2014 TSB Recommendations & TC Responses

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TSB Railway Investigation (R13D0054):

TSB Recommendation R14-01

From the TSB Initial Railway Safety Recommendations

The Board recommends that:

“The Department of Transport and the Pipeline and Hazardous Materials Safety Administration require that all Class 111 tank cars used to transport flammable liquids meet enhanced protection standards that significantly reduce the risk of product loss when these cars are involved in accidents.” (R14-01)

Transport Canada’s Response R14-01

(signed by the Minister on April 23, 2014)

On addressing DOT-111 tank car vulnerabilities (R14-01) Transport Canada will immediately and unilaterally prohibit the use of the highest risk group of older DOT-111 tanks cars.  A Protective Direction under subsection 32(1) of the Transportation of Dangerous Goods Act, 1992, will be issued on April 23, 2014 and will prohibit the use of those tank cars that have no continuous reinforcement of their bottom shell for carrying any Class 3 flammable liquid, including crude oil and ethanol.  Industry will have thirty days from this date to fully comply.

Transport Canada will require that all pre-CPC 1232/TP 14877 tank cars used for the transportation of crude oil and ethanol be phased out of service or refitted within three years.

In the interim, the train routing restrictions outlined below are designed to reduce these risks.  As North America’s integrated market necessitates close cooperation, it is important that in the longer term, Canada harmonizes with the U.S. to the greatest extent possible.  However, in this area, Canada will move more aggressively to address the safety concerns of Canadians.  The Departmental objective will be to meet or exceed any new U.S. standards, so officials will continue to work closely to harmonize and accelerate the technical work required to develop future, more stringent tank car construction and re-fit standards to further enhance the safety of Canadians. 

In addition, to ensure that the safety standard for these tank cars continues to be enhanced, to address the immediate safety issues, and as recommended by the Transportation of Dangerous Goods General Policy Advisory Council Working Group on Means of Containment, the Department will proceed expeditiously with Canada Gazette, Part II publication of 13 updated means of containment standards, including the 2011 standard for DOT-111 tank cars.  Canada introduced this revised DOT-111 tank car standard for consultation on January 11, 2014, proposing the requirement of end-of-tank protection, thicker and more impact-resistant steel tanks, and protected top fittings, to improve accident performance.

TSB Recommendation R14-02

From the TSB Initial Railway Safety Recommendations

The Board recommends that:

“The Department of Transport set stringent criteria for the operation of trains carrying dangerous goods, and require railway companies to conduct route planning and analysis as well as perform periodic risk assessments to ensure that risk control measures work.” (R14-02)

Transport Canada’s Response R14-02

(signed by the Minister on April 23, 2014)

On addressing route planning and analysis for trains carrying dangerous goods (R14-02), Transport Canada will issue an Emergency Directive under section 33 of the Railway Safety Act that will require railways carrying dangerous goods to implement minimum key operating practices to address the Board’s recommendation and manage the immediate safety issue, including speed restrictions for trains carrying dangerous goods, expansion of inspection requirements on restricted rail routes, and the completion of risk assessments for rail transportation routes.  These requirements are built upon voluntary approaches in the U.S., but also take into account differences in Canadian operations and areas where Canadian requirements are already more stringent.

The Emergency Directive would be in force for six months and may need to be renewed to reflect further consultation with stakeholders, including the Federation of Canadian Municipalities, unions and consideration of any additional U.S. requirements that may be established.  Any further safety advisories or recommendations in this area from the TSB will also need to be taken into account.

At the same time, Transport Canada will also issue a Ministerial Order under section 19 of the Railway Safety Act requiring railways carrying dangerous goods to formulate and submit for approval new rules based on these operating practices, to further improve the safe transportation of dangerous goods by rail in the long term.

TSB Recommendation R14-03

From the TSB Initial Railway Safety Recommendations

The Board recommends that:

“At a minimum, the Department of Transport require emergency response assistance plans for the transportation of large volumes of liquid hydrocarbons.” (R14-03)

Transport Canada’s Response R14-03

(signed by the Minister on April 23, 2014)

On addressing requirements for Emergency Response Assistance Plans (R14-03), Transport Canada will immediately issue a Protective Direction under the Transportation of Dangerous Goods Act, 1992, effective April 23, 2014, to require shippers to develop Emergency Response Assistance Plans (ERAPs) for specific higher-risk hydrocarbons (petroleum products - crude oil, gasoline, diesel, aviation fuel) and ethanol for any train with one or more loaded tank cars of these products. 

