CHAPTER III
THE TRANSPORTATION SAFETY BOARD OF CANADA
A. The Work of The Board
B. Assistance to Families of Victims
CHAPTER IV
RAILWAY SAFETY
A. Safety Issues
B. Rail Safety Issues
in The United States and France
CHAPTER III
THE TRANSPORTATION SAFETY BOARD OF CANADA
The Subcommittee and the Special Committee on Transportation Safety and Security met with the representatives of the Transportation Safety Board of Canada. The Subcommittee was privileged to meet with the Chairman and Executive Director of the United States National Transportation Safety Board both in Washington D.C. and in meetings at the World Conference on Transportation Safety. In addition, in Paris, Senators met with the Executive Director of the office of Air Accident Investigation.
Because of the importance that the Senate Special Committee on Transportation Safety and Security attributes to the work of the Transportation Safety Board, its Executive Director, Ken Johnson, appeared as our first witness. In his appearance before the Subcommittee, he explained the purpose and operation of the board:
The first matter is the question of why the board was established. Simply, it was established to advance transportation safety and to increase and maintain public confidence in the transportation safety system by ensuring that there was in place some sort of organization that was independent, that reported publicly, that was free of conflicts of interest, and that was separate from the regulatory agencies.
It was also very much, I think, the intent of Parliament to ensure that accidents in the four federally regulated modes of transportation would be treated consistently and that Canadians, when they read a report regarding an aviation or marine or pipeline accident, would be able to look at that report and have confidence that each problem was analyzed with the same degree of independence, the same degree of technical skill, and the same degree of objectivity. (1:34)
Mr. Johnson also explained that in order to have as complete a report as possible and to ensure there was no misunderstanding of the evidence given to the Board preliminary draft reports were circulated to all parties for comment before they were put into final form. He stated that "this ensures accuracy and provides an element of procedural fairness". (1:40)
Witnesses who addressed the work of the Transportation Safety Board have criticised it for four main reasons:
- there is no consistency or criteria as to what it will or will not investigate;
- it takes too long for it to render decisions;
- the practice of seeking comments from all interested parties on its draft reports slows down the process and could lead to helpful information being omitted from the final, publicly circulated draft; and
- it is not mandatory for Transport Canada to implement the recommendations of the Transportation Safety Board.
While we recognise the concerns expressed by these witnesses, we have gained an understanding through our hearings of the enormity of the task facing the Transportation Safety Board every time there is an accident or occurrence which the Board deems necessary to investigate. We believe the Board needs flexibility to choose when it will perform investigations and the thoroughness with which its work is undertaken. In addition, the complexity of the accident often inhibits the release of early reports.
We note that from the time of the establishment of the Subcommittee, the Safety Board has rendered numerous interim reports and findings. This has been quite instructive when dealing with matters of safety that need to be addressed quickly.
With regard to recommendations being adopted by the government, there seems to be a difference of opinion among different boards. The United States Board is especially proud of its record for the adoption of its recommendations by government. On the other hand, the Executive Director of the Office of Air Accident Investigation in France believes that the Safety Board should not become a political advocate for the adoption of its recommendations as it may compromise the independence of the office.
The Canadian Transportation Safety Board has an enviable record for the implementation of its recommendations by government. However, we believe that there should be a requirement placed on government to respond to each of the recommendations of the Safety Board by tabling its response in both Houses of Parliament. This would provide both the Canadian public and the Safety Board with information as to why recommendations have or have not been adopted.
In Washington D.C., the Subcommittee met with representatives of the United States Transportation Safety Board. These representatives outlined some of the differences between that Board and the Transportation Safety Board in Canada.
In the United States, NTSB members are an integral part of the investigative team. There is also an aggressive public follow-up by the NTSB to ensure the implementation of its recommendations. They are quite willing to make interim recommendations prior to the issuance of the final report. There is also provision made for dissenting views to be contained in the final Report of the NTSB.
