Safety communications for TSB investigation (R16M0026) into the July 2016 crossing accident in Moncton, New Brunswick
The occurrence
On 27 July 2016, at about 1:43 a.m., a CN freight train travelling westward on the Springhill Subdivision was approaching downtown Moncton, New Brunswick, when it struck and fatally injured a person in a wheelchair at the Robinson street public crossing.
TSB recommendations
The Canadian Transportation Accident Investigation and Safety Board Act specifically provides for the Board to make recommendations to address systemic safety deficiencies posing significant risks to the transportation system and, therefore, warranting the attention of regulators and industry. Under the Act, federal ministers must formally respond to TSB recommendations within 90 days and explain how they have addressed or will address the safety deficiencies.
Recommendation made on 15 February 2018
The issue of pedestrian safety at railway grade crossings is not new, nor is it unique to Canada. It has been the subject of multiple research projects and studies over the past decades, both nationally and internationally.
There are thousands of railway grade crossings in Canada that are regularly used by pedestrians. When a train strikes a person, the likelihood of serious injury or death is high. Although the number of accidents where individuals in wheelchairs have been struck by a train at grade crossings is low, the number of persons in Canada using assistive devices is on the rise. According to Statistics Canada, in 2012, upwards of 2 million Canadian adults were identified as having a mobility disability, with approximately 300 000 using a wheelchair.
Transport Canada's Grade Crossings Regulations (GCR) and associated Grade Crossings Standards (GCS), implemented in 2014, make it mandatory to reduce tolerances for flangeway gap width and depth, as well as for surface wear limits associated with a crossing designated for persons using assistive devices. The GCS also require that the sidewalk crossing surface extend at least 0.5 m past the sidewalk edge. These improvements, which must be implemented by 2021, focus primarily on crossing surface conditions. Beyond those requirements, there are few regulatory provisions that address safety at railway grade crossings for persons using assistive devices.
There are other engineering improvements that can be implemented to further enhance safety at designated crossings. Many of these improvements have been identified by Transport Canada as well as by other jurisdictions, such as the United Kingdom and Australia.
In Transport Canada's Pedestrian Safety at Grade Crossing Guide, various measures to improve pedestrian safety at grade crossings are presented. Although this guide is in draft form and has not been updated since 2007, many of the measures it contains remain relevant. However, their application is largely voluntary and therefore may not be systematically considered and implemented. Unless upgrades to the designated crossings go beyond surface condition improvements as prescribed by the GCR and associated GCS, persons using assistive devices will continue to be exposed to elevated risk at railway grade crossings. As designated crossings are identified and upgraded to the GCR and GCS, there is an opportunity to make additional safety improvements at these locations. Therefore, the Board recommends that:
The Department of Transport work with stakeholders to identify engineering options for the improvement of crossings designated for persons using assistive devices, conduct an assessment of their effectiveness, and update its regulatory provisions as appropriate.TSB Recommendation R18-01
Board safety concern
Safety concerns are expressed in final investigation reports. A safety concern focusses on an identified unsafe condition for which there is insufficient evidence to validate a systemic safety deficiency, but the risks it poses warrant highlighting. A safety concern provides a marker to the industry and the regulator that the Board has insufficient information to make a recommendation, but that as more data and analysis become available it will return to this unsafe condition if it is not redressed.
Safety of persons using assistive devices at railway grade crossings
Railway grade crossing design and maintenance is a responsibility shared between railway companies and road authorities. Transport Canada's GCR introduced the concept of designated crossings, whereby road authorities must inform railway companies of crossings within their jurisdiction that are designated for persons using assistive devices. Railway companies can then work with the road authorities to assess these designated crossings, identify their hazards and risks, and implement any additional enhancements and countermeasures to improve safety at these locations. This approach should allow railway companies and road authorities to better prioritize the allocation of resources relating to crossing safety.
The GCR required that the sharing of grade crossing information between railway companies and road authorities, including information about designated crossings, be completed by November 2016. Therefore, in the course of the investigation into this occurrence, the TSB attempted to gather information from the railway industry (through the Railway Association of Canada) and the regulator. The TSB determined that, as of November 2017, not allroad authorities had shared the required grade crossing information with the railway companies. Some of the information that was shared was incomplete or inaccurate. At the time of report writing, one year after the deadline for sharing crossing data, the extent to which this sharing have been completed cannot be quantified.
Although some railway companies had voluntarily implemented programs to support road authorities on this initiative, the Board is concerned that the sharing of prescribed data with the railways and the identification of designated crossings by road authorities have not yet been completed, and that, as a result, persons using assistive devices at public grade crossings continue to be at elevated risk.