ca/eng/mediaroom/infosheets-menu-7564.html.

The Transportation Safety Board's recommendations R14-04 specifically addressed the securement of unattended trains and recommended that Transport Canada require Canadian railways to put in place additional physical defences to prevent runaway equipment.

Following the accident, Transport Canada 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.

Transport Canada approved a strengthened Rule 112 of the Canadian Rail Operating Rules in October 2015 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 hand brakes, 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.

Transport Canada's oversight activities include monitoring the safety of railway companies' operations, as well as compliance with rules, regulations and engineering 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 April 1, 2015, the new Administrative Monetary Penalties 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. A list of Railway Administrative Monetary Penalties issued by Transport Canada can be found at https://www.tc.gc.ca/eng/railsafety/railsafety-975.html.

The Transportation Safety Board has reassessed Transport Canada's response to the recommendation on previous occasions. In its reassessment of March 2016 and March 2017, the Transportation Safety Board noted that the number of occurrences involving uncontrolled movement of railway equipment had remained unchanged over the last two years (i.e., 42 occurrences in 2015 and 2016 versus 30 occurrences in 2014). However, both TC and TSB noted that these occurrences covered numerous operational scenarios such as unintentional movement of equipment in railway yards while employees were actively assembling trains. It is also important to note that in a number of cases, 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).

TC and TSB have each put significant effort into analyzing the RODS data regarding uncontrolled movements and each organization has presented the other its data analysis methodology. Discussions continue with the aim of finding a common way to categorize and present the data which can lead to a deeper understanding of the causes.

In correspondence dated December 20, 2016 to Transport Canada, the Transportation Safety Board identified a malfunction of the reset safety control with rollaway protection systems 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 his 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 December 22, 2016 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 has reviewed the data which has been submitted by railway companies and has met with industry to discuss approaches to modify locomotive control software to address the issues raised. Industry is actively developing revised performance criteria for rollaway protection to address the gaps which have been identified in the current criteria. Following on this work, submissions are expected for amendments to associated rules. Once received, TC will analyze the submissions as per the Railway Safety Act to determine if they should be approved.

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.

Separately, the Railway Association of Canada (RAC) is consulting with affected associations/organizations regarding changes it is proposing to submit to incorporate requirements for exceptional circumstances not otherwise provided for in the previous version of the rule. It is expected RAC will file the revisions with the department by March/April 2018. 

Railway Association of Canada's response to Recommendation R14-04 (January 2018)

The RAC and industry actively worked with TC to strengthen the securement rule 112. A new rule is currently out for stakeholder consultation, and soon to be filed with the Minister. Although the rule in effect is understood and applied correctly, the new rule is clearer and is therefore easier for the end user to understand and apply.

In response to an emergency directive, the RAC and industry are researching rollaway protection application as a secondary line of defense for securement, including conducting a risk assessment and evaluating potential changes to the locomotive safety rules to add defined parameters on the requirements for rollaway technology. This work is being done in conjunction with TC and enhancements to CROR Rule 112.

In regards to TSB data, it should be recognized that changes to TSB reporting criteria in 2014 increased the number of occurrences being reported and needs to be considered when making comparisons to the 5 year average. Also, as noted in TSB's latest re-assessment, occurrences classified by them as "uncontrolled movements" include a number of operational occurrences, many of which are low speed or low risk as they occur in locations with safety protections in place.

TSB reassessment of response to Recommendation R14-04 (March 2018)

Since 2014, Transport Canada has put in place various measures to improve railway safety, including:

  • more stringent requirements in the revised rules for the securement of unattended railway equipment, such as additional physical means when unattended on main track, siding track, subdivision track and high risk locations;
  • improved regulations regarding companies' safety management systems;
  • regulations prescribing fines for contraventions to the Railway Safety Act; and
  • a new liability and compensation regime for federally regulated railways.

TC has continued to monitor implementation of CROR Rule 112 and companies for compliance.

In December 2016, after being notified of a locomotive defect relating to securement, TC issued an Order requiring railway companies to file with the Minister of Transport certain information regarding the locomotive models in service and the results of testing on locomotives that are equipped with rollaway protection. After receiving and reviewing the submitted information, TC met with industry to discuss approaches to modify the locomotive control software in order to address the issues raised.

Over the past year, the RAC and industry have been researching rollaway protection application as a secondary line of defense for securement. Upon completion of this work, submissions will be developed to amend the associated rules. TC will review the submitted amendments to determine if they should be approved.

The Board is encouraged that TC took immediate action on the identified locomotive defect, and that various approaches are being assessed to ensure that locomotive rollaway protection can be safely used as secondary line of defence for securement. The Board acknowledges that TC has continued to monitor implementation of CROR Rule 112 and to monitor companies for compliance.

In 2017, there were 62 occurrences involving uncontrolled movements, the second-highest in the past 10 years. When the ten-year average (2008-2017) of 54.1 uncontrolled movements per year is compared to the most recent 5 years (2013-2017)Footnote 2 , the average number of uncontrolled movements per year increased by 10% to 59.8. Uncontrolled movements continue to pose a risk to the rail transportation system. As the current defences do not seem sufficient to reduce the number of uncontrolled movements and improve safety, the Board considers the response to Recommendation R14-04 to be Satisfactory In Part.

Transport Canada's response to Recommendation R14-04 (February 2019)

The Transportation Safety Board's recommendations R14-04 primarily addressed the securement of unattended trains and recommended that Transport Canada require Canadian railways to put in place additional physical defences to prevent runaway equipment. 

Following the accident, Transport Canada 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.

Transport Canada approved a strengthened Rule 112 of the Canadian Rail Operating Rules in October 2015 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 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. 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. In 2018, Rule 112 was revised to incorporate requirements for exceptional circumstances not otherwise provided for in the previous version of the rule. The amendments prescribe the specific actions which must be taken when the full application of the requirements of 112 (a) or (b) are not possible in the following scenarios: mechanical defect is encountered enroute, equipment is derailed or coupled to derailed equipment, or separation is required for clearing a crossing for emergency vehicles. 

Reset safety control with rollaway protection

In correspondence dated December 20, 2016 to Transport Canada, the Transportation Safety Board identified a malfunction of the reset safety control with rollaway protection systems 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 [t]his 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 December 22, 2016 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. 

TC reviewed the submissions filed by companies and observed some of the testing conducted by companies. It was determined that various alert systems exist with different configurations and performance requirements, depending on the type, the manufacturer specifications and companies' setting preferences. Testing demonstrated that speed activation for the rollaway protection functionality, ranged from 0.5 mph to 4 mph. Testing also showed that the system would automatically reset itself when speed activation had been reached but then dropped below the pre-set threshold during the timeout period (when topography could cause the movement to decelerate for instance). Finally, railways are currently testing their safety control systems to verify rollaway protection functionality.

In recognition of these issues, industry has been working to develop new technology and conducted analyses to support a revision to the Railway Locomotive Inspection and Safety Rules which would contain the design specification, performance, inspection and testing requirements specific for locomotives equipped with rollaway protection technology. However this work is not yet completed. 

Uncontrolled Movements of Railway Equipment

Railway companies are required to report occurrences to the TSB in accordance with the requirements in the Transportation Safety Board Regulations. One category of occurrences which must be reported is the unplanned and uncontrolled movement of rolling stock. Uncontrolled movement is a broad category of occurrences that captures a number of situations that while similar, vary by cause, circumstances and risk. However, it is important to note that few uncontrolled movements are related to the securement of unattended equipment and that they occur most often in yards, for example, when railway employees are making-up trains.

The TSB has provided TC with the number of occurrences it has determined to be an uncontrolled movement. 

Actions taken by Transport Canada

Transport Canada reviews all occurrence data provided by TSB and follow-ups with railway companies as required to gather information which can lead to a deeper understanding of the causes.

In TC's analysis of the data, the following has been determined:

Year Total Carloads originating in Canada* (thousand) Total Occurrences ** Number of Cars Involved Number of Occurrences Involving Dangerous Goods (none involved the release of DGs) Location of Occurrence Investigated by TSB
1-5 >5 Un-known Main Track Non-Main Track Yard
2015 4,831 58 42 15 1 14 1 12 45 2
2016 4,846 51 26 23 2 10 2 11 38 4
2017 5,225 62 39 20 3 18 5 9 48 2
2018 - 65 60 5 0 14 4 14 47 4

* Source: Rail Trends 2018 Published by The Railway Association of Canada.  Accessed at www.railcan.ca

** Source: Transportation Safety Board

Both TC and TSB noted that these occurrences covered numerous operational scenarios with the majority occurring in yards while employees were actively assembling trains. The number of uncontrolled movements has remained relatively static over the last four years despite an increase in rail traffic. It is also important to note that in a number of cases, 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).

Railway Operating Employees work in a dynamic environment, where human error can cause occurrences due to a combination of factors such as knowledge, experience, and supervision.  The risk of accident or injury caused by human factors is not easily addressed by the regulator. Given there is no one measure that can address the numerous scenarios which can result in an uncontrolled movement of railway equipment,

TC continues to take action in the following areas:

Oversight of Railways and Enforcement of Regulatory Requirements with Respect to Uncontrolled Movements

Transport Canada's oversight activities include monitoring the safety of railway companies' operations, as well as compliance with rules, regulations and engineering standards through audits and inspections. TC has a number of enforcement tools and takes appropriate action in cases where non-compliance or safety concerns are found. For the occurrences of uncontrolled movements in 2017, TC issued 6 letters of non-compliance and a letter of warning for violations of the CROR. In addition, TC issued a Notice of Violation under the Railway Safety Administrative Monetary Penalties Regulations. In 2018, TC issued a Notice in response to one occurrence and a Notice and Order in response to two other occurrences. A complete list of enforcement action and measures to mitigate threats to rail safety is available at: https://www.tc.gc.ca/eng/railsafety/railsafety-569.htm.

