RAILWAY INVESTIGATION REPORT R12T0038 MAIN-TRACK DERAILMENT VIA RAIL CANADA INC. PASSENGER TRAIN NO. 92 MILE 33.23, CANADIAN NATIONAL OAKVILLE SUBDIVISION ALDERSHOT, ONTARIO 26 FEBRUARY 2012 Main-track Derailment VIA Rail Canada Inc. OCCURRENCE SUMMARY • Passenger Train No. 92 Aldershot, Ontario 26 February 2012 R12T0038 EVENT On 26 February 2012, VIA Rail Canada Inc. train No. 92 (VIA 92) travelled east from Niagara Falls to Toronto, Ontario, on track 2 of the Canadian National Oakville Subdivision. Beyond the stop at Aldershot Station, the track switches were lined to route the train from track 2 to track 3. The last signal required the train to proceed at 15 mph. VIA 92 entered the crossover at about 67 mph, causing the locomotive and all 5 coaches to derail. The operating crew was killed; 44 passengers and the VIA service manager were injured. About 4300 litres of diesel fuel spilled from the locomotive fuel tank. KEY SAFETY ISSUES • The rail industry relies on administrative defences to ensure crews follow signals. These defences alone are inadequate for situations where the train crew misperceives, misinterprets or does not follow a signal indication. • The absence of valuable information from in-cab voice and video recorders leaves unanswered questions and represents a lost opportunity to mitigate potentially serious crew resource management issues in the industry. • Many locomotives may be susceptible to cab structural, fuel tank and truck securement failure during derailments because there is no Canadian requirement to upgrade crashworthiness when locomotives are rebuilt. TSB RECOMMENDATIONS The Board recommends that Transport Canada require that: • Major Canadian passenger and freight railways implement physical fail-safe train controls, beginning with Canada’s high-speed rail corridors. • All controlling locomotives in main line operation be equipped with in-cab video cameras. • Crashworthiness standards for new locomotives apply to rebuilt passenger and freight locomotives. The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. Railway Investigation Report Main-track Derailment VIA Rail Canada Inc. Passenger Train No. 92 Mile 33.23, Canadian National Oakville Subdivision Aldershot, Ontario 26 February 2012 Report Number R12T0038 Summary On 26 February 2012, VIA Rail Canada Inc. passenger train No. 92 (VIA 92) was proceeding eastward from Niagara Falls to Toronto, Ontario, on track 2 of the Canadian National Oakville Subdivision near Burlington, Ontario. VIA 92, which was operated by 2 locomotive engineers and a locomotive engineer trainee, was carrying 70 passengers and a VIA service manager. After a stop at the station at Aldershot, Ontario (Mile 34.30), the train departed on track 2. The track switches were lined to route the train from track 2 to track 3, through crossover No. 5 at Mile 33.23, which had an authorized speed of 15 mph. At 1525:43 Eastern Standard Time, VIA 92 entered crossover No. 5 while travelling at about 67 mph. Subsequently, the locomotive and all 5 coaches derailed. The locomotive rolled onto its side and struck the foundation of a building adjacent to the track. The operating crew was fatally injured and 45 people (44 passengers and the service manager) sustained various injuries. The locomotive fuel tank was punctured and approximately 4300 litres of diesel fuel was released. Ce rapport est également disponible en français. Table of Contents 1.0 Factual Information .............................................................................. 1 1.1 The Accident ................................................................................................................ 2 1.2 Site Examination ......................................................................................................... 5 1.3 Emergency Response and Evacuation ..................................................................... 6 1.3.1 Initial Emergency Response ...................................................................................... 6 1.3.2 Subsequent Emergency Response and Evacuation ................................................ 7 1.4 Injuries .......................................................................................................................... 8 1.5 Weather ........................................................................................................................ 8 1.6 Recorded Information ................................................................................................ 9 1.7 TSB Re-enactment ..................................................................................................... 10 1.8 Subdivision and Track Information ....................................................................... 11 1.9 Protection for Track Work ....................................................................................... 12 1.10 Centralized Traffic Control System ........................................................................ 12 1.11 Canadian Rail Operating Rules and Compliance ................................................ 13 1.12 Signals Displayed for Eastbound Trains Stopping at Aldershot ....................... 15 1.12.1 Signal Indications Displayed When Lined Through on Track 2 ........................ 15 1.12.2 Signal Indications Displayed When Crossover Lined from Track 2 to Track 3 ........................................................................................................................ 16 1.13 Signal Testing ............................................................................................................ 17 1.14 VIA Locomotive Engineer Training ....................................................................... 18 1.15 Situational Awareness and Mental Models during Train Operations .............. 19 1.16 Additional Defences for Signal Indications .......................................................... 20 1.17 TSB Investigations Involving Misinterpretation of Rules or Signals ................ 21 1.18 Train Control Systems that Protect Against Signal Misinterpretation .............. 22 1.18.1 Proximity Detection .................................................................................................. 22 1.18.2 Cab-Signalling Systems ............................................................................................ 22 1.18.3 Positive Train Control .............................................................................................. 23 1.18.4 Automatic Trainstop at Toronto Transit Commission ........................................ 24 1.18.5 Computer-Based Train Control on Scarborough Light Rail System (TTC) ...... 24 1.18.6 Speed Control System at Toronto Transit Commission ...................................... 25 1.18.7 Train Control Systems at Amtrak ........................................................................... 25 1.19 Amtrak Locomotive Simulators ............................................................................. 27 1.20 Amtrak In-Cab Voice Recording ............................................................................ 27 1.21 Train Control Systems in Other Countries ............................................................ 28 1.22 VIA 92 Locomotive and Coach Information ......................................................... 29 1.23 VIA Locomotive Rebuild ......................................................................................... 29 1.24 Regulatory Requirements for Locomotive Crashworthiness ............................. 31 1.24.1 Locomotive Safety Rules .............................................................................................. 32 1.24.2 Locomotive Crashworthiness Standards – Association of American Railroads Manual of Standards and Recommended Practices Standard S-580 ....... 33 1.24.3 Association of American Railroads Manual of Standards and Recommended Practices S-5506 – Requirements for Locomotive Fuel Tanks ............................. 35 1.25 American Public Transit Association Standards .................................................. 36 1.25.1 Locomotive Cab Corner Posts ................................................................................. 36 1.25.2 American Public Transit Association Requirements for Locomotive Cab Rollover Protection ................................................................................................... 37 1.26 Crashworthiness Assessment of Locomotive VIA 6444 ...................................... 37 1.26.1 VIA 6444 – Cab Corner Posts .................................................................................. 37 1.26.2 VIA 6444 – Cab Rollover Protection ....................................................................... 37 1.26.3 VIA 6444 – Fuel Tank ............................................................................................... 38 1.26.4 VIA 6444 – Truck Securement ................................................................................. 38 1.26.5 VIA 6444 – Crew Restraint ...................................................................................... 38 1.27 Regulatory Requirements for Passenger Coach Crashworthiness .................... 38 1.28 Crashworthiness Assessment of VIA Light, Rapid, Comfortable Coaches ...... 39 1.28.1 VIA Light, Rapid, Comfortable Coach Collision Posts ....................................... 39