The Department will also announce the establishment of an Emergency Response Planning Task Force with members from key partners and stakeholders.  This group will provide a dedicated forum with support from a team of experts to respond to recommendations of the Transportation of Dangerous Goods General Policy Advisory Council Working Group on Emergency Response Assistance Plan requirements.  The Task Force will focus on ERAP activation processes, support the development of co-operative industry approaches to ERAP development and the development of information sharing protocols, and promote the development of unified incident command structures.  The Task Force will also review and provide advice on the possible expansion of Emergency Response Assistance Plan requirements to other Class 3 flammable liquids.



Canadians will always remember what happened in Lac-Mégantic on that tragic night in July 2013. The victims and residents of Lac-Mégantic continue to be foremost in our minds as we, as a government, take further action to improve railway safety for all Canadians.

Following the Lac-Mégantic tragedy, Transport Canada's work has been driven by three key objectives. First, and most importantly, Prevention – keeping the trains on the track. Second, Effective Response – enhancing the safety of tank cars that carry crude oil, which will reduce the impacts of a derailment; enhancing emergency response requirements for shippers and support firefighters' and other first responders' need for information, communications and coordination. Finally, Transport Canada has launched a review of the Liability and Compensation regime for federally regulated railways.

Following the events of July 2013, Transport Canada responded to early advisories from the TSB, and took immediate action by establishing a two-person minimum for locomotive crews on trains carrying dangerous goods, and by imposing stricter rules for securing unattended trains.

In my response of April 23, 2014, to three interim recommendations from the TSB, I highlighted the additional measures taken by Transport Canada, including:

 Removing the least crash-resistant DOT-111 tank cars from dangerous goods service (completed as of May 23, 2014);

 Introducing new safety standards for DOT-111 tank cars (published in Canada Gazette, Part II, on July 2, 2014), and requiring those that do not meet the new standards be phased out by May 1, 2017;

 Requiring railway companies to slow key or certain trains transporting dangerous goods and introduce other key operating procedures as of April 23, 2014;

 Ensuring route planning and risk analysis for railways transporting dangerous goods was being conducted and has now become a standard practice. These risk assessments will be reviewed this winter by Rail Safety experts to identify any additional safety actions that may be useful to further enhance safety, such as consideration of appropriate Class of track for key routes;

 Requiring emergency response plans for even a single tank car carrying crude oil, gasoline, diesel, aviation fuel, and ethanol. Emergency Response Assistance Plans (ERAPs) have been reviewed, approved and as of September 20, 2014, there are now expert teams ready to respond to any petroleum spill if needed; and

 Creating a task force that meets regularly and brings municipalities, first responders, railways and shippers together to strengthen emergency response capacity across the country (in place).

I have also initiated the following regulatory measures to strengthen the safety of the railway system and the carriage of dangerous goods:

 On February 8, 2014, proposed Grade Crossings Regulations were published in Canada Gazette, Part I, that would establish new safety standards for federally regulated grade crossings;

 On March 15, 2014, proposed Railways Operating Certificate Regulations were published in Canada Gazette, Part I, that would require railway companies to hold a valid Railway Operating Certificate in order to operate on federally regulated railways in Canada;

 On July 2, 2014, published in Canada Gazette, Part II, regulations updating means of containment standards, including those for DOT-111 tank cars, and introducing a requirement for proof of classification of dangerous goods;

 Also on July 2, 2014, published in Canada Gazette, Part II, regulations amending the regulations on safety marks for dangerous goods;

On July 5, 2014, proposed amendments to the Transportation Information Regulationswere publishedin Canada Gazette, Part I, that would require Class I and Class II rail carriers to report leading indicator data to Transport Canada;

 On July 5, 2014, proposed new Railway Safety Management System Regulations were published in Canada Gazette, Part I, that would modernize existing requirements and help railways better identify and manage safety risks;

 On July 18, 2014, posted a regulatory proposal to phase out DOT-111 tank cars and mandate a more robust tank car standard specifically designed for the transport of flammable liquids called the TC-140; and

 On October 22, 2014, the Railway Safety Administrative Monetary Penalties Regulations, were published in Canada Gazette, Part II, which will come into force on April 1, 2015 and will introduce fines as an additional enforcement tool.

