Taking the time required
5 July 2013
Posted by: Dan Holbrook
Completing a TSB accident investigation
At the TSB, the time it takes to complete an investigation and to produce a public report is a topic that is always on the table. Internally, we refer to this subject as “timeliness”. In recent years, we’ve improved our mechanisms to track the progress of investigations at each milestone and made sure that individuals take ownership for every step. Directors of Investigation are held accountable for the progress of investigations, and targets are discussed regularly at the highest level. Consequently, we’ve gotten much better at managing our own production.
Clearly we recognize that the timely release of our investigation reports can be directly linked to our relevance and success. In most circumstances, public interest fades with time, a fact that must be taken seriously at the TSB. Let me explain why.
Advancing transportation safety
We are in the safety investigation business. Our purpose is to advance transportation safety without assigning blame. We do this by conducting independent investigations into selected transportation occurrences so we can identify safety deficiencies and make recommendations to reduce or eliminate the risks associated with these deficiencies. While we have been given comprehensive powers to investigate, we’ve been limited in our ultimate power to that of a recommending body. This means that when we want something to change we must create a compelling case or a convincing argument. We must use all the tools in our toolkit, including public interest. With public interest behind us, it is much easier to bring about change. Therefore, the timely completion of investigations can help us advance transportation safety.
Communicating transportation safety
Getting the safety message into the hands of those who can make the necessary changes is also important. The TSB does not have to wait until the end an investigation to communicate vital safety information. In addition, often safety issues that require urgent action are reported to us through a confidential reporting system: SECURITAS. Whatever the circumstance, these safety issues can be communicated immediately through Safety Information Letters and Safety Advisories issued to those who can effect change. In the case of validated safety deficiencies at the national or international level, the Board can issue interim recommendations while an investigation is ongoing.
Conducting a thorough TSB accident investigation
Now, let’s get to what I really wanted to talk about, that being, why it is also very important to take the time required to complete a thorough investigation. In the case of larger, more complex investigations, completing a thorough analysis often involves in depth laboratory work, data interpretation and extrapolation, simulations and tests. Sometimes these tasks can run simultaneously, sometimes they must be concurrent with the outcome of one task determining the conduct of the next. In our world, post-accident damage can leave us with very little physical evidence and, unfortunately, few witnesses to interview. In these circumstances, we must be able to take the time we need, regardless of timeliness concerns. The stakes are just too high to rush. Let me give you an example from my own experience.
TSB investigation into a train derailment in Lillooet, B.C.
In the late afternoon of June 29, 2006, shortly after cresting the steep mountain grade to begin the 30 mile descent into Lillooet, British Columbia, CN train 567 began to accelerate out of control. The crew used all means at their disposal to control the train’s speed; however, it continued to accelerate and eventually derailed, killing two of the three crew members. The locomotive event recorder was destroyed in the post-crash fire. The TSB’s task of determining why the train’s brakes could not control the speed was hampered by the absence of meaningful data. It looked like we would never know for sure why this accident happened.
Then, after 18 months of investigation, analysis, testing and simulation, one tenacious investigator decided to re-examine the end of train device, known as a Sense and Braking Unit (SBU). This device, mounted at the rear of freight trains, is essentially a radio telemetry device that measures and transmits end of train brake activity to the locomotive engineer. The investigator had previously noted the presence of a GPS antenna on the SBU, but had been told that this particular model was not equipped with the GPS function. Through further examination, it was determined that the SBU was indeed equipped with a GPS unit. He was then told that any data that may have been stored on the device was volatile and would have disappeared when the batteries died.
Long story short, the device had non-volatile memory (did not need power to be retained). He was able to recover air brake activity, time and GPS location information that we were able to use to simulate the accident and determine why the train had lost control.
Animation of the train derailment in Lillooet, B.C.
Simply put; if we had not taken the necessary time, we would not have determined why this accident happened.
It probably seems like I am talking out of both sides of my mouth, but such is the dilemma we face. On the one side, timeliness is important to the TSB in helping us get our safety message accepted and acted upon, and on the other side, I am cautioning that complex investigations take time. Investigators need to be able to take the necessary time to think things through and follow their intuition. If transportation safety is to be advanced, we must accept that there are times when “timeliness” has to take a back seat.
Dan Holbrook began working in the railway industry in 1977 where he held both unionized and management positions. After moving to Transport Canada, Dan worked as a Railway Safety Inspector and Regional Manager. Dan joined the TSB in 1995 as the Railway Operations Specialist. For the last 12 years, he has been the Western Regional Manager in the Rail/Pipeline Branch. Dan is the father of 3 teenagers and enjoys fitness, food and fun.
- Date modified: