(The Transportation Safety Board of Canada (TSB) issued the following news release on July 29.)
GATINEAU, Quebec — The Transportation Safety Board of Canada (TSB) today issued its final investigation report into the passing of a signal indicating STOP by VIA Rail Canada Inc. train No. 52 on 19 January 1999.
The Board has recommended that:
The Department of Transport, in conjunction with the railway industry, establish comprehensive national standards for locomotive data recorders that include a requirement for an on-board cab voice recording interfaced with on-board communications systems. (R03-02)
On the day of the incident, at approximately 0830 eastern standard time, VIA 52 passed signal No. 2328S at Mile 232.8 of the Canadian National Kingston Subdivision at the Trenton Junction Station while it was indicating STOP. The train subsequently passed through a main track switch and came to a full stop at Mile 232.17.
The TSB found that the crew members did not react promptly to the stop indication at signal 2328S. Given that the train was operating at close to the maximum allowable speed (100 mph), they could not have stopped even if they had observed and reacted when the signal came into view.
The Board noted that conversations being conducted with a trainee on VIA 52 at that time may have distracted the regular crew members, thus increasing the risk of omission of the check for the indication displayed by signal 2352S.
The Board also found that signal systems are not upgraded to the same level of safety as those required by the most recently recommended design principles. New signal system design principles are not implemented retroactively in Canada unless there is a specific problem or when risks are deemed to be high.
The Transportation Safety Board of Canada is an independent agency operating under its own Act of Parliament. 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.