TSB Rail Safety Advisory Letter re: Reported malfunction of transitway automatic crossing protection

TSB Rail Safety Advisory Letter re: Reported malfunction of transitway automatic crossing protection
Posted on March 30, 2014 | Unpublished Admin | Written on February 25, 2014
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Publisher

Publisher:
Transportation Safety Board

Author's Note:

Author's Note:

On Feb. 25th, the Transportation Safety Board of Canada issued two letters to the City of Ottawa regarding their investigation into the OC Transpo Via Rail bus crash on September 18, 2013. This is the second letter of the two.

Below the letter you will find the City's response in a memo to the Mayor and City Council from Deputy City Manager Steve Kanellakos.

Click here to read the 1st letter.

Below the letter you will find the City's response in a memo to the Mayor and City Council from Deputy City Manager Steve Kanellakos. - See more at: http://unpublishedottawa.com/letter/868/tsb-rail-safety-advisory-letter-...

25 February 2014

His Worship Jim Watson
Mayor, City of Ottawa
110 Laurier Avenue West
Ottawa, Ontario
K1P 1J1

Dear Mr. Mayor:

Subject:

RAIL SAFETY ADVISORY LETTER – 02/14
Reported malfunction of transitway automatic crossing protection

At 0832 EDT on 18 September 2013, westward VIA passenger train No. 51 (the train) departed Ottawa VIA Station on time and proceeded westward en-route to Toronto. At 0847, OC Transpo Double Decker (DD) Bus No. 8017 (the bus) departed the OC Transpo Fallowfield Station on the OC Transpo Bus Transitway (Transitway). At 0848, while proceeding at about 47 mph, the train entered the Transitway crossing, located at Mile 3.30 of VIA Rail's Smith Falls Subdivision (the crossing) and was struck by the northbound bus. As a result of the collision, the front of the bus was sheared off. The train, comprised of 1 locomotive and 4 passenger coaches, derailed but remained upright. Among the bus occupants, there were 6 fatalities, 5 serious injuries and 30 minor injuries reported. No VIA crew members or passengers were injured.
 
The Transitway is a 2-lane asphalt road that is restricted to transit (bus) traffic. It extends from the OC Transpo Fallowfield Station for 812 feet (247.5 m) eastward towards Woodroffe Avenue. From that point, the Transitway transitions into a left hand curve (in the direction of travel) that turns northward where it runs parallel and adjacent to Woodroffe Avenue (see Appendix 1). From the stop sign at Fallowfield Station, the roadway speed limit is 50 km/h up to just north of the crossing, where the speed limit changes to 90 km/h. Traffic on the Transitway comprises about 1000 buses per weekday.
 
The Smith Falls Subdivision consists of single main track that extends from near the Ottawa VIA Station (Mile 0.0) to Smith Falls, Ontario (Mile 34.40). Train movements are governed by the Centralized Traffic Control System as authorized by the Canadian Rail Operating Rules (CROR) and supervised by a Rail Traffic Controller (RTC) located in Dorval, Quebec. About 14 passenger trains per day operate over the crossing. The authorized train speed in the vicinity of the crossing is up to 100 mph. However, trains departing VIA's Fallowfield Station are restricted to 10 – 15 mph until they are clear of the crossings at Woodroffe Avenue and Fallowfield Road, respectively. Likewise, trains arriving are slowing for the stop at the station.

The crossing traverses the Transitway at a 50 degree angle. It is equipped with Automatic Warning Device (AWD) protection that includes flashing lights, bells, gates and constant warning time track circuits. Based on the data download from the signal bungalow, it was determined that:

  • the crossing lights, bells and gates were activated about 47 seconds prior to the accident;
  • once activated, the crossing lights flash/bells sounded for about 12 seconds before the gates began to descend;
  • it took an additional 12 seconds for the gates to fully deploy; and
  • the gates were fully horizontal for 25 seconds prior to impact.

On 11 February 2014, OC Transpo reported a malfunction of the VIA Crossing AWD protection at the Transitway crossing. This incident involved 3 OC Transpo buses. This type of incident is not normally reportable to the TSB. However, in light of the accident and in response to heightened public concern, the TSB followed up on the incident as part of its ongoing investigation (R13T0192). Based on information collected from OC Transpo, VIA Rail and the crossing signal bungalow, the following sequence of events was established. At about:

21:45
Westbound train VIA 39 arrived at the Woodroffe Avenue (Mile 3.28) and Transitway (Mile 3.30) and all AWD crossing protection was activated.