As stated above, the United States Board prides itself on its record for implementation of its recommendations; eighty three percent have been adopted. Each transportation mode within the jurisdiction of that Board has a separate office with engineering support services. They also rely on the parties affected by the accident to participate and help in the investigation. Their focus during investigation and in making recommendations is to prevent the next accident.
This focus is the same for the office of Air Accident Investigation in France, in that "the only objective of an investigation is the prevention of accidents". The main problem faced by this office is the length of time it takes to render reports on accidents. While this office makes recommendations, they are not binding.
We would like to see the role of the Board expanded so that in addition to air, marine, rail and pipeline accidents it would also be responsible for the investigation of highway accidents especially those involving large transport trucks. We believe the lack of investigation of these accidents by this Board represents a serious deficiency in Canada’s approach to transportation safety. Data compiled through the research conducted by this Board could be extremely helpful in preventing future highway accidents.
The Special Committee plans to meet with representatives of the Transportation Safety Board on future occasions as we believe recommendations for improvement in the safe operation of transportation in Canada should be discussed from time to time with the Board.
One matter that the Special Committee will be pursuing in the months to come is a proposal that the Safety Board be given jurisdiction to deal with the investigation of military transportation accidents. We wish to discuss this proposal with representatives of the Department of the National Defence and with other experts in safety investigation.
B. Assistance to Families of Victims
In September 1998, the Chairman of the Special Committee and the Committee’s Researcher from the Library of Parliament, John Christopher, attended a symposium in Washington D.C. hosted by the National Transportation Safety Board on the subject of family and victims assistance relating to transportation disasters. The Board is the lead U.S. federal agency, designated by the Aviation Disaster Family Assistance Act, in addressing the needs and concerns of aviation accident victims and their families, when the accident occurs inside the United States.
The U.S. State Department is the lead federal agency with respect to the assistance to families of U.S. citizen victims in all instances involving an aviation disaster outside the United States. There is a Memorandum of Understanding between the State Department and the NTSB setting the responsibilities and procedures to be followed in an aviation disaster outside the United States. This is to ensure that there is no unnecessary duplication and to streamline efforts to assist families.
In its lead role, the Department notifies the families when an aviation accident occurs outside the United States and assists in making arrangements after the death of an American citizen abroad. It also helps in ensuring ease of travel for families who wish to travel to the scene of the accident.
What has evolved over the past few years, is a greater degree of co-ordination and co-operation among all the stakeholders in a foreign aviation incident. The State Department as the lead agency, co-ordinates efforts with the NTSB, the airlines and foreign governments to ensure that families are provided with the best possible assistance.
Critical to the success of assisting families is the need for highly trained trauma personnel to be in place. Airlines must be prepared to invest the time and money in training their employees for this task. As well, the efforts of all those willing to offer help must be co-ordinated. This role is given by statute to the Safety Board.
Serious problems arose after the TWA flight 800 tragedy and some other aviation disasters because of the slowness in releasing the passenger list/manifest to the families of the victims. Family members often complained of phone calls not answered or returned and the general lack of information surrounding the victims of the aviation disaster. Because of this, the Department of Transport adopted the Enhanced Passenger Manifest Rule that requires all US and foreign airlines to collect the full name of each US citizen travelling on fights to and from the United States and to request a contact name and phone number from those passengers. This rule came into effect on October 1, 1998, and it is hoped that it will make the compilation of passenger lists and notification of next of kin a more efficient and humane process.
In conjunction with this, the airlines are developing more sophisticated systems for managing information regarding customers and family members affected by an aviation disaster. Continental Airlines, for example, has developed the Incident Centre Activity Reporting Database (ICARE Database) to maintain customer information regarding the customer’s name, next of kin, physical description of the customer, list of hospitals where customers have been taken, and the name of the family escort assigned to the customer and/or family member. In addition, the names of the emergency response volunteers are maintained in the database to ensure the best match between the volunteer and the survivor/ family member (e.g. language, religion). Such a database tool is designed to manage information received about an aviation disaster in order to better assist in the provision of prompt and compassionate services to family members.
