Gatineau, Quebec, 6 March 2012 - Today the Transportation Safety Board of Canada (TSB) released its final investigation report (R10Q0011) into the 25 February 2010 derailment of a VIA Rail Canada passenger train in St-Charles-de-Bellechasse, Quebec.
VIA Rail passenger train 15, travelling from Halifax to Montreal, entered a siding track while travelling at excessive speed, resulting in the derailment of 2 locomotives and 6 passenger cars. Two locomotive engineers and 5 passengers were injured, and there was extensive damage to railway and private property. Contributing factors included snow accumulation on signal lenses and the crew’s expectation that a Canadian National freight train they sometimes meet would be delayed at Charny, Quebec. These likely led to the crew’s misperception of the advance signal before the siding as an indication to proceed without restriction. Furthermore, poor visibility may have led the crew to only act on the St. Charles-de-Bellechasse home signal just 500 feet before the main-track switch, causing the train to enter the siding at excessive speed.
“We know from many investigations that crews sometimes misinterpret railway signals,” said Ed Belkaloul, TSB’s Manager, Eastern Region Operations. “The answer lies in additional safety defenses so that railway signals will always be correctly identified,” he added. The TSB has been calling for these defenses since 2001. The Board remains concerned that without additional backup safety defenses to help ensure that signal indications are consistently recognized and adhered to, the risk of a serious train collision or derailment remains.
The investigation also uncovered safety deficiencies related to medical testing for employees. Since this investigation, railway industry procedures have been changed to expedite the transfer of medical information between employers, and to restrict an employee’s service if additional medical testing is not conducted in a reasonable time.
The lack of voice recordings onboard locomotives continues to make investigations more challenging. This kind of information has proved invaluable in numerous investigations in other modes of transportation. In the St-Charles accident, and in the recent VIA Rail derailment in Burlington, Ontario, investigators did not have access to such recorders to help them uncover safety deficiencies. The Board made a recommendation in 2003 calling for voice recorders on locomotives, and again reiterates its call for action in this investigation report.
The Board remains concerned that voice recordings have not yet been introduced on Canadian trains. The lack of this critical source of data deprives investigators of a key tool as they seek to find out what happened and what can be done to prevent similar occurrences.
The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
The final investigation report R10Q0011 and all related materials are available on the TSB website at www.bst‑tsb.gc.ca.
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Transportation Safety Board of Canada
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