The February 2012 VIA Rail train 92 derailment in Burlington, Ontario

Wendy Tadros
Chair of the Board, Transportation Safety Board of Canada
Rob Johnston
Manager, Central Region and Headquarters
Burlington, Ontario
11 June, 2013

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Opening Remarks

Wendy Tadros

Thank you for joining us this morning.

On the 26th of February 2012, VIA 92 derailed just past Aldershot station, near Burlington, Ontario. Three crew died and dozens of passengers were injured, some very badly. The Transportation Safety Board of Canada dedicated time and expertise to this independent investigation, and today we are here to give you the results. We know what happened, when it happened, and what needs to be done to prevent it from happening again. That's why we are making three recommendations to Transport Canada, calling for fundamental changes to our rail system:

  • so that trains will automatically slow down and stop when they are supposed to;
  • so that what happens in the locomotive cab gets recorded;
  • and so crews are given a better chance of surviving an accident.

I'll talk more about those recommendations in a few minutes, but first, I have with me today Mr. Rob Johnston, the expert who heads all TSB rail investigations in this region. Mr. Johnston has decades of experience in derailment investigations, and he will take you through exactly what happened and what went wrong that day.

Rob Johnston

Good morning. You're about to see a simulation compiled from a number of sources, including a re-enactment and the locomotive event recorder from VIA 92, which unfortunately had no voice recording. This simulation is from the perspective inside the cab. I'm going to walk you through, explaining what the signals displayed, when, where they were displayed, and how fast the train was going.

First you will see the signal near Waterdown Road. Next is a stop at Aldershot Station. After departing the station, you will hear a train horn, suggesting the crew saw something on the tracks ahead. Finally, you will see the signals at Aldershot East.

But first, a short word about signals: Similar to traffic lights, railway signals display green, yellow and red lights. However, in contrast, rail signals are differentiatedby position, by the combinations of lights displayed, and by flashing of the lights. They are also connected along the route to provide a progression of signals that informs the crew how to control train speed and how to approach the next signal.

I'll add here that our investigation carried out extensive testing of the signaling system, and we determined that the signals that day did not malfunction; they operated exactly as intended.

Now, to the accident.

VIA 92 was on a scheduled afternoon run from Niagara Falls to Toronto. One locomotive pulling five coaches.

We begin with the train travelling east on track 2, the middle track, approaching a regular stop at Aldershot station. The signal near Waterdown Road displays “clear to slow,” or yellow over yellow, which means proceed at track speed approaching the next signal at no more than 15 mph.

Then the train begins to slow, and soon pulls into Aldershot station, where it stops for about 7 minutes. Normally, VIA trains departing the station are routed straight through on track 2. However, on this day they were routed around a work crew which had a permit to perform work on the track ahead.

Departing the station, the next signals, at Aldershot East, display “slow to limited,” or red over flashing yellow and green lights, which meant proceed at no more than 15 mph past the signal and through the crossover.

But the train accelerates, and the horn sounds as the crew sees the workers ahead.

The train should be travelling at 15 mph approaching the crossover. Instead, it approaches at 67. Due to this excessive speed, the locomotive derails, flips to its side, slides down the embankment and collides with the building.

Following any accident, investigators begin with many questions. Chief among them, obviously, is “what happened?” Here, that was fairly straightforward: a train was travelling 67 mph through a crossover with a maximum speed of 15 mph. Due to the excessive speed, the train derailed. Three men died, and more than half of the 70 passengers were injured.

But for the Transportation Safety Board, the bigger question is always why an accident happened. Because only when we understand the why can we be clear about how it needs to be fixed.

And so we asked: did the crew not see the signals? That's highly unlikely. The crew was familiar with this territory, and this was a routine run for them. Their shift had just started, the signals were directly in front with no obstructions, in clear view for at least two minutes, and they were flashing. Moreover, there were three engineers in the cab that day, with over 80 years of combined railway experience.

It is much more likely that the signal was seen, but misperceived. Our experts identified several possible theories, each of which in isolation or combination could explain why.

  • We know the stop at Aldershot station interrupted the flow of signals. This crew may have forgotten the signal at Waterdown Road and been strongly influenced by the expectation that they would continue on Track 2, as usual.
  • It is equally possible that the work crew on the track ahead provided a distraction from the signal. Again, the sounding of the horn would seem to support this, considering they sounded the horn in an area where horns weren't normally used.
  • Another possibility is that the crew became focused on the flashing yellow and flashing green—and not the red light at the top. If so, the signal could have been misinterpreted as “proceed at track speed” rather than “slow down to 15 mph.”