What is critical to the success of any family assistance program is preparedness. Without a proper response plan and highly trained personnel in place, families of victims would not receive adequate assistance after an aviation disaster. The federal government in the United States has taken the initiative and have moved to have American air carriers put such a plan in motion. How effective they are will depend upon how much time, money and effort the airlines are willing to devote to such an enterprise.
Two challenges face the future implementation of the victim and family assistance program.
The first is: how does one ensure that smaller air carriers with limited financial resources and a small employee base will be able to develop an adequate family assistance program?
And second: with the airline business being a truly global industry, how does one get the world airline community to adopt similar programs to deal with aviation disasters?
These two challenges will have to be addressed if the goal of providing prompt and compassionate assistance to families after an aviation accident is to be attained.
We believe the government of Canada should adopt a similar procedure regarding airlines that operate within Canada.
The rail industry in Canada has undergone profound change in the last few years. The introduction of highly sophisticated computers and other high-tech equipment and pressures to be financially competitive have combined resulting in a downsized labour force. In addition, Canadian National Railway has been privatized and a number of Short Line Railways have emerged.
Tables 1 and 2 illustrate rail accidents in a comparative form over the past ten years. It should be noted that the Transportation Safety Board changed its reporting requirements in 1992. The new regulations eliminated the monetary damage reporting threshold. All main track and non main track accidents became reportable as long as the damage to the rolling stock rendered it unsafe. Previously, derailments and collisions were only reportable if casualties or dangerous goods were involved, or, for main track accidents, if there was property damage in excess of the monetary threshold.
Now all crossing accidents are reportable. Previously, all public highway crossing accidents were reported, whereas accidents at farm and private crossings were reported only if they involved a casualty, dangerous goods or derailment resulting in property damage in excess of the monetary threshold.
Table 1 illustrates the rail accident rate and explains that if the reporting requirements had remained constant, the rail accident rate, with the exception of 1996, has remained virtually constant for many years. Table 2 illustrates the numbers of various types of rail accidents in a comparative context over the last five years.
Ron Jackson, Assistant Deputy Minster, Safety and Security Group Federal, Transport Canada told the Subcommittee that the main safety related problems in the rail industry were safety at level crossings, trespassing accidents and main track derailments. Statistics indicate increases in all three types of accidents, but there has been a notable increase in main track derailments in recent years. From 1993 to 1997 there has been a sizeable increase in main track derailments from 126 in 1993 to 177 in 1997.
At this time, the Special Committee is not satisfied with the reasons received by the Subcommittee for the increase in main track derailments. It is not sufficient to answer, as representatives from CP Rail did, that weather conditions have been significantly worse in recent winters than before. Railways have had to operate in winter in this country since the beginning of rail travel and we do not accept this reasoning.
After reading the Transportation Safety Board report of the main track collision of a Canadian National train and an uncontrolled movement of 20 rail cars near Edson, Alberta, we are concerned with the possible lack of importance placed on safety by rail carriers. We have also read the Board report into the Via Train derailment west of Biggar, Saskatchewan. In relation the derailment at Biggar, the Safety Board states:
Examination of the wreckage, post-accident interviews with passengers, train crews and On Train Service Personnel, and a survey of passengers safety features of other Via Train operations have confirmed the presence of a number of significant shortcomings in current passenger safety practices.
(TBS Reflection, Winter 1998, p.8)
We wish to review carefully with all rail carriers their safety preparedness and the work they have done subsequent to these two accidents to correct the deficiencies set out by the Transportation Safety Board.
We note that the Government has tabled amendments to the Railway Safety Act in the House of Commons. These amendments are designed to require railways to implement safety management systems and, among other matters, to clarify and strengthen the powers of railway safety inspectors. We look forward to discussing this proposed legislation with the rail industry and Transport Canada.