21:46
Train VIA 39 cleared the Transitway crossing and the system deactivated. The north gate (southbound lane) went up (recovered), but the south gate (northbound lane) remained down (did not recover). As a result, the crossing lights remained activated as designed.

21:47
Northbound OC Transpo bus 6364 (1st Bus) arrived at the Transitway crossing and noted that the Woodroffe Avenue crossing protection was deactivated, but the Transitway crossing lights were on with the south gate down and the north gate upright. The driver stopped the bus about 50 feet from the crossing. The driver then applied the emergency brake, activated the emergency 4-way flashers on the bus, reported the situation to OC Transpo Control on the radio and waited for OC Transpo Supervisors to arrive.

OC Transpo Control diverted transit traffic to Woodroffe Avenue. Transit Supervisors were dispatched to the site.

21:48
Southbound OC Transpo bus 6565 (2nd Bus) was already on the Transitway when the driver heard the radio call to OC Transpo Control reporting the situation. Approaching the crossing, the driver slowed the bus, stopped at the crossing and activated the bus emergency 4-way flashers. The driver observed that the south gate was down and bus 6364 (1st Bus) was stopped in front of it on the northbound lane. However, the north gate was up which indicated to the driver that it was clear for the bus to cross. Based on his previous experience as a school bus driver, the driver opened the bus front door and driver's side window and looked both ways to confirm that it was safe before proceeding across the track and continuing to OC Transpo Fallowfield Station.

21:51
Two Transit Supervisors arrive on scene.

21:52
Southbound OC Transpo bus 5065 (3rd Bus) had been a few minutes behind bus 6565 (2nd Bus) on the Transitway when the driver also heard the radio call. When bus 5065 (3rd Bus) arrived at the crossing, bus 6565 (2nd Bus) had already departed. The driver (3rd Bus) slowed and stopped the bus about 60 feet from the crossing and activated the bus emergency 4-way flashers. The driver observed that the south gate was down, bus 6364 (1st Bus) was stopped in front of it on the northbound lane and a Transit Supervisor attempted to manually lift the south gate but could not.

21:53
The Transit Supervisors directed bus 6364 (1st Bus) onto the southbound lane, around the south gate, over the crossing and back onto the northbound lane. Since the north gate was already upright, the Transit Supervisors then directed bus 5065 (3rd Bus) to proceed over the crossing.

21:55
OC Transpo Control notified VIA's Rail Traffic Controller (RTC) that the south gate at the Transitway crossing was malfunctioning.

21:56
The Transitway crossing data download identified that the south gate had recovered and recovered to the upright position.

22:00
RTC dispatched a Signal Maintainer to the site and issued General Bulletin Order (GBO) No. V355 which stated Automatic warning devices defective at public crossing at grade mile 3.28 and mile 3.30 Smiths Falls sub. Stop before fouling and provide protection by a crew member until crossing fully occupied.

No Track Occupancy Permit was issued and OC Transpo Control was not notified nor were they required to be.

22:10
The Signal Maintainer arrived on site and observed that both crossing gates were up and all lights were off.

22:12 – 22:20
The Signal Maintainer cleaned frost from the south “gate up” contacts and verified that the internal heater for the south gate signal box was working.

22:20 – 22:23
The Signal Maintainer performed a series of tests to verify system operation.

22:24
The System tests were completed and the alert was reset.

22:59
Remaining at the scene, the Signal Maintainer observed the next train (VIA 48) traverse the crossing. The crossing protection functioned as required.

Based on the collected information, the following observations were made:

  • The crossing AWD functioned as designed. While crossing signals are generally reliable, frost on contacts can periodically cause activation problems. However, the system is designed to “Fail- Safe”. In this situation, the frost on the south “gate up” contacts prevented the activation of the south gate after the passage of VIA 39. With the south gate remaining down, the system “Failed Safe” as the lights and bells remained activated to warn road vehicles that it may not be safe to traverse the crossing. The lights and bells remain active until the system either recovers or is repaired. In this situation, the system recovered by itself at 21:56, after the buses had passed but before the Signal Maintainer arrived.

  • Between the time that VIA 39 had passed (21:46) and the system recovered (21:56), the 3 OC Transpo buses that remained on the Transitway had traversed the crossing. To accomplish this, OC Transpo personnel (OC Transpo Control, 3 drivers and 2 Transit Supervisors) each took what, at first glance, can be considered reasonable steps to minimize the risk at the crossing. However, there was still some risk in the activities undertaken.

  • OC Transpo Control re-routed traffic and then called VIA Rail. The VIA Rail RTC issued a GBO at 22:00, but this information was not relayed back to OC Transpo nor was it required to be. With no railway track protection in place, all 3 buses had traversed the crossing while at least one Transit Supervisor accessed the crossing and manually tried to lift the south gate while crossing protection was activated.