Transport Canada is also recruiting additional staff in rail safety and transportation of dangerous goods to provide for a three to five year audit cycle of safety management systems for rail and so that high risk transportation of dangerous goods sites are inspected every three to five years, or more frequently if required.

At the same time, the department has enhanced inspections, documentation and follow-up for railway safety and the transport of dangerous goods, including more frequent inspections at sites where petroleum products are transferred from one mode of transport to another (e.g., from rail to truck). Transport Canada has also proposed fines, mandatory railway operating certificates, and tough new regulations for reporting on classification and testing of dangerous goods.

I have carefully reviewed the Board's final report and recommendations, and informed by extensive discussion with U.S. officials, key stakeholders, the Federation of Canadian Municipalities, and subject matter experts, Transport Canada has developed a coordinated plan that is aggressive, yet achievable. This plan will complement and build upon the Department's previous efforts to further strengthen railway safety. In implementing these actions, the Department's objective remains to address the areas of highest risk to the public and to reinforce the Government of Canada's commitment to the safety of all Canadians.

While this response is focused on the TSB's specific recommendations and Safety Advisories related to the Lac-Mégantic tragedy, Transport Canada will take additional steps this fall and winter related to further enhancing railway safety in Canada, including finalizing regulations and issuing new rules, establishing research projects and ensuring enhanced oversight of these measures.

Transportation Safety Board Recommendation R14-04

"The Department of Transport require Canadian railways to put in place additional physical defences to prevent runaway equipment."

Transport Canada will fully implement this recommendation.

Actions Already Taken: As noted, Transport Canada previously issued an Emergency Directive on July 23, 2013, requiring the securement of unattended trains carrying dangerous goods and established a minimum number of two crew members required for operating a train carrying dangerous goods. Transport Canada further issued a Ministerial Order on July 23, 2013, requiring companies to formulate new rules or revise existing rules to ensure the provisions of the Emergency Directive were addressed permanently.

The department subsequently approved updated Canadian Rail Operating Rules, which encompass more stringent requirements for unattended equipment. Transport Canada has conducted targeted inspections in these areas and found full compliance with the revised rules.

Transport Canada has also published the Railway Safety Administrative Monetary Penalties Regulations in Canada Gazette, Part II, which will come into force April 1, 2015 and will provide the department with an additional enforcement tool to fine railways for contraventions of the Canadian Rail Operating Rules and other rules and regulations made under the Railway Safety Act.

On-going and Further Action: Today, in the interest of ensuring the continued safety and security of railway transportation, Transport Canada issued an Emergency Directive requiring railways to improve their operating practices with respect to securement of railway equipment. Specifically, railways are ordered to use a standardized handbrake application table based largely on TSB past studies and our experts’ calculations, and clear mandatory handbrake testing processes. The Emergency Directive will also immediately require additional physical securement measures such as permanent derails, mechanical emergency devices, mechanical lock parking devices (once approved by the American Association of Railroads), Reset Safety Controls (RSC), moving the equipment to a track protected with derails or bowled terrain verified by survey or track profile, or other appropriate physical securement device accepted by the department to be in use on all trains left unattended on main track or in other high risk locations. Transport Canada will also develop monitoring plans to ensure operators adhere to the outlined requirements.

Transport Canada has also issued a Section 19 Ministerial Order to address the provisions of the aforementioned Emergency Directive permanently. The Ministerial Order will include development of additional provisions around the application of other secondary physical defences as appropriate (which may include requirements for multiple brake systems), and require that the rules be based on an assessment of safety and security risks.

In addition to issuing today's Emergency Directive and Ministerial Order, pursuant to section 36 of the Railway Safety Act, the department is ordering railway companies and local railway companies to file with the department, within 14 days of receipt of the letter, a copy of their company instructions implementing the requirements of this Emergency Directive. These instructions include but are not limited to Operating bulletins, Summary bulletins, General Operating Instructions and Special instructions.

Transport Canada will closely monitor the implementation of this Emergency Directive and will continue to work with the railway industry to identify and address any possible residual risks well in advance of the Rule submission deadline.  Should any unforeseen vulnerabilities be identified that are not addressed sufficiently in the Rule proposed by industry, TC would issue an amended Emergency Directive to immediately address any such issues.

Transport Canada’s Rail Safety Oversight Program includes conducting audits and inspections. These monitoring activities are planned annually, reviewed regularly, and revised as required using evidence-based risk indicators. Common risk indicators include accident investigations, safety records, results of previous inspections, and safety audits. Transport Canada takes appropriate enforcement action as required for any instances of non-compliance and, as of April 1, 2015, this will also include the ability to issue fines in the event of contraventions to the Railway Safety Act, and its rules and regulations.