In response to uncontrolled movement of an attended train which resulted in the fatalities of three crew members, and given the exact cause of the accident is still under investigation by the TSB, and as a precaution to prevent further accidents in similar circumstances, TC issued a ministerial order under the Railway Safety Act to all railway companies mandating the use of handbrakes should a train be stopped on a mountain grade after an emergency use of the air brakes.

Employee Knowledge and Experience in Safe Train Operations

Transport Canada continues its work to ensure the operating employee training and qualification policy framework is up-to-date, effective, and reflective of the needs of an evolving and dynamic railway industry. The department is working toward a regulatory proposal in the Canada Gazette, Part I in early 2020. 

In addition, in 2018, TC developed a guideline for remote control locomotive (RCL) systems. The guideline is informed by work conducted by TC from 2016-2018, which was presented to members of the Advisory Council on Railway Safety. TC examined areas such as qualification/training/experience, mitigating measures to reduce the risk of accidents or incidents, mainline operation, train speed and crew size. TC also conducted industry site visits (where operating procedures and training programs were observed), and reviewed Transportation Safety Board (TSB) occurrence data and United States regulatory requirements and guidance. The guideline recommends that railways take actions including establishing common standards to be implemented by all railway in two key areas: training and qualification of employees and RCL operation. This guideline has been provided to stakeholders for comment and will be finalized early in 2019. 

In conclusion, 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. In addition, TC continues to work with stakeholders [to] take action to reduce the number of uncontrolled movements.

Railway Association of Canada's response to Recommendation R14-04 (February 2019)

The RAC and industry actively worked with TC to strengthen the securement rule 112. In 2018, the RAC filed revisions to the rule with the Minister. These were approved and went into effect on May 18, 2018. The revised rule is written to make the instructions easier to understand and is restructured to provide a situation-based layout, which will assist compliance. The revision also includes new instructions to guide users on how to respond to occasional exception circumstances that were not otherwise provided for in the previous version of the rule.

In response to an emergency directive, the RAC and industry continue to research rollaway protection application as a secondary line of defense for securement, including conducting a risk assessment and evaluating potential changes to the locomotive safety rules to add defined parameters on the requirements for rollaway technology.

In regard to TSB data, it should be recognized that changes to TSB reporting criteria in 2014 increased the number of occurrences being reported and needs to be considered when making comparisons to the 5-year average. Also, as noted in TSB's latest reassessment, occurrences classified as “uncontrolled movements” include a number of operational occurrences, many of which are low speed or low risk as they occur in locations with safety protections in place.

TSB reassessment of the responses to Recommendation R14-04 (March 2019)

To gain a deeper understanding of the causes of uncontrolled movements, Transport Canada (TC) reviewed all TSB-reportable occurrences of this type and followed-up with the railway companies as required. As there is no one measure that can address the numerous scenarios involving uncontrolled movements, TC continued to take action in the following areas:

  • In 2018, CROR Rule 112 was revised to incorporate requirements for exceptional circumstances not otherwise provided for in the previous version of the rule. The amendments prescribe the specific actions to be taken if the full application of Rule 112(a) or Rule 112(b) is not possible in the following scenarios: mechanical defect is encountered enroute, equipment is derailed or coupled to derailed equipment, or separation is required for clearing a crossing for emergency vehicles.
  • TC's oversight activities (through inspections and audits) included the monitoring of railway companies' operations with respect to compliance with rules and regulations that relate to uncontrolled movements.  
  • TC has a number of enforcement tools and takes appropriate action in cases where non-compliance or safety concerns are found. In 2018, TC issued a Notice in response to one occurrence and a Notice and Order in response to two other occurrences.
  • In February 2019, in response to the uncontrolled movement of an attended train that resulted in 3 crew member fatalities, TC issued a ministerial order to all railway companies mandating the use of handbrakes should a train be stopped on a mountain grade after an emergency use of the air brakes.
  • TC continued its work to ensure that the operating employee training and qualification policy framework is up-to-date and effective. TC is working toward a regulatory proposal to be published in the Canada Gazette, Part I in early 2020. 
  • In 2018, TC developed a guideline for remote control locomotive (RCL) systems. This guideline was provided to stakeholders for comment and is expected to be finalized in early 2019.

In addition to TC actions, the Railway Association of Canada and industry has continued to research rollaway protection applications as a secondary line of defense for securement, including conducting a risk assessment and evaluating potential changes to the locomotive safety rules to add defined parameters on the requirements for rollaway technology.

In 2018, there were 66 occurrences involving uncontrolled movements, the second-highest in the past 10 years. Uncontrolled movements continue to pose a risk to the rail transportation system. Despite actions taken, the current defences do not seem sufficient to reduce the number of uncontrolled movements and improve safety. Therefore, the Board considers the response to Recommendation R14-04 to be Satisfactory in Part.

Next TSB action

The TSB will monitor progress on the implementation of CROR Rule 112 and the related procedures to prevent uncontrolled movements. 

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