Rail transportation safety recommendation R97-06
Reassessment of the responses from Transport Canada to Rail Safety Recommendation R97-06
Recommendation R97-06 in PDF [98 KB]
Adequacy of Rail Safety Regulatory Overview
On the evening of 12 August 1996, all three occupants in the cab of the lead locomotive of Canadian National (CN) westward freight train No. 117 were fatally injured when their train, which was travelling at approximately 54 mph, collided head-on with a cut of 20 runaway cars moving eastward at about 30 mph, approximately six miles east of Edson, Alberta.
It is the Board's view that Transport Canada's (TC) regulatory overview must ensure that railways have effective systems in place for ensuring the maintenance of safety standards in their day-to-day operations. This investigation determined that, in view of CN's recognition that a large number of derails were warranted across the country, adequate regulatory and infrastructure overview had not been maintained by TC to ensure that the railways were consistently complying with the requirements of the Track Safety Rules.
The Board concluded its investigation and released report R96C0172 on 15 September 1997.
Board Recommendation R97-06 (15 September 1997)
Although the principal concern arising from this occurrence involves regulatory overview of rail infrastructure, systemic shortcomings in compliance with national safety standards may be jeopardizing other aspects of rail safety. The Board has previously observed potential systemic deficiencies in such areas as car inspection practices and yard operating procedures. To ensure compliance with national safety standards, the Board recommended that:
The Department of Transport develops and implement policies and procedures for a national audit program that will effectively evaluate the railways' ability to maintain national safety standards.
Transportation Safety Recommendation R97-06
Response to R97-06 (12 December 1997)
TC accepted the recommendation and indicated that they would develop and implement policies and procedures for a program commensurate with a performance-based approach and risk assessment practices to address this issue.
Board Assessment of Response to R97-06 (13 May 1998)
This response was assessed as having Satisfactory Intent.
Additional Response to R97-06 (28 July 2006)
TC forwarded an update which stated that TC has developed and is presently implementing an Integrated Safety Oversight Program. This includes the involvement of all Rail Safety Oversight Programs in assessing all or part of a railway Safety System. A draft Audit Process Manual was developed that will assist in evaluating the railway's ability to maintain national safety standards. A Risk Based Planning program was also developed and implemented. This recommendation remains open for TC.
Board Reassessment of Response to R97-06 (25 August 2006)
In 2001, TC's Safety Management System Regulations came into effect. Canadian railways must now have a safety management system filed with TC. Even though five years has elapsed since the regulations came into effect, it appears that not all components of these safety management systems are functional.
Because only some components are fully functional, the overall effectiveness of TC's program cannot be completely measured. This response has been reassessed as having Satisfactory Intent.
Additional Response to R97-06 (November 2009)
TC continues to implement its "Integrated Safety Oversight Program". Business processes are being developed in the 4 key areas of the Rail Safety Oversight Model: Integrated Risk-Based Business Planning, Monitoring, Enforcement, and Railway Performance Analysis Assessment. Under Monitoring, an integrated National Audit Program with an accompanying Business Process has been developed and approved by Rail Safety Senior Management. The National Audit Program is based on the Safety Management System (SMS) concept and principles. The Railway SMS Regulations form the foundation for the National Audit Program; however, the Program does include the conduct of functional specific audits. The Equipment Division of Rail Safety has implemented policies and procedures and a national audit program for the equipment functions of federally regulated railways. The Operations Division of Rail Safety has finalized the Operations Inspection Program that includes audit modules. Auditor training is currently being delivered to Rail Safety inspectors.
Additional Response to R97-06 (January 2010)
TC Rail Safety is in the process of creating a new Audit/Risk Assessment/Compliance Branch in response to Railway Safety Act review and re-organization. The branch will provide additional functional direction and control in three areas: national audit planning and control, risk assessment and control, and compliance expertise. Program integration within Rail Safety has been identified as a key element of a robust and efficient inspection program. TC is also working on incorporating discreet elements of SMS into the operations inspection program in keeping with the design and methodology of the equipment program.
Board Reassessment of Response to R97-06 (16 September 2010)
In consideration that TC's national audit program has been developed to meet the intent of the recommendation, and also that a new branch is being developed in response to the Railway Safety Act review and re-organization, the Board reassesses the response to Recommendation R97-06 as Fully Satisfactory.
Next TSB action
This deficiency file is Closed.