Railway Safety Act Review Panel
Opening Remarks by
Wendy A. Tadros

Transportation Safety Board of Canada
to the Railway Safety Act Review Panel
Ottawa, Ontario
April 2, 2007

Thank you, Mr. Chair.

Good morning to all.

I appreciate the opportunity to appear before your panel today to provide the TSB's perspective on improving railway safety and I hope it will assist you in your important work. I bring with me today a wealth of experience. To my left is Mr. Ian Naish, our Director of Rail Investigations. Also with us today are his managers, Mr. Ed Belkaloul, Mr. Kirby Jang and Mr. Dan Holbrook.

Let me begin by introducing you to the work of the Transportation Safety Board of Canada (TSB). I want to talk to you about the way in which we work to advance rail safety. Specifically, I want to talk to you about how we work to bring about change - through the safety solutions we offer government and industry.

Rail safety is important, and in the past few years in particular, it has increasingly concerned Canadians. For evidence of this, you have to look no further than the front page of this morning's Globe and Mail where the headline reads: "River turns to acid as train derails." The story is on the Ontario Northland accident; the latest in a number of derailments with environmental consequences. The legislation designed to ensure rail safety has to do its job. We have a number of concrete suggestions to help improve rail safety for the benefit of all Canadians and it will be my pleasure to share them with you today.

Who We Are

The TSB is an independent agency whose sole purpose is to advance transportation safety by investigating marine, pipeline, railway, and aviation accidents. Our role will always be to inform the public about what happened, why it happened and to suggest solutions. The TSB is not a regulator, nor a court; that means that we don't make laws, nor do we find guilt or assign blame.

How We Work

The TSB receives about 1400 reports of rail occurrences each year and they range from the serious multi-car derailments and fatalities that you read about in the news to relatively minor incidents in rail yards.

When we are notified of an occurrence, we collect the initial information and determine whether to deploy an investigation team to the sit

e. And Canadians have come to identify us with the big TSB-BST letters on the shirts and jackets worn by our investigators.

After an initial assessment, we decide if a full investigation is warranted and, once an investigation is under way, if we find unsafe conditions, we do not wait for our final report to make them known - we act immediately by communicating with those who can make transportation safer.

Along the way, there are a number of tools we use to communicate risks. It may be through safety recommendations as we did most recently in the Brockville and Whitby investigations. Or we may choose to send out safety advisories or safety information letters as we did with respect to Canadian National (CN) train operations - following the derailment that spilled sodium hydroxide into the Cheakamus River.

When all is said and done, our role is to advise the public, regulators and industry about what happened and why it happened - in an impartial and unbiased way. Ultimately, we do this by making all our reports and all our recommendations public.

Just to give you a snapshot - in 2006, the TSB made 14 Rail investigation reports public, and issued two safety recommendations, eight safety advisories, and six safety information letters. Many of these communications have already led to concrete actions by industry and regulators to mitigate risks and thereby improve safety.

Effectiveness of our Work

Our big safety payoff occurs when everyone agrees during the course of an investigation about what needs to be done. In this way, safety deficiencies are addressed quickly and, rather than making recommendations, we report on the safety action taken in our final report. Recent safety actions resulting from our work include improvements made by Canadian Pacific Railway (CPR) to rail traffic control systems as a result of our Whitby investigation.

Sometimes, interim recommendations are the best course of action and they too are effective. Interim recommendations allow the TSB to focus attention on validated safety deficiencies so that the regulator and industry can react faster and devote early resources to addressing our findings. Often, the problem is one that can be remedied before the Board releases its final report. That was certainly the case with our McBride investigation.

This being said, the TSB does not impose changes on the transportation industry nor on regulators. Solutions to transportation safety are a shared responsibility amongst many players and our job is to make a convincing case for change. When our recommendations go unheeded, we are finding a stronger voice to influence those who can make transportation safer.

In an effort to make the case for change and find our voice, we have invested in two key initiatives. The first is to issue more investigation updates so the public, the regulator and the industry will know more, earlier. We did this recently in our investigation in Lévis, Quebec. This is a bit of a balancing act as we try to provide factual information that has been proven, without prejudging the final outcome of the investigation.

The second important initiative has to do with tracking the action taken. We are actively monitoring the response to our recommendations and clearly communicating our assessment of those responses to those who can improve safety. And we are posting those responses and our assessments on this site.

