Rail transportation safety investigation R16H0002
Update: The TSB has completed this investigation. The report was published on 19 September 2016.
Table of contents
Expanding the Use of Locomotive Voice and Video Recorders in Canada
View final report
About the study
In May 2015, the Transportation Safety Board of Canada launched a safety issues investigation (safety study) on the use of locomotive voice and video recorders under the Canadian Transportation Accident Investigation and Safety Board Act.
Key railway stakeholders participated in the safety study, including Transport Canada, the Railway Association of Canada, Canadian Pacific Railway, Canadian National Railway, VIA Rail, GO Transit, and the Teamsters Canada Rail Conference.
The safety study assessed current technology and regulatory issues, operational and human resources, and potential safety benefits of the expanded use of on-board recorders. The study collected background information for the development of an action plan to implement locomotive voice and video recorders.
Recommendation R03-02: National standards for locomotive data recorders
Recommendation R13-02: In-cab locomotive video cameras
Related TSB railway investigation reports
Train passed a signal indicating stop
VIA Rail Canada Inc.
Train No. 52
Mile 232.8, Kingston Subdivision
19 January 1999
Via Rail Canada Inc.
Passenger train No. 92
Mile 33.23, Canadian National
26 February 2012
TSB calls for implementation of voice and video recorders on locomotives in Canada
Read the news release
Kirby Jang, Director of Investigations - Rail/Pipeline, joined the TSB in 2003 as Manager, Regional Operations, and since that time has completed or reviewed over 50 rail accident investigations. Before joining the TSB, Mr. Jang worked primarily in the railway industry for a number of engineering consulting firms. In his capacity as railway systems consultant, he was directly responsible for the management and successful completion of over 100 technical projects. Mr. Jang's education credentials include a Bachelor (1984) and Master (1985) of Applied Science from the University of Waterloo in Civil Engineering, and a Master of Business Administration (1992) from the University of Toronto.
Jon Stuart has been a human factors specialist for over 20 years, and has published in the fields of Artificial Intelligence, Sports Science, Industrial Psychology, and Systems Safety. Since obtaining his doctorate in applied psychology from Loughborough University in England, he has worked in the roles of systems designer, customer researcher, and accident investigator. After building Nortel's approach to incorporating human factors into accident investigation, Dr. Stuart joined Transport Canada's Civil Aviation, where he developed the System Safety Branch's methodology for collating safety information. Dr. Stuart joined the TSB as a Senior Human Performance Analyst in 2003. He has managed the Human Factors and Macro Analysis Division, as well as participated in air, marine and rail investigations, including the 2012 derailment of a VIA Rail passenger train in Burlington, Ontario.
Christina (Missy) Rudin-Brown has been a Senior Human Factors Investigator since joining the TSB in October 2012. She holds PhD and Master of Arts degrees in Experimental Psychology from the University of Toronto, a BA (Hons.) in Psychology from the University of Ottawa, and is a board member of the Canadian College for Certified Professional Ergonomists (CCCPE). Before joining the TSB, Dr. Rudin-Brown was a Senior Research Fellow with the Human Factors team at the Monash University Accident Research Centre (MUARC) in Melbourne (Australia) and spent over 10 years as a Human Factors specialist in Transport Canada's Road Safety Directorate. Dr. Rudin-Brown has published over 85 peer-reviewed papers across a number of transportation safety areas, including: operator behaviour and adaptation, driver speed choice, operator distraction, road infrastructure and rail level crossing safety, transportation safety policy, child and adult occupant protection and operator impairment.
Darlene Roosenboom has been with the Railway/Pipeline Investigations Branch of the Transportation Safety Board of Canada (TSB) since 2004. Currently Specialist/Senior Investigator, Operations, she has provided oversight on a number of other investigations, and is also a trusted agent of TSB's confidential reporting system, Securitas. Before joining the TSB, Ms. Roosenboom worked for Canadian National Railway Company (CN) for 15 years, predominantly as rail traffic controller; she also held management positions in the work program office, and was a crew coordinator. Ms. Roosenboom obtained her Bachelor of Arts degree from York University in 1992, majoring in Sociology.
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Class of investigation
This is a class 1 investigation. These investigations—also known as safety issue investigations (SII)—analyze a series of occurrences with common characteristics that have formed a pattern over a period of time. These investigations, which may result in recommendations, are generally completed within 730 days. For more information, see the Policy on Occurrence Classification.
TSB investigation process
There are 3 phases to a TSB investigation
- Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
- Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
- Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.
For more information, see our Investigation process page.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.