TSB Recommendation R20-01

Transport Canada agrees with Recommendation R20-01, and is taking immediate steps to address identified and future gaps in the rail safety regulatory regime by the following actions:

Action #1

• Transport Canada is preparing a Ministerial Order, anticipated in September 2020, requiring industry to create a new Rule that provides additional requirements when conducting switching operations. The Rule will require that once switching is complete, it must be left properly secured.

Action #2

• Transport Canada continues to revise the Railway Employee Qualification Standards Regulations to strengthen oversight requirements and address gaps related to training and experience of employees to ensure that they can safely conduct their duties. In fall 2020, the Department will launch stakeholder consultations on key aspects of the regulations. Publication of the regulatory proposal in Canada Gazette, Part I, is planned for spring 2021.

The initiatives will provide opportunities for further engagement and discussions, including the requirements under Railway Safety Act for the industry to consult with labour organizations when drafting a new rule. Ultimately, this is to better understand the underlying causes of uncontrolled movements and provide nationally consistent standards to mitigate the risks of uncontrolled movements that occur during switching activities, and reduce their frequency.

Transport Canada (TC) agrees with the recommendation and has proposed a two-step action plan. The first step, to issue a Ministerial Order (MO), was completed on 29 September 2020 – MO 20-09. It directed the railway industry to revise the Canadian Rail Operating Rules to address three key risks during switching operations as follows:

1. Requirements for location of switching operations
2. Requirements when performing switching operations
3. Requirements for switching with remote control locomotives

The MO requires industry to meet and discuss the proposed rules with affected associations and organizations and to file the proposed rules with the Minister of Transport by 01 June 2021.

While switching without air is routine and occurs every day in the railway industry, the practice has some inherent risks that can result in serious consequences. TC has recognized that these risks and their potential for severe outcomes need to be addressed as quickly as possible. The rapid issuance of the MO brings needed attention to this matter and clearly demonstrates TC’s interest in reducing the safety deficiency highlighted under Recommendation R20-01.

Although TC’s past regulatory focus for reducing unplanned/uncontrolled movements has been largely directed at the securement of equipment, it is encouraging that the MO may improve the likelihood of solutions being put in place for increasing the lines of defence against hazards inherent with switching operations. The effectiveness of TC’s response, however, cannot yet be fully ascertained until the consultations with the railway industry and its labour representatives have occurred, the underlying causes of uncontrolled movements that occur while switching without air are better understood, and strategies have been developed and implemented to reduce their frequency. Therefore, until the consultations are complete and strategies to reduce the frequency of uncontrolled movements that result from switching without air have been identified and implemented, the response to Recommendation R20-01 is assessed as being Satisfactory in Part.

The second step in TC’s response makes reference to future stakeholder consultations on key aspects of the Railway Employee Qualification Standards Regulations. These are planned for fall 2020; however, they have not yet been initiated. The goal is to strengthen oversight requirements and address gaps related to training and experience of employees in the regulations to ensure that they can conduct their duties safely. This should address the Board safety concern issued at the same time as Recommendation R20-01.

The Board is encouraged that TC acknowledges the existence of gaps in the training and qualification for employees in safety-critical positions and that it is actively working in a number of areas to address these gaps, including amendments to the regulatory framework.

In September 2020, TC issued MO20-09 requiring railway companies and local railway companies to revise the Canadian Rail Operating Rules (CROR) to incorporate provisions governing switching operations. CROR were revised and filed with the Minister on June 1, 2021. These rules were approved by the Minister on July 29, 2021 and came into effect on October 28, 2021.

Transport Canada reaffirms its agreement with this important recommendation. Taking action in this area, the department has implemented several measures to mitigate the risk of uncontrolled movements that occur while switching without air. Following the September 29, 2020 Ministerial Order (MO) 20-09 on this topic, Transport Canada approved changes to the Canadian Rail Operating Rules (CROR) to improve safety and prevent uncontrolled movements while conducting switching operations, and to ensure that equipment is properly secured while switching. These changes came into force on October 28, 2021. The amended CROR now prescribes:

• when air brakes must be used during switching operations to ensure a consistent approach across the railway system (Rule 113.3);
• measures to ensure that stationary equipment is secured during switching operations to prevent uncontrolled movements (Rules 113.1 and 113.2); and
• speed restrictions when switching is conducted with a remotely controlled locomotive (Rule 70).