Railway Safety Act Concerns

As I have said, we work to bring about change through the solutions we offer to government and industry.

Your invitation to meet has caused me to step outside the confines of the Canadian Transportation Accident Investigation and Safety Board Act and to focus on the Railway Safety Act (RSA) and I came to the conclusion that, while some legislative tinkering may be in order, massive amendments to the RSA are, in my view, not required.

The legislation is fundamentally sound. What is required is to put into effect what we have learned since the implementation of the RSA. In some ways, this is harder.

What have we learned since the inception of the TSB in 1990? Let me start with the methodology we followed to get where we are. For each of the Board's recommendations, there has been a thorough investigation - sometimes more than one - in which the TSB has clearly demonstrated a serious systemic safety deficiency.

We have then looked for means to address these problems in the system. We back up our arguments for what needs to be done to go forward with a recommendation.

We've seen from hard experience that, if there is a problem in the system and it is not addressed, it will happen again. I find myself repeating a now familiar refrain at more and more news conferences…and it goes like this: "We've said this before…."

I now want to tell you about three of our recommendations that I think make that point. Each represents something we've said before. Each represents a recurring risk in the rail system. And each will help you in the delivery of your mandate.

The first area of concern is with the implementation and operation of safety management systems (SMS). I want to preface my remarks by indicating that the Board feels that the promotion of safety management systems is the right way to go in taking a more holistic approach to the enhancement of transportation safety. The objectives of a safety management system are to ensure that safety is given management time and resources and is subject to performance measurement and monitoring on par with financial and production goals.

The intended outcome of SMS, a relatively new approach to safety in North America, is to reduce fatalities and injuries, and to reduce property damage and the impact of accidents on the environment.

The TSB's first opportunity to examine these issues can be found in our report on runaway cars at Edson, Alberta.1 From this investigation, the Board recommended a national audit program to effectively evaluate the ability of railways to maintain national safety standards.

We also voiced our concern over "rule book" culture and the effectiveness of safety management programs. In its response, Transport Canada expressed the will to implement this recommendation, but so far, effective safety management systems have not been put in place on Canada's railways.

Since Edson, there have been other TSB investigations that revealed shortcomings in the application of SMS.

For example, our investigation of a bridge collapse in McBride, British Columbia, revealed that both the railway inspection recording procedures and the regulatory audit procedures were found to be deficient.

Because it is by definition a complex approach, SMS needs careful attention and nurturing to work well. It also almost always requires a change in the culture of the companies and the regulator in order to implement.

I would urge you to review what the Board has found with respect to SMS and consider whether effective safety management systems would go a long way toward making Canada's railway's safer. In doing so, you will also have to consider whether there should be a legislative requirement for SMS.

Second, more traffic moving on Canadian lines has meant longer and heavier trains and the increased wear and tear on track is a safety issue that appeared on the Board's radar as far back as 1990. In that year, the TSB investigated a derailment on CPR's Aldersyde Subdivision. The cause was found to be a broken rail. The subdivision had been tested in April - some six months before the derailment - and no defects were found.

A review of ultrasonic test tapes revealed indications that should have been recognized by the operator and that would have warranted manual ultrasonic inspection. Following this investigation, the Board recommended that the Department of Transport reassess the adequacy of Canadian railway requirements for main line rail testing, taking into account the age of the rail and the nature of the traffic and, further, that the Department of Transport sponsor research to improve the effectiveness of current rail testing methods. Since then, testing methods have improved somewhat.2

However, the issue of rail fatigue life is still there. I can tell you candidly that this is an issue we are once again looking at in the Lake Wabamun investigation. Many derailments are caused by problems with track. Canada has a vast network; therefore, I will not pretend that these issues are easy to tackle, but when it comes to testing the safety of the rails, we need the highest standards possible and I suggest that these are issues you might well take a careful look at.

Thirdly, I want to talk to you about an issue that is closely tied to long, heavy trains. It is the issue of train marshalling. In 2004, following an occurrence in Drummondville, Quebec, the TSB made a recommendation dealing with in-train forces and safe train operation. This recommendation was made after a string of accidents dating back to 2000 in which train configuration was a central issue.3 I must say that the railways implemented new end-of-train technology and we rated the response to our recommendation as fully satisfactory.

