TSB Watchlist: advancing transportation safety, issue by issue
By Faye Ackermans,
Member, Transportation Safety Board of Canada
This article was originally published in Inside Track magazine.
Although Canada's transportation system is considered one of the world's safest, that doesn't mean it's free from risks. Accidents still happen, and investigations by the Transportation Safety Board of Canada (TSB) continue to highlight serious underlying risk factors that are all too common.
Last fall, the TSB released Watchlist 2018, identifying the key issues that must be addressed to make our air, marine, and rail transportation systems even safer. The current Watchlist highlights seven issues: two specific to Canada's aviation sector, one to the marine sector, and one that affects our railways. The remaining three issues are “multimodal,” impacting all three transportation sectors.
Progress: removal of old issues
For Watchlist 2018, the TSB was able to remove three issues, two of them in rail: the transportation of flammable liquids by rail, and the requirement for on-board voice and video recorders in main-track locomotives.
To accomplish the former, railway companies acted to conduct thorough route planning and analysis (including risk assessments), and the industry, as directed by Transport Canada, phased out the older “legacy” tank cars so that more robust tank cars are now used when transporting large quantities of flammable liquids, thereby reducing the likelihood of a dangerous-goods release during accidents. With regard to the latter, the Government of Canada brought forward legislation that will see voice and video recorders installed on all lead locomotives operating on main track.
Not all problems in rail, however, have been addressed as successfully.
Following railway signal indications
For over a century, Canada has relied on a system of visual signals to control traffic on a significant portion of its rail network. These signals convey direction such as operating speed and the operating limits within which the train is permitted to travel. Sometimes, however, train crews misinterpret or misperceive a signal indication. How often? Between 2008 and 2017, there was an annual average of 33 reported occurrences where a train crew did not respond appropriately to a signal in the field. And while the probability of a missed signal leading to an accident may be low, the resulting collision or derailment could have catastrophic consequences.
Train signal misinterpretation or misperception has been on the Watchlist since 2012. The TSB has made two recommendations on the issue, first in 2000 and again in 2013.Footnote 1 In Europe and the United States, some railways already have train-control systems that activate a cab alarm or even stop the train if the crew does not respond appropriately to a signal. In comparison, Transport Canada (TC) and the Canadian railway industry have remained firmly in “study mode”—with many meetings but insufficient progress on implementing the solutions.
This issue will therefore remain on the Watchlist until TC requires railways to implement additional physical safety defences, ensuring that signal indications governing operating speed and operating limits are consistently recognized and followed.
Slow progress addressing TSB recommendations (multimodal)
Since its creation in 1990, the TSB has issued just over 600 recommendations across all modes, the vast majority directed at Transport Canada as the regulator. Too often, however, sufficient or timely action is not taken, even when the minister agrees with the recommendation. In fact, there are dozens of TSB recommendations that have been active for over a decade without achieving a fully satisfactory response. Five of these are railway-related, including a 17-year-old TSB recommendation on the need for additional backup safety defences against signal misinterpretation.Footnote 2 With respect to this safety deficiency, occurrence data show that the number of railway movements exceeding limits of authority have increased over time.Footnote 3
Slow response to addressing TSB recommendations was first highlighted in Watchlist 2016. Although there has been some subsequent progress, most of the progress has been due to changes in the operating environment or to voluntary actions taken by industry—not due to government action. This issue will therefore remain on the Watchlist until:
- TC acts to reduce the number of active recommendations over 10 years old—most notably those that would bring Canada in line with international standards and where the government has already indicated its agreement.
- Change agents targeted by other dormant recommendations demonstrate that risks have been reduced enough that those recommendations can be closed by the TSB.
- The Government of Canada reviews and improves interdepartmental processes for expedited implementation of safety recommendations.
Fatigue management (multimodal)
Since the early 1990s, the TSB has identified sleep-related fatigue as a contributing factor or a risk in at least 90 occurrences, 31 of these in the railway sector. Fatigue management, which was first added to the Watchlist in 2016, has long proved challenging for employers and employees—notably because of unpredictable start times in freight operations, long duty hours, and rotating day and night shifts. The current work/rest rules do not reflect the latest fatigue science, and they only apply to operating crews. Instead, the regime relies on an individual's ability to judge his/her own fatigue, rather than a shared employer–employee responsibility for proactive fatigue management.
Going forward, what's needed is a profound change in attitudes and behaviours, both at the management and operational levels. To foster this paradigm shift, the issue of fatigue management in transportation will remain on the Watchlist until:
- TC develops a policy framework for managing fatigue—one based on its review of fatigue management systems, fatigue science, and best practices.
- TC works with industry and employee representatives and fatigue science specialists to develop a comprehensive approach to fatigue management in the rail sector.
- TC completes amendments to the Work/Rest Rules for Railway Operating Employees, 2011, based on fatigue science.Footnote 4
Safety management and oversight (multimodal)
In Canada, all federally regulated railways have been required to have safety management systems (SMS) since 2002. Recent TSB investigations, however, have found that these are not always effective at identifying hazards and mitigating risks.Footnote 5 That's partly because requiring companies to have an SMS is only half of the issue: there must also be appropriate regulatory oversight. Unfortunately, TC has not always been effective at identifying companies' ineffective processes and then intervening in a timely manner.
Recently, TC and the Railway Association of Canada co-hosted an SMS workshop, sharing ideas and best practices with industry and other stakeholders. TC has also made progress by helping companies implement the requirements of the Railway Safety Management Systems Regulations, and by completing at least one comprehensive audit for each federally regulated railway. Further, the results of these audits have been shared with the railways, including the list of required corrective actions. Those are good steps, but more must be done. Specifically, this issue will remain on the Watchlist until:
- operators that have an SMS demonstrate that it is working—that hazards are being identified and effective risk-mitigation measures are being implemented.
- TC not only intervenes when operators are unable to manage safety effectively, but does so in a way that succeeds in changing unsafe operating practices.
Looking ahead: what comes next?
Any issue that makes it onto the Watchlist is, by definition, complex—which means everyone involved will need to work together for a safer system. Operators, for instance, will need to consult with unions to change work practices and integrate technology. Legislators and central agencies, meanwhile, will have to find ways to accelerate the pace of regulatory change.
As for the TSB, we will work hard to make sure that the call to action is heard—and heeded. We'll meet with stakeholders from coast to coast and, in late 2019, we will conduct a mid-cycle review of the Watchlist issues to gauge progress. Where advancements have been made, we'll say so, but if not enough has been done, we'll say that too. That's because even the hardest problems have a solution, and when it comes to the safety of people and the integrity of our transportation infrastructure and the environment, Canada can't afford to be anything other than a world leader.
—Faye Ackermans has over two decades of experience in the rail industry, including 15 years in rail safety and regulatory affairs. Since 2014, she has been a Member of the Transportation Safety Board of Canada.
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