The crew of Via train No. 92 in Burlington, Ont., misperceived a warning signal to slow down before their locomotive and five passenger cars were involved in a deadly derailment in February 2012, according to a report released today by Canada's Transportation Safety Board that recommends "fail-safe" train controls.

The TSB on Tuesday tabled its findings on the causes of the derailment, which saw the train accelerating eastward out of Aldershot station at 108 km/h, missing a signal that warned crew members to slow down as they were being switched onto a different track using a crossover designed for a maximum speed of 24 km/h.

The derailment, which happened about 60 kilometres west of Toronto, killed three members of the train's crew when the locomotive toppled onto its side and slammed into a building. The derailment also left 45 passengers injured.

"There could have been a distraction between them, or it could have been unclear between them who was responsible," said TSB official Jon Stuart. "It is equally possible that the work crew on the track ahead provided a distraction from the signal."  

But some say blaming the engineers is taking the easy way out.

"I don't believe they got that signal wrong," said Gail Robinson of Cornwall, Ont. Her former husband is one of the three engineers the TSB says missed the signal. 

"They [the TSB] are still blaming it on the same thing as they did last February," she told CBC News.

The TSB report (read the full report at the bottom of this story) included three main recommendations. Chief among them was the implementation of positive train control (PTC) systems on Canadian railways. Such systems are able to override the actions of train crews when their operators fail to obey signals to stop or slow down.

Other recommendations include:

  • Installing both video and voice recorders in all locomotive cabs.
  • Beefing up crash-protection standards so that rebuilt locomotives meet the same standards as new ones. Train 92's locomotive was rebuilt, a loophole that allowed it to not be subject to tougher standards, though the TSB admits this may not have been enough to save the crew. About 90 per cent of all locomotives in use in freight and passenger operations in Canada are rebuilt units, according to the TSB.

In its report, the TSB also lays out a number of factors that may have caused the crew to miss the slowdown signal as it travelled through Burlington toward Toronto.

TSB manger Rob Johnston said train control signals work in progression and a short stop at Aldershot minutes before the derailment may have "interrupted the progression of signals." The move from track 2 to track 3 was also unusual for that location. "It's possible the crew assumed they would continue on track 2 as they did 99 per cent of time," said Johnston.

The report also says the crew may have been distracted by a maintenance crew working on the tracks ahead of where the accident occurred. The train blew its horn prior to the derailment, something they would not normally do along that section of track, suggesting Via engineers saw the track crew up ahead. But that may have served as a distraction, causing the Via engineers to miss the slowdown signal.

With no video evidence, the TSB report says there is no way to be certain what caused the crew's failure to obey the signal.

"We'll likely never know," said Johnston.

Repeatedly during Tuesday's news conference, both TSB chair Wendy Tadros and Johnston cited the lack of positive train control systems as the key factor in the derailment.

Canada 'way behind' other countries

"About once a month, somewhere in Canada there's a disconnect between what the signal displays and the action the crew takes," said Tadros. She said Canada is "way behind" other countries that already have positive train control, including many European countries and railways in India and China.

"We need to fix this because if we don’t, it will happen again," she said.

The incident has thrown new fuel into the debate over positive train control systems (PTC).

Lawmakers in the United States passed legislation recently demanding that some forms of PTC be implemented across the country by 2015.

Several railways, including Amtrak, and some local commuter services already employ a variation of PTC. But the nationwide system demanded by U.S. Congress is facing resistance and pushback from the rail industry, which says the cost and complexity of installing PTC systems across America by 2015 is unattainable.

So far, no major Canadian railroad has implemented PTC. CN owns and maintains the tracks where the Via derailment took place.

In a statement, Via said it plans to have outward-facing cameras installed on all its trains by 2014. Installation of voice recorders is expected to be done by later that same year. After that, the passenger rail company said it will consider installing inward-facing cameras.

In a separate statement, CN said it "will continue to work closely with Transport Canada ... on the subject of physical fail-safe train controls."

CN said it is working to comply with rules mandating PTC in the United States, where CN has extensive operations.

However, CN also expressed some doubt about PTC's ability to prevent such accidents. 

"PTC, as currently being implemented, is a technologically complex system that as of yet has not been proven in any large scale industry implementation," the release states. "In CN's view, further deployment of PTC beyond the existing mandated rollout should not be pursued until we can fully validate the reliability and operability of the system."