Transport Canada will also hire additional specialized staff to strengthen oversight related to train securement and to monitor compliance with these additional levels of defence to prevent runaways. Rail Safety personnel will:

  • Develop and implement targeted oversight requirements related to new rule(s) focused directly on securing trains; and
  • Identify and challenge any technical gaps in railways' risk assessments and provide technical advice/direction on new securement rules, special instructions, and daily bulletins/safety issues identified by inspectors in the field.

Recognizing that technological solutions may provide for additional improvements to mitigate risks of runaway trains in the coming years, Transport Canada will intensify its collaboration with industry through the Railway Research Advisory Board to help lead the implementation of technologies to enhance railway safety. The department has further strengthened its collaboration with U.S. counterparts via a July 2014 Memorandum of Cooperation signed with the U.S. Federal Railroad.

Administration to facilitate further information exchange, and to help in identifying technical cooperation projects.Transport Canada will also initiate a strategic research initiative program to investigate alternatives that would enhance brake system performance, focusing on braking systems and train securement technologies. Such technologies will be developed under, but not limited to, the following themes: remote brake application systems, wayside temperature detectors, and handbrake monitoring devices.

Through these measures, Transport Canada will provide for multiple layers of defence for securement to prevent runaway trains.

Transportation Safety Board Recommendation R14-05

"The Department of Transport audit the safety management systems of railways in sufficient depth and frequency to confirm that the required processes are effective and that corrective actions are implemented to improve safety."

Transport Canada will fully implement this recommendation.

Actions Already Taken: Transport Canada has developed a comprehensive Management Action Plan to respond to the November 2013 Auditor General’s findings on oversight of railway safety, including Safety Management Systems (SMS). This plan is being implemented in full. Transport Canada is also currently developing an enhanced SMS Compliance Assessment Tool based on international standards that will be completed in February 2015.

New Railway Safety Management Systems Regulations have been proposed and a 90 day comment period in Canada Gazette, Part I, has just closed. The proposed changes, which include requirements for railway companies to conduct risk assessments of significant changes to their operations and to submit them to Transport Canada, will also improve how railway companies develop, implement, and assess their SMS, and include new or updated processes to:

  • Require railway companies to implement a non-punitive reporting system for contraventions to the Railway Safety Act;
  • Analyze data and trends to identify safety concerns;
  • Manage organizational knowledge so that employees can perform their duties more safely;
  • Improve work scheduling to prevent employee fatigue; and
  • Create annual safety targets and select appropriate initiatives to reach those targets.

As noted above, the Railway Safety Administrative Monetary Penalties Regulations, published in Canada Gazette, Part II, will introduce fines as an additional enforcement tool to improve railway safety. Under the authority of the Railway Safety Act, as of April 1, 2015 Transport Canada can fine railways for contraventions of the Act, or regulations and rules made under the Act. Future revisions to the Administrative Monetary Penalties Regulations would include provisions of new recent regulations, including the proposed Safety Management System Regulations.

As well, the Railway Operating Certificate Regulations, pre-published in Canada Gazette, Part I, would provide the department with the authority to suspend or cancel the Railway Operating Certificate for non-compliance with safety requirements or SMS regulations.

As recommended by the Auditor General, Transport Canada has undertaken a review of its risk-based oversight program to assess the number of audits and inspections required. The 2014-15 risk-based business planning process was completed using a revised methodology. As a result, the number of planned inspections remained relatively stable; however, the number of planned audits has increased. Additional funding has been provided to augment the department's railway audit capacity.

Transport Canada continues to address Auditor General recommendations.

On-going and Further Action: In addition to these steps already taken, Transport Canada has revised its inspection and audit plans to allow for increased frequency of SMS audits, and allowing for audits to be completed on a three to five year cycle.

Transport Canada will also recruit specialized auditors in each region to provide guidance to inspectors on conducting SMS audits and on the elements of an effective SMS. The department is also developing training for auditors on several key factors of the new SMS regulations, including the revised audit requirements, more stringent follow-up procedures and the use of new enforcement provisions (including Administrative Monetary Penalties). This will include clear provisions for effective action to be taken for any non-compliance or on-going safety issues.