In addition, Transport Canada held a workshop with industry and labour representatives on May 17, 2021 concerning uncontrolled movements. Participants reviewed analyses of the uncontrolled movement data, underlying causes, risks, and measures taken to date. Building on the outcomes of the workshop, the department will publish a call for proposals to research potential mitigation measures applicable to uncontrolled railway equipment movements. That research will look into:

• integration of new and existing technologies with modern railway switching operations;
• analysis of human factors contributing to this issue; and
• best practices from other transportation modes and sectors.

In parallel, Transport Canada continues to move forward with updating the regulatory regime for railway employee training and qualification. Progress in this area has accounted for landmark reports on rail safety in Canada, such as the February 2021 Auditor General’s follow-up audit on rail safety oversight, extensive review of observations and findings from TSB investigation reports, as well as from Transport Canada inspections and audits. Drawing on these findings, the department has prepared proposed regulatory changes aligned with the TSB’s recommendations and findings, including with respect to training programs, crew resource management, on-the-job training, and re-certification. To support a consultative approach in this area, on November 16, 2021, Transport Canada published a discussion paper^{Footnote 2} that outlines key policy considerations (e.g. scope of application, training requirements, examinations and evaluations) for updating the Railway Employee Qualification Standards Regulations. The discussion paper has been posted on TC’s website for a 60-day consultation period and during this period, the department will also engage in targeted consultations with stakeholders. Pending the results of these consultations, publication of the regulatory proposal in Canada Gazette, Part I, is planned for spring 2022.

Building on this progress, Transport Canada will undertake the following actions to further mitigate the risks of uncontrolled movements:

• Host a second workshop with industry and labour representatives, scheduled for January 24, 2022, to further assess the effectiveness of measures taken to date, and to explore next steps;
• Conduct a review of international train securement practices, with an emphasis on safety measures on mountainous terrain (2022); and
• Develop a discussion paper on potential solutions for integrating crew resource management practices into the Safety Management Systems Regulations (2022).

This recommendation is related to the TSB Watchlist 2020 key safety issue of “Unplanned/uncontrolled movements of rail equipment” that create high-risk situations that may have catastrophic consequences. It is also linked to Recommendation R14-04, in which the Board recommended that “the Department of Transport require Canadian railways to put in place additional physical defenses to prevent runaway equipment.”

In December 2021, TC reaffirmed its agreement with the recommendation. On 28 October 2021, following MO 20-09, the CROR were amended and now prescribe:

• when air brakes must be used during switching operations to ensure a consistent approach across the railway system (Rule 113.3);
• measures to ensure that stationary equipment is secured during switching operations to prevent uncontrolled movements (rules 113.1 and 113.2); and
• speed restrictions when switching is conducted with a remotely controlled locomotive (Rule 70).

In spring 2021, TC held a workshop with industry and labour representatives on the subject of uncontrolled movements and published a call for proposals to research potential mitigation measures. The Board looks forward to the results of these research initiatives.

TC also continues to move forward with updating the regulatory regime for railway employee training and qualification. To support a consultative approach in the area of training programs, crew resource management, on-the-job training, and recertification, on 16 November 2021, TC published a discussion paper that outlines key policy considerations for updating the Railway Employee Qualification Standards Regulations and has identified that it intends to conduct industry consultations.

The Board notes that, pending these consultations, publication of the regulatory proposal in the Canada Gazette, Part I, is planned for spring 2022.

The Board further notes that, in 2022, TC

• hosted a second workshop with industry and labour representatives;
• plans to conduct a review of international train securement practices; and
• plans to develop a discussion paper on potential solutions for integrating crew resource management practices into the Safety Management Systems Regulations.

The publication of the regulatory proposal and additional strategies to reduce the frequency of uncontrolled movements that result from switching without air are imminent. However, until the details of the proposals are clear, the Board considers the response to Recommendation R20-01 to be Satisfactory in Part.