TSB ‘encouraged’ by some rail safety action, pushes for mandatory on-board voice recorders

Canada’s Transportation Safety Board is concerned that some small air carriers and flight training schools are not required to have safety management systems and that railways are not required to have on-board video and voice recorders in locomotives, TSB said in a report to parliament Wednesday.

TSB  — whose mandates include accident investigations involving aviation, railways, marine and pipelines — released its annual report through the Leader of the Government in the House of Commons, Peter Van Loan. That report covers the period April 1, 2013 through March 31, 2014 and therefore does not include two recommendations released earlier this week from its investigation into the July 6, 2013 rail accident in Lac-Mégantic, Quebec that killed 47.

“Presently, the Board is concerned that there is no requirement for on-board video and voice recorders on locomotives,” TSB said in its annual report. That concern did not arise from Lac- Mégantic. “The rail industry should ensure that communications in locomotive cabs are recorded.”

In June 2013, TSB had recommended in-cab video recorders in locomotives, in an accident report. On Feb. 26, 2012 VIA Rail Canada Inc.’s train No. 92 derailed northeast of Hamilton, Ont., killing all three operating crew members. TSB said in the report that the crew “may have” misinterpreted a “clear to slow” signal indicating a speed limit of 15 miles per hour near the Aldershot station in Burlington.

“A number of TSB rail investigations have identified human factors as an underlying condition or an unsafe act,” TSB said in its annual report Aug. 20, 2014. “Many of these investigations would have benefitted from a recording of crew communications immediately prior to the accident.”

Overall, TSB “is encouraged by indications from Transport Canada that important safety action is in the works,” the board added.

TSB, which reports directly to Parliament through the Leader of the Government in the House of Commons, is a separate organization from Transport Canada.

“The number of accidents in 2013 increased by 3% from the 1613 accidents reported in 2012, but decreased by 4% from the 2008-2012 annual average of 1721 accidents,” TSB said of air, marine, pipeline and rail accidents. “The number of reported incidents increased to 1737 in 2013 from 1318 in 2012, and from the 2008-2013 average of 1364. In 2013, the TSB also received 618 voluntary reports.”

In aviation, safety management systems remain a concern.

“Since 2005, large air carriers in Canada have been required to have safety management systems,” TSB said. “This requirement doesn’t, however, extend to smaller carriers, such as air taxis, helicopter operators, commuter airlines, and flight training schools, which together are responsible for 94% of all commercial aviation accidents and 96% of all commercial aviation fatalities. The Board is concerned that, in the absence of (Transport Canada) requirements, the passengers and aircraft of these smaller operators are being placed at unnecessary risk.”

TSB noted that 11 pipeline accidents were reported in 2013, up from the annual average of nine during the five-year period from 2008 through 2012.

“The last fatal accident on a federally-regulated pipeline system occurred in 1988,” TSB noted.

In a separate report Aug. 19 on the Lac- Mégantic disaster, TSB made two new recommendations. One was that the federal government require Canadian railways to “put in place additional physical defences to prevent runaway equipment.” The other was that Transport Canada “audit the safety management systems of railways in sufficient depth and frequency to confirm that the required processes are effective and that corrective actions are implemented to improve safety.”

On July 5, 2013 a Montreal, Maine and Atlantic (MMA) Railway train with 72 oil tanker cars had been stopped before midnight near Nantes, about 180 kilometres south of Quebec City. At about 1 a.m., the train started to move down a 1.2% grade into Lac-Mégantic, picked up speed and 63 tanker cars derailed. Forty-seven people died.

“That tragedy, in fact, has become a flashpoint, highlighting the safety of our rail network as a key national issue,” TSB chair Wendy Tadros wrote in TSB’s annual report Aug. 20, 2014. “Canadians from Saint John, to Winnipeg to Vancouver are paying attention to the risks of shipping dangerous goods through their towns and cities, and along their lakes and rivers. And they want assurances it will be done safely.”

TSB issued three recommendations Jan. 23 during the Lac- Mégantic investigation. Transport Canada had 90 days to respond, so those recommendations had not been assessed as of March 31. Therefore, the report to parliament indicates Transport Canada’s response had yet to be assessed. But separate notices on the TSB website suggest the government is making progress. 

One recommendation published Jan. 23 was that the federal government require “Class 111 tank cars used to transport flammable liquids meet enhanced protection standards that significantly reduce the risk of product loss when these cars are involved in accidents.” TSB now considers Transport Canada’s response to be “satisfactory in part” because the government is prohibiting the use of some “older Class 111 tanks car” and Transport Canada will also require “pre-CPC 1232/TP 14877 tank cars used for the transportation of crude oil and ethanol be phased out of service or retrofitted” within three years.

“Until all pre-CPC 1232/TP 14877 tank cars are no longer used to transport flammable liquids and a more robust tank car standard with enhanced protection is set for North America, the risk will remain,” TSB said on its website.

The second recommendation issued Jan. 23 was for the government to “set stringent criteria for the operation of trains carrying dangerous goods, and require railway companies to conduct route planning and analysis as well as perform periodic risk assessments to ensure that risk control measures work.”

TSB has assessed the response as “satisfactory intent” because the government has ordered railways “to formulate and submit for approval new rules to improve their operating practices for the safe and secure transportation of dangerous goods.” Transport Canada also now requires railways “set improved criteria for the operation of trains carrying dangerous goods, to conduct route planning and analysis, and to perform initial and periodic risk assessments.”

The third recommendation TSB published Jan. 23 was to “require emergency response assistance plans for the transportation of large volumes of liquid hydrocarbons.” TSB now considers Transport Canada’s response as “fully satisfactory.”

In April, Transport Canada issued an order requiring emergency response assistance plans from railways “for the transportation of higher-risk hydrocarbons and flammable liquids, including ethanol, for any train with one or more loaded tank cars of these products.” Those plans “will be required for the offering for transport or import by rail of commonly transported hydrocarbons and flammable liquids that present a higher risk, even for smaller volumes of one loaded tank car,” TSB notes.