B. Rail Safety Issues in The United States and France
i) United States
The meetings held by the Subcommittee with representatives of the Federal Railroad Administration, the Association of American Railroads and Amtrak in Washington D.C. revealed concerns about safety issues similar to those encountered in Canada. The Federal Railroad Administration focuses its attention on nine areas associated with safety:
- Human factors (fatigue)
- Rolling Stock defects (brakes)
- Track Research (metal fatigue, reactions to extreme heat and cold)
- Train Systems
- Train Control Systems
- Grade Crossing Improvements (human factors, control device)
- Passenger Train Safety (car strength, seat configuration)
- High Speed Rail (safety systems)
- Hazardous Materials Research
The Association of American Railroads believes their biggest safety hazards are at grade crossings and with trespassers. They have instituted a program to make all railroad people aware of the cost of accidents and the cost of settlements. In their opinion, deregulation has brought about greater investment in track and equipment and an incentive for railroads to solve their own problems.
Amtrak believes the future of train travel lies in high speed trains and related issues such as a dedicated corridor, protecting trains at crossings and from trespassers. Amtrak has its own police force of 350 persons who not only protect the trains, but also visit schools and community groups to publicize safety issues.
ii) France
When the Subcommittee was in London, England, it took the chunnel to Brussels. From Brussels it travelled by high speed rail to Paris and toured the repair and maintenance facility owned and operated by French High Speed Railroad. High speed rail is possible in France because of a dedicated track. There are no level crossings and the track is kept clear of trespassers by fences and tunnels for animals. Travelling at 300 km/hr the train is too fast to use a normal signal system so a series of computer terminals is in place every 500 meters in the track that can signal to stop the train. The rails are checked by eye and by computer. There is also a black box on every train and hot box detectors on the track. In France there is no investigation board for rail accidents. If an investigation is warranted , the government can appoint a Special Commission.
The Subcommittee was informed that the French Government mandates the railroad to implement and maintain a safety program. There is no government rail inspection in France. It is a self regulating system. The major objective of the passenger security system is to reassure and protect passengers and employees from the threat of violence and destruction of equipment. The railroad has 1500 agents who deal with passenger security. While they do not have the full powers of a local police officer or the national police, they can intervene and apprehend suspects if they see or suspect a crime is being committed.
There is concern about terrorist attacks on the high-speed rail lines as there has been one such failed attack. The rail company believes that in the future it will rely on automatic equipment to check passengers to ensure safety and security. More emphasis will be placed on automated systems than on the human element in screening passengers.
Problems with accidents at level crossings in France are as prevalent as they are in Canada, the Subcommittee was told. To improve safety at level crossings the rail company has:
- lengthened the warning time for the lowering of the gates;
- b) conducted research into different warning systems – intensity and placement of warning lights and use of variable signalling;
- c) improved education programs in the schools and elsewhere as to the dangers of level crossings; and
- d) used digital video equipment to monitor level crossings and driver behaviour.
The Subcommittee was told that the combination of these efforts has improved safety at level crossings.
The safety issues raised in the travels of the Subcommittee are similar to those encountered in Canada. The Special Committee will pursue these issues throughout its mandate, emphasizing the need to concentrate on safety at the workstation. That is, work should be conducted in a safe environment focusing on the interface between those charged with responsibility of safe operation of the equipment and the equipment itself.
The business decisions of the two Class 1 Railways to abandon significant stretches of track in various areas of Canada have given rise to an increase of short line railways. The Subcommittee was pleased to hear from Peter McCarron, Regional General Manager for Rail Tex Inc. and General Manager of two short line railways when it was in Halifax. The Subcommittee was impressed by the commitment of Rail Tex to safety as well as its commitment to training employees for safety sensitive positions they may occupy.
Although short line railways are not new in Canada, it is our belief that they will grow in number in next few years. Their development should be monitored both by provincial governments and by Transport Canada to ensure the high standards that they have initially set for themselves are maintained.
While short line railways are provincially regulated, we understand the provincial requirements are similar to those which affect the Class 1 Railways. The Special Committee supports this degree of regulation of short line railroads.
TABLE I
Accident Rate - Rail
(Number of accidents per million train-miles)
Under previous TSB reporting criteria (prior to August 1992), a number of main-track derailments, non main-track collisions and derailments were not reportable thus accounting for some of the increases since 1992.
TABLE II
Accidents - Rail