1) The TSB presentation discusses uncontrolled train movements and failures to follow railway signal indications. It notes that despite efforts, not enough has been done to significantly reduce uncontrolled movements. 2) The TSB has made several recommendations to Transport Canada to require additional physical defenses and automatic parking brakes to prevent runaway equipment and reduce uncontrolled movements. Current assessments of recommendations are partly satisfactory. 3) Failures to follow signals have led to numerous derailments and injuries over the past decades. The TSB has repeatedly recommended physical fail-safe controls be implemented, beginning with high-speed corridors, but action is still needed according to the presentation.

1. Faye Ackermans – Member, Transportation Safety Board of Canada
TSB presentation – Crude by Rail 2022

2. About the TSB
• Independent agency, created in 1990 to advance transportation safety in
Canada.
• Conduct investigations in air, marine, pipeline and rail.
• Does not attribute blame or determine civil or criminal liability.
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3. Risk: Environmental & Reputational
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4. Watchlist 2020
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5. 5
3 Types of uncontrolled
movements
1. Insufficient securement of rolling stock when left unattended
2. Rail cars switched without using the air brake system
3. Loss of control with available brakes

6. Uncontrolled movements
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7. 7
Uncontrolled movements
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8. TSB recommendation R14-04
The TSB recommends that Transport Canada require Canadian railways to put in
place additional physical defences to prevent runaway equipment.
Current assessment: Satisfactory in part
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9. Safety Concern - 2018
• Despite numerous efforts from Transport Canada and rail industry to
change operating rules and practices, not enough has been done to
significantly reduce the number of uncontrolled movements.
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10. TSB recommendation R20-01
The TSB recommends that Transport Canada work with the railway industry and
its labour representatives to identify the underlying causes of uncontrolled
movements that occur while switching without air, and develop and implement
strategies and/or regulatory requirements to reduce their frequency.
Current assessment: Satisfactory in part
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11. R19C0015 – Field, B.C.
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12. TSB recommendation R22-01
The TSB recommends that Transport Canada establish enhanced test standards
and requirements for time-based maintenance of brake cylinders on freight cars
operating on steep descending grades in cold ambient temperatures.
Current assessment: Not yet assessed
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13. TSB recommendation R22-02
The TSB recommends that Transport Canada require Canadian freight railways to
develop and implement a schedule for the installation of automatic parking
brakes on freight cars, prioritizing the retrofit of cars used in bulk commodity
unit trains in mountain grade territory.
Current assessment: Not yet assessed
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14. Following railway signal indications
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15. Occurrences per million MTM
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16. Following railway signal indications
From 1990 to 2021, 80 occurrences could have been prevented
using a physical fail-safe defence. This resulted in:
53 DERAILMENTS
530 DERAILED ROLLING STOCK
41 TRAIN COLLISIONS
35 RESULTED IN A DERAILMENT
EIGHT FATALITIES
318 INJURIES
TO EMPLOYEES AND
PASSENGERS
35 occurrences/year from 2004-2021. Three recommendations:
2000 | R00-04
BACKUP SAFETY DEFENCES
DORMANT AS OF 2021
2013 | R13-01
IMPLEMENT PHYSICAL FAIL-SAFE
CONTROLS
2022 | R22-04
EXPEDITE PHYSICAL FAIL-SAFE
CONTROLS ON KEY ROUTES*
*Expansion of 2013 | R13-01
40% of
Canada’s
main line
trackage is a
key route.
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17. TSB recommendation R00-04
The TSB recommends that Transport Canada and the railway industry implement
additional backup safety defences to help ensure that signal indications are
consistently recognized and followed.
Current assessment: Satisfactory in part
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18. TSB recommendation R13-01
The TSB recommends that Transport Canada require major Canadian passenger
and freight railways implement physical fail-safe train controls, beginning with
Canada's high-speed rail corridors.
Current assessment: Satisfactory in part
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19. TSB recommendation R22-04
The TSB recommends that Transport Canada require major Canadian railways to
expedite the implementation of physical fail-safe train controls on Canada’s
high-speed rail corridors and on all key routes.
Current assessment: Satisfactory in part
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20. Action is needed
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