TSB rail safety year in review 2021-2022


Written by

William C. Vantuono, editor

Pursuant to subsection 13(3) of the Canadian Transportation Accident Investigation and Safety Board Act, the Transportation Safety Board (TSB) of Canada submitted its annual report to Parliament for the period from April 1, 2021 to March 31, 2022.

The report (downloadable below) covers rail, air, sea and pipeline transportation. Here are excerpts from the Rail Transport section.

The TSB received 1,232 rail transportation occurrence reports in 2021 (1,038 accidents and 194 incidents), including 60 fatalities. The 1,038 accidents represent a 5% increase from 2020, but a 3% decrease from the 10-year average of 1,071. The 60 rail-related fatalities reported in 2021 are the same as the previous year, but below the 10-year average of 71. Of the fatalities, 42 involved trespassers, compared to 40 in 2020 and the 10-year average of 40. The number of fatalities at level crossings, 16, fell in 2021 from 18 of 2020 and is below the 10-year average of 23. The TSB is “conducting ongoing research to better understand winter crossing accidents as part of a safety issue investigation.”

Accidents, incidents and fatalities related to rail transport, 2017 to 2021

Of all rail transport accidents, 86 involved dangerous goods. This figure is higher than 82 in 2020, but lower than the ten-year average of 125. Two accidents in 2021 resulted in the release of dangerous goods.

There were 194 rail transportation incidents reported to the TSB in 2021, a 15% decrease from 229 in 2020 and a 30% decrease from the 10-year average of 277) There were 109 incidents involving movements that exceeded authorization limits, representing 56% of all rail transport incidents in 2021—40 fewer than in 2020 and below the ten-year average of 129.

The TSB defines the accident rate as “a measure of rail transportation safety”. According to TC data, rail activity on main lines (non-yard) in 2021 decreased by 1% compared to 2020. The accident rate on main lines in 2021 was 4.8 accidents per million train-miles, up from 2.8 in 2020 and above the 10-year average. of 2.5. As in 2019 and 2020, part of the mainline accidents in 2021 consist of “an unusually high number of right-of-way fires reported to the TSB in 2021, 137, which mainly explains the increase in the accident rate on the main lines. ”

Accident rates on main lines, 2011 to 2021

TSB personnel deployed to 11 rail transportation occurrences in 2021-22, an increase from 2020-21, started 8 investigations and completed 9.

Following his investigation report into the 2019 derailment of 2 locomotives and 99 cars of a 112-car Canadian Pacific grain train in which all three crew members were fatally injured near Field (BC), the Board issued three recommendations aimed at making cold weather train operations safer in mountainous terrain. The TSB “calls for improved testing standards and requirements for spot maintenance of brake cylinders on freight cars traveling on steep downgrades in cold ambient temperatures; establishment of a timetable for the installation of automatic parking brakes on freight cars; give priority to the modernization of cars used in unit trains of bulk goods in mountainous territory; and CP to demonstrate to TC that its safety management system can effectively identify hazards arising from operations using all available information, including employee hazard reports and data trends; assess the associated risks; and implement mitigation measures and validate their effectiveness… Following the occurrence, the TSB sent Rail Safety Advisory Letters to Transport Canada (TC) on preventing uncontrolled movements for stopped trains on grades less than 1.8%, the air brake system, the inspection and maintenance of grain hopper cars used in CP unit train operations, and the efficiency of the brake test No. 1. Transport Canada took several initiatives after the event, such as the approval of the new Rule 66 proposed by the railway industry Canadian Rail Operating Rules (REF) as well as the use of Automated Train Brake Effectiveness technology in place of No. 1 air brake test requirements on CP grain unit trains traveling between points in Western Canada and the Port of Vancouver. Following the event, CP removed more than 5,000 grain cars from service for repairs, among other things.

The TSB’s investigation report into the collision of a VIA Rail passenger train and an unoccupied CN hi-rail vehicle at Les Cèdres, Quebec, “highlights the importance of having physical defenses in place to prevent employee fatigue from contributing to events”. The passenger train was traveling eastward at the authorized speed of 95 mph on the north main track of the CN Kingston Subdivision. The two engineers aboard the locomotive noticed a bright light in the distance. When the running locomotive engineer realized that the fire appeared to be coming from rolling stock on the same track as the train, a full air brake application was initiated and the locomotive horn and bell sounded . A few seconds later, the train, still traveling at nearly 83 mph, struck an unoccupied van-type track at Mile 30.5, in the municipality of Les Cèdres. There was no derailment and no one was injured. An analysis was performed to assess the fatigue of the signal maintainer during this occurrence. It was determined that the employee had likely accumulated a sleep debt, a condition that contributes to fatigue, given his many consecutive night shifts involving long hours and the fact that he slept during the day when the sleep quality is reduced. “As this event shows, work schedules that increase the risk of fatigue among railway employees can create high-risk situations with potentially serious consequences. Fatigue poses a risk to transportation safety due to its potential to degrade several aspects of human performance… Following the occurrence, TC sent a notice to CN indicating that the measures put in place to prevent occurrences such as this had been deemed insufficient. Later, CN informed TC that it had developed an employee assessment tool to check their knowledge of the regulations governing the protection of track work.

The TSB said that of the nine responses to rail transportation safety recommendations that the Board assessed or reassessed in 2021-2022, “none were rated as fully satisfactory,” with 4 rated as Satisfactory Intent and 5 as Satisfactory. in part.

TC continued its work to update the railway employee qualification and training regulatory regime. “This means that, although action is not yet sufficiently advanced to reduce transport safety risks, progress is being made to address the safety gap identified in Recommendation R18-02 calling for standards of training and qualification for railway employees in safety-critical positions. The Board has therefore reassessed the response to the recommendation as indicating Satisfactory Intent.”

The TSB also reassessed the response to Recommendation R14-05 on auditing safety management systems, one of the recommendations issued following the TSB’s investigation into the main track runaway and derailment of 2013 in Lac-Mégantic (Quebec). TC “reported that it has completed audits of all federally regulated railway safety management systems and is in the early stages of implementing an audit framework targeted to measure the effectiveness of safety management system processes. The Board is encouraged by the progress and therefore considers this response to demonstrate Satisfactory Intent. »

With respect to recommendation R13-01 on intrinsically safe physical train controls, the TSB “considers the responses of the Railway Association of Canada and TC to be partially satisfactory and strongly encourages both organizations to accelerate the pace of ETC (Enhanced Train Control) implementation. The underlying safety deficiency was identified following a TSB investigation into a rear-end train collision more than 20 years ago. For all active recommendations, the TSB will continue to monitor the progress of planned actions and call for action to reduce or eliminate these deficiencies.

Download the full TSB report:


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