However, excessive in-train forces were identified as contributing factors in three further derailments that occurred in 2005 on the Kingston Subdivision4 and we renewed our concern. In 2005, there was another occurrence on the same subdivision also clearly linked to marshalling and we again brought our concerns about this systemic issue to Transport Canada's attention.5

In the intervening period, there was a derailment into the Cheakamus River. In the summer of 2005, this derailment killed the fish population in the river and unleashed a storm of negative coverage. Again, candidly, I can tell you that train marshalling is an issue that is being looked at as a part of our investigation.

These are three examples of key issues we have made recommendations about and where I feel there is room for improvement.

The final issue that I want to raise with you has to do with the tools that we need to continue to identify systemic issues in the rail system. It is the issue of event recorders. As you know, event recorders have been in use in the Air and Marine industries for many years and have proved invaluable to investigators for determining the sequence of events leading to the accident.

Recorder information, in turn, has been used to identify safety deficiencies and has led to many safety improvements.

The simple fact is that the recorders currently in use on locomotives often do not survive an accident - especially when there is a fire. We lost much needed evidence in a number of fatal rail accidents, most notably in Edson, Conrad, Mont-Saint-Hilaire, McBride and Lillooet, for want of an event recorder built to withstand conditions typical of a train accident.

This is in stark contrast to aviation industry standards for event recorders.

For example, since the aircraft accident at Dryden in 1989, crashworthiness standards for cockpit voice recorders and flight data recorders have been mandated. The result is that we get the information we need. For example, in the Swissair accident, despite the incredible forces exerted on the aircraft, we were able to retrieve data, and in both the MK Airlines and Air France accidents, fire did not breach the recorders.

I think you can understand why the Board wants the rail industry to come up to the standards in place in other transportation industries and why it has made recommendations regarding locomotive event recorders. In September 2002, we recommended that Transport Canada ensure that the design specifications for these event recorders include provisions regarding the survivability of data.6

In July of the following year, we recommended that Transport Canada and the railway industry establish comprehensive national standards for locomotive event recorders "that include a requirement for an on-board cab voice recording interfaced with on-board communications systems.7

A requirement to ensure survivability and require voice recording on locomotives would enhance TSB's ability to investigate and bring more safety deficiencies to light.

I would urge you to look seriously at this issue. I can tell you from personal experience that, had the freight train in Hinton, Alberta, carried a robust recorder, there would have been little need for a public inquiry and there would have been no lingering doubts about what happened.

It is my hope that these and other issues can and will be addressed through the work of your panel. For some, the answer may be legislative change and for others, the answer may not be so obvious.

If I can give you any advice today, I would encourage you to "mine" the work that has been done by the TSB, particularly the findings in our reports of the last 17 years, and to put the lessons learned into practice. To that end, I am providing you with all the TSB rail recommendations, including government and industry responses and our rating of those responses.

We've done the leg work and offered solutions to government and industry but more needs to be done. As a body of work, they represent the systemic issues at play in rail safety today. Mine them and your panel could, in my opinion, bring about a vast improvement in rail safety.

Should you require it, I would be happy to provide any background or technical expertise to assist you in your deliberations.


Our independence, proven processes and the technical accuracy of all our work has fostered confidence within the transportation sector. To be sure, the working relationship between the TSB and the Department of Transport is a very good one and I think that we have a strong relationship with the rail industry as well. We work hard on our side to maintain our independence and to provide leadership in the transportation system.

If you are interested, we would be more than pleased to welcome members of this panel to visit our Engineering Laboratory, located near the Ottawa International Airport. Our laboratory is the cornerstone of much of the work that we do - work that is internationally recognized. A tour of the facility provides one with a better understanding of the leading edge scientific work done by TSB investigators.

In closing, let me assure you that everybody at the Board is fully committed to improving transportation safety. We strongly believe that we have made, and continue to make, an important contribution to safety - and I appreciate your interest in hearing our point of view. I hope that you will take a careful look at the solutions we have offered to government and industry since 1990 and mine it well.

Thank you. We would be pleased to answer your questions.

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1.   TSB report R96C0172

2.   TSB report R90C0124

3.   R00Q0023, R01T0006, R01M0061 and R02C0050

4.   R05D0039,R05T0051 and R05T0070

5.   Canadian National train derailment, November 4, 2005

6.   Recommendation R02-04

7.   Recommendation R03-02M