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9/15/2025
For 35 years, the Transportation Safety Board of Canada (TSB) has led the discovery of the “why” of accidents, sharing the lessons learned so change agents have the information they need to make lasting improvements to transportation safety.
Since 1990, the TSB has led over 2,000 independent investigations, issued more than 630 safety recommendations, and released hundreds of safety communications in the air, marine, pipeline and rail transportation sectors. Over 80% of recommendations have been fully implemented, helping to prevent occurrences, reduce risks and save lives.
In 2010, the TSB launched its Watchlist, a program which highlights systemic issues that need to be addressed to make Canada’s transportation system even safer.
The latest edition, issued in 2022, identified the persistent safety challenges in rail transportation: following railway signal indications, unplanned and uncontrolled movement of rail equipment, safety management, regulatory surveillance and fatigue management.
The next Watchlist will be released this fall and will continue to spotlight critical safety gaps and advocate for industry and regulators to identify and implement lasting solutions.
A number of rail occurrences have profoundly shaped rail transportation safety in Canada.
The 2013 derailment in Lac-Megantic, Quebec, remains the most devastating in Canadian history, resulting in 47 fatalities and the destruction of much of the town’s core. Following the investigation (R13D0054), the TSB issued multiple key recommendations, including R14-01, R14-02 and R14-03, which focused on improved tank car standards, route planning and analysis, and emergency response assistance plans. All three have since been fully addressed, leading to significant improvements in rail safety practices and equipment.
In 2017, a foreman was fatally injured during an uncontrolled movement of a rail car in Melville, Saskatchewan. The investigation (R17W0267) prompted recommendation R20-01, which called for measures to reduce the frequency and risks of uncontrolled movements that occur while switching without air. The recommendation was closed this year after defenses against uncontrolled movements were strengthened and the number of uncontrolled movements in this category decreased.
In 2019, a freight train derailed near Field, British Columbia, fatally injuring three crew members. The investigation (R19C0015) resulted in recommendation R22-04, which called for enhanced brake cylinder standards and maintenance for freight cars on steep grades in cold weather. Its full implementation has enhanced safety on steep grades.
These recommendations, fully implemented and now closed, show how lessons learned from tragedy can lead to significant improvements in rail safety.
The TSB has been calling for physical fail-safe train controls for more than 25 years. This call was further reinforced by one of the TSB’s most recent recommendations, which arose from a 2019 main track collision.
In January 2019, an eastbound freight train collided with a westbound freight train near Portage la Prairie, Manitoba, resulting in the derailment of both trains.?
The investigation (R19W0002) found that current Canadian railway operations rely heavily on administrative defenses, such as operating rules and crew compliance. When these defenses fail, and no physical fail-safe systems are in place, preventable accidents can occur.
In 2022, the TSB called for all major Canadian railways to expedite the implementation of physical fail-safe train control systems on high-speed corridors and key routes. Since recommendation R22-04 was issued, collisions, derailments and near-misses involving crews not following railway signals have continued to occur, highlighting the need for the regulator and the industry to take urgent action on this issue.
Across the industry, many key players are taking proactive steps — not because they are required to, but because it’s the right thing to do. By anticipating risks and acting early, tragedies can be prevented.
Change takes time, but persistence drives progress. The TSB’s impact is built on the dedication of its investigators, whose work has led to safer skies, pipelines, railway operations and waters. Every investigation and lesson learned brings us closer to a single goal: a transportation system that’s ready to respond, ready to improve and ready to protect Canadians.