We will also continue to develop enhanced inspector tools and industry guidance. We will conduct more rigorous review of risk assessments and follow-up on mitigations. Railway risk information will be incorporated into industry risk profiles which will guide future safety policy development as well as priorities for inspections and audits.

Transport Canada will ensure that information on risks from each region and directorate is shared with relevant internal stakeholders and that new safety leading indicator data is incorporated into departmental systems to ensure the department stays ahead of trends and relevant operational changes in the industry. A national review process to closely monitor all operators with compliance or on-going safety issues has also been established.

These actions will support Transport Canada in conducting more frequent and thorough SMS audits. Audits will now involve more rigorous review and timely follow-up tied to enforceable penalties for non-compliance.

Transportation Safety Board Advisory 06/14

"Transport Canada may wish to review its monitoring and inspection program to ensure that mined gases and liquids, such as petroleum crude oil, are accurately classified throughout the transportation cycle."

Actions Already Taken: On October 17, 2013, Transport Canada issued Protective Direction No. 31 which required any person importing or offering crude oil for transport to immediately test the classification of the oil and make the results of such testing available to Transport Canada on request. It also requires industry to provide Safety Data Sheets (SDS) for the tested product to the Canadian Transport Emergency Centre (CANUTEC). Until testing is complete, any crude oil being transported is required to be treated as a Class 3 Flammable Liquid Packing Group (PG) I.

Transport Canada has also prioritized inspections at high-risk crude oil transloading facilities. Additionally, for its 2014-2015 inspection schedule, Transport Canada has made verification of required classification documentation a priority.

In April 2014, Transport Canada issued Protective Direction No. 33 which requires shippers of specific flammable liquids, including crude oil, gasoline, diesel, aviation fuel, and ethanol to develop ERAPs. These plans came into operation on September 20, 2014.

In July 2014, a regulatory amendment was approved that provides authority for TDG inspectors to conduct a more thorough verification of classification of dangerous goods. This amendment now means that industry must prove the results of their testing and the validity of their testing methods. During the upcoming year, Transport Canada will verify proper classification documentation as a priority in dangerous goods inspections.

On-going and Further Action: Transport Canada is conducting further research into crude oil properties, behaviour and hazards through the collection and chemical testing of samples at different sources in the supply chain. A Memorandum of Understanding is in place with a provincial government laboratory and special cylinders are being produced to conduct the sampling this fall. Final results of the research are expected in spring 2015, and will later be shared at the United Nations Sub-Committee of Experts on the Transport of Dangerous Goods.

Beyond that, Transport Canada is recruiting engineering and scientific expertise to support our oversight capacity in verifying the proper classification of dangerous goods and to provide technical advice to inspectors in the field.

Based on the results of this research Transport Canada will then develop and conduct a special classification targeted inspection campaign that will focus on specific issues and concerns. The results of this campaign, combined with the research results, will feed into risk analyses which will be used to appropriately adjust our risk-based inspection plan and regulations.

Transport Canada will also increase the frequency of inspections (every one to three years or more frequently if required) of higher risk TDG sites, including annual inspections at high risk crude oil loading facilities using existing enforcement tools when there is non-compliance.

Over the medium term, the Department will further assess the factors contributing to misclassification, and develop and implement a rigorous strategy for targeted corrective actions in these areas through inspection, regulatory amendments, and other courses of action.

Through these actions, Transport Canada is working to ensure dangerous goods are properly classified through accurate product testing and that classification and testing procedures undergo rigorous verification.

Transportation Safety Board Advisory 07/14

"Transport Canada may wish to review the processes and procedures in place to ensure that short line railway employees receive the necessary training to perform their duties in a safe manner."

On-going and Further Action: Transport Canada remains committed to monitoring federal railways and has made training a focus for audits in the upcoming year. In the short term, Transport Canada will issue a Ministerial Order under section 36 of the Railway Safety Act, requiring all railways (including short lines) to submit training plans to the Department for review. Transport Canada is hiring additional staff to monitor and review these training plans and identify any gaps or common concerns.

Subsequently, early in 2015, the Department will carry out targeted audits of short line railways, to determine whether specific gaps remain in industry training plans, along with identifying any other issues.

Based on the audit findings, Transport Canada will determine the need for new requirements for a strengthened training regime to cover such things as approved training plans, qualifications for railway trainers, and training frequency, where required.

Through these actions, Transport Canada will work to ensure Canada has a short line railway workforce that is well-trained to perform their duties in a safe manner.