Railway crossings are railway property. Trains have the right- of- way and can appear at any time. No person should access live tracks without proper railway protection or attempt to lift crossing gates that have been activated and deployed.

  • The south gate remained down while the north gate recovered and was upright. All parties involved assumed that the south gate should be up. Although rare, there are also circumstances where a gate may not come down. Without additional information from the railway, there is no way to determine which gate is in the wrong position. In these situations, traversing a crossing before a gate comes down could place the travelling public at risk.

  • The first bus driver on the scene took appropriate action by stopping the bus, reporting the incident and waiting for assistance. OC Transpo Control took a safe course of action by re-routing all transit traffic until the situation was resolved. Otherwise, OC Transpo had no Standard Operating Procedures in place to deal with this type situation. Consequently, there was no track protection in place, the driver of each bus took a different action to negotiate the crossing and the Transit Supervisors may have placed themselves at risk.

Although the parties involved took reasonable steps to minimize the risk at the crossing and there were no adverse consequences, it would appear that there are opportunities to improve safety. With this in mind, OC Transpo, in conjunction with VIA Rail, may wish to develop and implement Standard Operating Procedures to ensure safe operations when unusual activations or malfunctions of crossing automated protection occur.

We would appreciate if you can inform us of any safety measures you plan to implement. We will take these measures into consideration as part of our ongoing investigation.

Yours sincerely,

Original signed by

Kirby Jang
Director
Investigations, Rail/Pipeline

Cc:

Mr. Luc Bourdon,
Director General,
Rail Safety
Transport Canada

Mr. Kent Kirkpatrick

City Manager
City of Ottawa

 
Mr. John Manconi

General Manager Transit Services
City of Ottawa

 
Ms. Jean Tierney

Senior Director,
Safety, Security & Risk Management
VIA Rail Canada Inc

Mr. Marc Tessier

Director,
Corporate Security & Regulatory Affairs
VIA Rail Canada Inc.

 
Mr. Nicolas Panetta

Manager Risk Management
VIA Rail Canada Inc.

 

Appendices

Appendix 1 – Site Diagram

 

 

MORE:

Letter Response

In response to the Transportation Safety Board's letters, Deputy City Manager Steve Kanellakos sent the following memo to Mayor Jim Watson and City Councillors on March 12th...
 

The purpose of this memorandum is to provide Members of Council and the Transit Commission with an update on the work the City has undertaken in response to the Transportation Safety Board observations presented to the City at a Technical Briefing which took place with the Transportation Safety Board (TSB) on Friday, October 11, 2013 and the TSB safety advisory letters issued on Monday February 25, 2014.

Council will recall that in the response to the Technical Briefing Observations made by the TSB on October 11, 2013, the City immediately took the following actions:

  • Removal  and trimming  of vegetation in the crossing/Transitway area;
  • Reducing  the  speed in both directions  approaching the crossing to 50 km/hour; and,
  • Enhancements to the signage in the crossing area.

In addition to this work, the City also undertook a review of the feasibility of installing an amber warning signal (a flashing light) before the crossing which may provide enhanced notice and visibility for northbound traffic. Such a warning signal would potentially be coordinated with the crossing light signal. With respect to this item, I can advise that City staff and VIA Rail are continuing their work on the proposed signal and will be recommending options in this regard shortly.

On February 25, 2014, the TSB issued two safety letters to the City. The first letter noted that the City may wish to put measures in place to ensure that buses are able to stop safely in advance of an activated railway crossing signal.  Suggested measures included reviewing the by-law that governs the operations of vehicles on Transitway, reviewing potential speed reductions, and installing an amber early warning signal for southbound traffic.

The second letter noted that OC Transpo, in conjunction with VIA Rail, may wish to develop and implement Standard Operating Procedures to ensure safe operations when unusual activations or malfunctions of crossing automated protection occur.

With respect to these Safety Letters issued on February 25, 2014, I can provide the following updates:

  • Legal Services and OC Transpo staff have reviewed City of Ottawa Transit By-law 2007-268, Schedule A, which currently governs the operations of vehicles on the Transitway and have concluded that an amendment to the By-law is justified in order to create an offence similar to what is currently found in the Highway Traffic Act to prohibit vehicles from crossing at a railway crossing when a warning of an approaching train is given. Staff are finalizing the details and will bring forward the appropriate report(s) and amendments in the near future;
  • City staff will conduct a comprehensive review of speed limits on the Transitway along the corridor from the Nepean Sportsplex to south of the Fallowfield Station, including the approaches to the railway crossing near Fallowfield Station.  The review will consider the physical design, speed of the roadway, the operating characteristics of OC Transpo buses, the sight line to traffic signals and railway crossings signals, the reaction times of operators to signals, and other physical factors such as gradient and curvature of the Transitway.  The review will follow the best safety engineering practices and also the newest draft railway crossing regulations published recently by Transport Canada, and will be conducted by qualified engineers with assistance from City staff.