None of those theories is any more or less likely than the others. And the truth is we will never know for certain. We can't—not without definitive proof, such as a voice or video recording of who did what, and who said what, and when.

Still, there are key lessons to be learned. This investigation taught us a lot about what fundamental changes are needed to make Canada's rail system safer. And so today we are making three recommendations, which Madame Tadros will explain.

Wendy Tadros

Our first recommendation calls for an automatic, fail-safe way of stopping trains. You have heard what happened that day. Did the crew of VIA 92 misperceive a signal? We think so. But it could just as easily have been a crew on a freight train, and it could have happened anywhere there are signals.

In Canada, our busiest rail corridor, from Quebec City to Windsor, is run by a kind of choreography: the rail traffic controller sets up the movement of many trains and then directs the system to show the appropriate signals. When the train crews follow those signals, everything runs smoothly. The problem is that about once a month, somewhere in Canada, there is a disconnect between what the signal displays and how the crew perceives it.

That's a risk. And we need to drive that risk down. That means investing in safety, in technology, so trains will automatically slow down, and stop, even if the crew misperceives a signal.

We can start by looking at the United States, where they've had an Automatic Train Control system in the Northeast Corridor for over 60 years. In fact, they're now looking at the next generation of this technology, and on many more lines. We can also look to the rest of the world. The United Kingdom. France, Germany, Italy, Denmark, Sweden, New Zealand, Australia, India, China. Each of these countries has some system that intervenes to apply the brakes and slow the train when needed.

At the TSB, we made our first recommendation for these additional defences more than a decade ago. In response, the industry has implemented more “rules” and “procedures,” but this hasn't fixed the fundamental problem. And these accidents keep happening.

Again, it's not just passenger trains. Every day, hundreds of freight trains encounter thousands of signals all over Canada. Those trains carry chemicals. Flammable liquids. And more and more oil. And those tracks run along our rivers and lakes, and through our cities.

A misperceived signal once a month is too often. Three fatalities is three too many. Canada needs to be a world leader. And right now, we're lagging behind. Way behind. We need to innovate, because if we don't there will be another accident. That's why today the Board is recommending that major Canadian passenger and freight railways invest in technology, in an automatic fail-safe way of stopping trains, beginning with Canada's high-speed rail corridors.

That's our first recommendation. Our second calls for in-cab video cameras. To prevent similar accidents in the future, we need to understand why these things happen. In this accident, we know what the signals displayed. And we know how fast the train was going. We also know that locomotive crews are highly trained to follow signals and that they must call and acknowledge those signals within the cab.

But what, exactly, happened inside that locomotive during the fateful minutes before and after Aldershot station? The simple answer is that we will never know, not for sure—not without objective evidence.

The aviation industry has benefitted from voice recordings for almost sixty years. And some in the marine industry are considering adding video recordings to supplement the voice recordings they already have. The TSB first called for voice recorders on trains in 2003, and we've been pushing for them ever since. Why? Because understanding the environment and interaction between the crew members is vital. While VIA has committed to installing voice recorders in their fleet, the rest of the rail industry seems to be sticking with the status quo: no change—and therefore no real answers. That's a lost opportunity.

Today the Board is going even further, recommending in-cab video cameras in all lead locomotives in main line operation.

Our final recommendation focusses on improving the chances that a crew will survive a crash.

In the U.S., any locomotive built after 2008—and every older one that undergoes a major rebuild—must meet standards for crashworthiness. In Canada, the rules only apply to new locomotives. But this locomotive was not new. It was rebuilt. And so, like over 90 percent of freight and passenger locomotives in Canada, it didn't have to meet today's tougher standards.

Would that have been enough to save the lives of three men that day? It's impossible to say, but it's a loophole we need to close, and that's why the Board is recommending that crashworthiness standards for new locomotives also apply to rebuilt passenger and freight locomotives.

To summarize, today the Board is making 3 recommendations. We are calling for fundamental changes to our rail system:

  • so trains will automatically slow down and stop when they are supposed to;
  • so that what happens in the locomotive cab gets recorded;
  • and so crews are given a better chance of surviving an accident.

Thank you.