Transportation Safety Board recommends changes due to fatal Ontario VIA Rail accident

Canada’s Transportation Safety Board is recommending the installation of controls designed to automatically stop trains that miss signals and also expresses concern that employees in “safety-critical positions” are “not always adequately assessed for medical fitness.”

TSB released Tuesday a report from its investigation into a derailment in early 2012 of a passenger train that killed three locomotive engineers in Burlington, Ont., north of Hamilton.

On Feb. 26, 2012, VIA Rail Canada Inc.’s train No. 92 was on its way from Niagara Falls to Toronto. After it stopped at and left the Aldershot station, it entered a crossover which had a speed limit of 15 miles per hour (about 24 km/h). The train was travelling at 67 miles per hour (about 107 km/h) and derailed. The locomotive and the first coach car slide down an embankment.

All three operating crew members were fatally injured and a VIA Rail service manager was injured, as were 44 passengers. The fuel tank was punctured, releasing about 4,300 litres of diesel.

“The accident location was within a high-speed (centralized traffic control system) rail corridor, which is one of the busiest rail corridors in Canada with traffic volumes of up to 100 trains per day,” the report noted, adding there are normally 49 GO Transit commuter trains, 18 VIA Rail and 28 freight trains per day going through Aldershot.

“The risk of this type of accident is not confined to passenger trains because many freight trains carry all manner of dangerous goods and, should there be an accident, there is significant risk to the public and the environment.”

TSB added that since 2001, “a signal indication was misidentified, misinterpreted or not immediately recognized on average of 11 times a year.”

The probability of an accident may be low, TSB stated in the report, but “the consequences to the public or the environment can be extremely serious.” This, TSB notes, “argues for adding defences in depth to the rail system to prevent accidents where the crew members do not respond to the signals displayed.”

On Feb. 26, 2012, 11 seconds before VIA 92 derailed, the train passed a signal which displayed a “clear to slow” signal, meaning the speed limit is 15 mph.

TSB investigators speculated in the report that the crew “may have … misinterpreted” that the signal displayed the “advance clear to limited” rule. The report suggested the crew “was likely focussed on resolving the apparent track occupancy conflict of the signals work crew working ahead … rather than properly identifying the indication of the signal.”

But without in-cab voice recordings, “it is impossible to identify the precise cause with certainty,” the report noted.

TSB added that in 2003, it had recommended “national standards for locomotive data recorders that include a requirement for an on-board cab voice recording interfaced with on-board communications systems.”

That recommendation was in a report of an incident, in January 1999, in which a VIA train passed a signal near Trenton, Ont. indicating the train was supposed to stop. That incident resulted in no derailment, injuries or damage other than damage to a switch that was forced open by the train’s wheels.

In its report on the VIA 92 tragedy, TSB is recommending in-cab video recorders. It is also recommending “physical defences” so a train will be stopped automatically if a signal is missed.

Fail-safe systems have been “widely used in commuter rail systems throughout North America since the 1930s to ensure compliance with stop indications,” TSB noted in the report.

TSB is also recommending that standards for crashworthiness that apply to new locomotives also apply to rebuilt locomotives.

When the locomotive used by VIA train 92 was rebuilt, TSB noted, “there was no structural upgrade in the area of the cab to protect against rollover or impact.” It was originally built before 1995 and the rebuild “did not include the structural requirements outlined in Part II of the Locomotive Safety Rules and nor was it required.”

Those safety rules stipulate that new locomotives for freight trains are required to conform to the Association of American Railroads Manual of Standards and Recommended Practices (S-580) or “equivalent standard,” while passenger locomotives are required to conform to the American Public Transit Association (APTA), the Association of American Railroads Manual of Standards and Recommended Practices or “equivalent standard.”

After the locomotive on VIA train 92 slid down the embankment, it rolled over and struck the concrete foundation of a building. The cab roof area was crushed downwards.

“Due to the nature of the accident, it could not be determined with any certainty if the crew would have survived even with improved rollover protection,” TSB stated. “While it is recognized that it may not be possible to design a vehicle in which the occupants survive all crash scenarios, survivability will improve with more robust design.”

TSB also noted in its report that alcohol was found in the urine of the engineer in charge, though toxicology tests indicated the alcohol had been consumed more than 12 hours prior.

But TSB noted the in-charge locomotive engineer (ICLE) “had been suffering from a mood disorder and had had difficulties managing the use of alcohol for over 10 years.”

The ICLE had not been at the controls. Normally the operating locomotive engineer sits at the controls on the right side of the cab while the ICLE sits on the left side of the cab and “performs the duties of the conductor,” TSB noted.

Toxicology results showed the presence of medication including quetiapine and oxycodone, both of which “may cause drowsiness,” TSB reported. TSB added the medical condition of the ICLE – though known by Canadian National Railway Company, his previous employer of 21 years — had not been reported to VIA Rail, a crown corporation. VIA was originally a subsidiary of CN but CN was privatized in 1995.

In a previous accident investigation report, TSB had found that “if medical information is not effectively tracked, transferred and communicated when an employee working in a safety-critical position moves to another railway company, health issues that affect operator performance can remain undetected, increasing the risk of unsafe train operations.”

TSB made that finding in its investigation into an accident in 2010 on a VIA train travelling near Saint-Charles-de-Bellechasse, Que. That train “entered a siding switch, which had an authorized speed of 15 mph, while travelling at approximately 64 mph.”

After the release of that report, TSB noted, VIA Rail and CN “placed increased attention on ensuring that medical files were transferred between companies when an employee changed employer.”

Although VIA requires new operating employees to pass a VIA pre-employment medical assessment, that process was not in place in 2009, when the ICLE who was killed in the February, 2012 derailment near Aldershot joined VIA. TSB noted neither the engineer nor his doctor had informed VIA Rail of the medical issues.

“As several TSB reports including this one have identified gaps in the system, the Board is concerned that current practices and requirements do not always ensure that employees in safety-critical positions are adequately assessed for medical fitness,” TSB noted, adding that in aviation and marine, assessments are done by physicians approved by Transport Ca
nada and the results of those assessments are sent to Transport Canada for review.

“Operating crew members also have a responsibility to declare these health conditions to the company,” TSB stated. “Such conditions must be carefully assessed and regularly monitored by the company if they continue to work. However, the drugs used to treat these conditions, or the conditions themselves, may lead to an individual being excluded from a safety-critical position. Therefore, there is a risk that employees will not self-declare during a company assessment.”

According to its website, the top speed for VIA passenger trains in the Windsor to Toronto corridor is more than 95 miles per hour (150 kph).

In recommending fail-safe systems to stop trains when engineers miss signals indicating they are supposed to slow down or stop, TSB noted the Toronto Transit Commission has such a system on its subway trains. The TTC trains have trip arms that lower when the train passes a signal that indicates the operator can move ahead.

“When the signal requires a stop (that is, red aspect) the wayside trip arm is raised to the danger position so that it engages the trip valve and activates and emergency brake application,” TSB stated of the Toronto subway.