GATINEAU, QC—While recognizing significant positive action taken by the regulator, the Transportation Safety Board of Canada (TSB) remains concerned about Transport Canada’s (TC) response to outstanding recommendations stemming from its investigation into the Montreal, Maine & Atlantic Railway (MMA) train that derailed on 6 July 2013 in Lac-Mégantic, Quebec.
“Transport Canada continues to take important steps to address the rail safety deficiencies we identified in our Lac-Mégantic investigation,” said Kathy Fox, Chair of the TSB. “With respect to preventing runaway trains, TC has introduced multiple layers of defences that, if fully implemented, will significantly reduce risks. But with respect to TC auditing and oversight activities, we are concerned that the department has not yet put in place an effective oversight regime that guarantees all railways will be audited in sufficient breadth and frequency to ensure safety issues are addressed in a timely manner.”
The investigation determined that more robust defences are required to prevent runaways. Even if they have a low probability of occurrence, these events can have extreme consequences, particularly if they involve dangerous goods—as was seen in Lac-Mégantic. For this reason, the Board recommended that TC require Canadian railways to implement additional physical defences to prevent runaway equipment.
In October 2014, TC issued an Emergency Directive (which expires 29 April 2015) that addresses many of the weaknesses in the Canadian Rail Operating Rules pertaining to the securement of equipment.
Along with a standardized hand brake chart and explicit instructions for hand brake effectiveness testing, additional physical securement measures must be used. TC also said it 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.
If the proposed measures are fully implemented on a permanent basis, the risk of runaway equipment will be significantly reduced; therefore, the Board assesses the response as having Satisfactory Intent.
Until Canada’s railways make the cultural shift to safety management systems (SMS), and TC nd TC makes sure they have effectively implemented SMS, the safety benefits will not be fully realized. For this reason, the Board recommended that TC audit the SMS of railways in sufficient depth and frequency to confirm that the required processes are effective, and that corrective actions are implemented to improve safety.
TC has committed to bringing into force additional regulations and enforcement capabilities, hiring more auditors and strengthening its training programs. While significant progress has been made, TC has not yet demonstrated that it has implemented an effective oversight regime to ensure all railways will be adequately audited.
Furthermore, TC has not committed to auditing every SMS component within a given time period. As a result, deficiencies within a railway’s SMS may not be identified and addressed in a timely manner; therefore, the Board assesses the response as being Satisfactory in Part.