Following the comprehensive review, staff will make any required adjustments to enhance signage and to improve operating practices along the Transitway, and will work with VIA Rail if any further issues are identified with the design or configuration of the railway crossing.

  • With respect to the suggestion made by the TSB of installing an amber early warning signal for the southbound Transitway traffic, I can confirm that staff are conducting the engineering review regarding a southbound signal.
     
  • I can also confirm that senior Via Rail and City staff have met to improve information sharing and to establish communications protocols between the two organizations. Integrated and comprehensive procedures are being finalized and will be implemented shortly. As an interim measure, all parties involved have confirmed contact numbers and processes for notifications.

As noted in my memorandum of February 26, 2014 to Members of Council the review of OC Transpo’s procedures for rail crossings is ongoing with work being finalized by our external engineering firm MMM Group. An update to the Transit Commission is expected for April 2014.

In addition to the work related to the TSB, I wanted to provide updates on the following work that is also being undertaken:

  • The City received a direction from Employment and Social Development Canada (ESDC) in January 2014 that advised us that in their officer’s opinion, OC Transpo had not sufficiently identified and assessed the workplace health and safety-related hazards at railway crossings where operators are required to work. While all of the railway crossings meet the applicable safety standards for design and maintenance, the ESDC direction requires the City to assess the crossings in a different way – that is, as part of the workplace for transit operators pursuant to the Canada Labour Code. The City has retained safety engineering consultants from MMM Group, and their subcontractors Flood Murray International and Human Factors North, to review this matter.  The consultants will assess the ergonomic considerations for transit operators at railway crossings and the current OC Transpo operating procedures, and define assessment methods that can be used consistently into the future. This work will include a review of Canadian and international best practices, an assessment of human factors such as driver workload, and on-site physical reviews under both summer (full foliage) and winter (bare trees) conditions.

Following this safety engineering assessment, staff will arrange for any necessary changes to operating procedures, bus configuration and road configuration and will also work with the railway companies with respect to any issues identified that are within their responsibility.

Finally, OC Transpo has taken additional measures which include:

  • Written directives to operators reminding them to:
  • Follow the Highway Traffic Act and exercise safe and defensive driving practices;
  • Watch for railway crossing flashing lights (signals).  If the lights are flashing, stop safely and well before the railway tracks;
  • Always follow the posted speed limits and, when approaching the railway crossings, slow down, hover over the brake pedal and watch for train movement in both directions of the railway tracks.  Proceed with caution; and,
  • Always be prepared to stop.
  • Daily internal radio announcements to operators to remind them to exercise caution when approaching a rail crossing, and to adhere to the posted speed limits;
  • Transit Supervisors and Special Constables have undertaken proactive speed monitoring, and conduct routine monitoring of bus operations at this and other locations. This operation is performed throughout the year at various locations on our system, as part of our safety program, In addition OC Transpo special constables will proactively enforce speed compliance on the Transitway;
  • Rail safety is covered in all New Bus Operator Training including a minimum of three visits to rail crossings;
  • All new bus operators visit the Transitway crossing at Fallowfield as part of the rail and Transitway training;
  • Licensing testing for all operators is sanctioned by Ministry of Transportation and includes a field test over a railway crossing to ensure compliance with all regulations and training;
  • The importance of adhering to and being familiar with all aspects of rail crossing procedures is addressed with operators in all employee assessments;
  • Special Constables and Fare Inspectors have been certified to present Operation Lifesaver presentations for the public, which is a rail safety education program with the goal to prevent collisions between trains and motor vehicles;
  • Operation Lifesaver, Rail Safety Operations Program or an equivalent is being assessed for operator training;
  • For any crossing incident, reporting protocols are clearly established so that staff in the OC Transpo control room has direct contact with VIA Rail and their contractor, Rail Term, in order to respond appropriately; and,  

I would like to also acknowledge the cooperative work demonstrated by all staff and unions at OC Transpo.  Their commitment to safety is recognized and appreciated. 

I will continue to report as more information becomes available.

Original signed by:

Steve Kanellakos

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