Research Article

Transportation Research Record

2021, Vol. 2675(1) 49–66
Ó National Academy of Sciences:
Process Safety Approach to Identify Transportation Research Board 2020
Article reuse guidelines:
Opportunities for Enhancing Rail sagepub.com/journals-permissions
DOI: 10.1177/0361198120957008

Transport Safety in Canada journals.sagepub.com/home/trr

Fereshteh Sattari1, Renato Macciotta2, and Lianne Lefsrud1

Abstract
The amount of dangerous goods (DG) transported by rail within Canada has increased by an average of approximately 25%
since 2004, with a 42.5% increase in transported fuels and chemicals between 2011 and 2017. Further, movement of DG by
rail is forecasted to continue increasing. Sustainable growth in the transport of dangerous goods (TDG) by rail will require
acceptable safety levels. This study provides insight into key occurrence types for TDG and their causes, to better focus on
risk control strategies, including measurement and control of leading and lagging safety indicators. This work also reviews cur-
rent safety performance and Canadian railway incident occurrence databases. The results of the analyses suggested that the
performance against lagging indicators currently being reported is adequate, including derailments and collisions (main and
nonmain track), serious injuries (including fatalities), DG leakers, and releases. Furthermore, a list of the rail accidents with
the greatest number of fatalities was used to calculate a crude estimate of societal risk associated with rail transportation.
According to UK Health and Safety Executive (HSE) recommendations, this analysis indicated that the estimated rail trans-
port risks would be considered acceptable when assessed at a milepost scale. However, there are opportunities for further
enhancing safety reporting, management, and performance.

Canada’s transportation networks have been identified
as the backbone of Canada’s economy, supporting hun-
dreds of thousands of jobs, contributing billions to the
gross domestic product, and allowing for robust domestic
and international trade (1, 2). In particular, the railway
sector provides affordable and efficient travel to more
than 84 million passengers each year and moves approxi-
mately 70% of all intercity surface freight and half of
Canada’s exports (3), which translates to Can$310 billion
(Can$1 = US$0.745 in August 2020) worth of goods
being moved by rail each year. One transportation activ-
ity that is essential to most industries but commonly
associated with the oil and manufacturing industries is
rail transport of dangerous goods (TDG) (4). DG are
defined in the Transportation of Dangerous Goods Act
(5), and include explosives, flammable and combustible
substances, toxic substances, oxidizing substances, and
corrosive substances, among others. Rail transport of
fuels and chemicals, which account for most TDG by
Canadian Class 1 railways (Canadian National Railway,
CN, and Canadian Pacific Railway, CP), increased
42.5% between 2011 and 2017 (6).
Recent railway incidents such as Lake Wabamun in
2005 and Lac-Mégantic in 2013 involving the release of
DG have shown the potentially significant consequences
of these events (7, 8). This has resulted in public concern
and an increased sensitivity to the risks of TDG by rail
(9, 10). In response, and with the acknowledgment that
sustained growth requires continuous improvement in
safety performance, the rail industry and Transport
Canada have been working on initiatives that will
enhance rail transportation safety (11, 12). The work
presented here is part of these initiatives and focuses on
enhancing the current strategies for managing the risks
associated with TDG by rail. This paper adopts process
safety concepts and tools (13) to analyze the Canadian
railway incident database for federally regulated opera-
tions. Further, the paper highlights a subset of immedi-
ate and basic causes of railway incidents with a greater
1
Department of Chemical and Materials Engineering, School of Engineering
Safety and Risk Management, University of Alberta, Edmonton, Alberta,
Canada
2
Department of Civil and Environmental Engineering, School of Engineering
Safety and Risk Management, University of Alberta, Edmonton, Alberta,
Canada
Corresponding Author:
Lianne Lefsrud, Lefsrud@ualberta.ca
50
potential for serious consequences. A broader aim of the
paper is to provide an example of the framework used
for analyzing the safety performance of rail transport at
the national scale, which could be adopted in other juris-
dictions facing similar challenges.
Trends in Canadian Rail Transport and Transport of
Dangerous Goods
Canadian railway operations cover a vast network that is
over 40,000 km in length and characterized by extreme tem-
peratures and the remoteness of some of its operations.
The industry reported a moderate increase in freight
transport of goods between 2004 and 2007 (about 440 to
460 billion gross ton-miles [GTM]), followed by a decline
in 2008 to 2009 (to below 400 billion GTM) attributed to
the economic downturn in that period. Transport of
goods subsequently increased consistently, to almost 560
billion GTM in 2017 (40% increase). This represents an
average annual increase rate of 20 billion GTM (3, 6).
Passenger transportation showed a consistent decrease
between 2005 (about 0.92 billion passenger-miles) and
2014 (0.83 billion passenger-miles) except for a peak in
2008 (0.99 billion passenger-miles). Passenger transporta-
tion has since shown a consistent increase between the
0.83 billion passenger-miles in 2014 and 0.97 billion
passenger-miles in 2017.
Train traffic, in relation to the number of trains and
distance traveled, can be aggregated as the number of
train miles per year. Figure 1a shows freight, passenger,
and aggregated train-miles between 2004 and 2017 for
railway members of Railroad Association of Canada,
RAC (6), and Figure 1b presents the amount of DG
transported between 2004 and 2017.
It can be concluded from these figures that there was a
steep traffic decrease in 2008 to 2009, consistent with the
decrease in transported goods and the economic down-
turn, and a subsequent recovery between 2010 and 2014.
Furthermore, although TDG showed a decrease in 2015
to 2016, there had been an increasing trend from 2009.
Process Safety
Clear consideration of safety in the transportation plan-
ning process is required by the Transportation Equity
Act for the 21st Century (TEA-21) enacted in 1998 (14).
Process safety involves managing systems for handling
DG by integrating good design principles, safe proce-
dures and guidelines, and optimized engineering and
operating practices. Process safety also involves different
aspects of preventing and controlling incidents related to
hazardous material. In other words, process safety
focuses on handling accidents or incidents resulting in
lost production, or serious or minor injuries (13).
Transportation Research Record 2675(1)
Figure 1. (a) Freight, passenger, and aggregated train-miles (upper
graph) and (b) Dangerous Goods-originated carloads (lower graph)
for Canadian railways member of Railway Association of Canada,
2004–2017 (6).
In transportation, DG are common freight, and when
these substances are not properly controlled, there is the
potential for loss of containment (15). Therefore, analy-
sis of the severity of accidents/incidents can be underta-
ken through classification of the occurrences in relation
to their reported consequences, as well as the occurrence
type, to estimate potential scenarios. To this end, the aim
of this study was to classify occurrences, using process
safety approaches, into incidents, near misses, and sub-
standard conditions and practices.
Data Collection: Railway Safety Trends
Reported in Canada
An initial understanding of rail transportation safety per-
formance can be gained by examining occurrence statis-
tics. The Transportation Safety Board of Canada (TSB)
publishes annual railway incident statistics for federally
regulated operations in Canada, which include freight
and passenger transportation (16). TSB reports these as
‘‘occurrences,’’ which include incidents with loss, near
misses, and a subset of substandard conditions and prac-
tices. TSB defines a reportable incident as that in which
(1) a person is killed or sustains serious injuries when get-
ting on or off or being on board rolling stock, or coming
in contact with rolling stock or its contents, or (2) the
rolling stock or its contents sustain damage that affects
safe operations or threatens the safety of people, prop-
erty, or the environment (16). It is noted that incident
Sattari et al
Figure 2. TSB classification of (a) incidents and (b) accidents per occurrence type (2014–2017).
Note: R/S = rolling stock; COLL. = collision.
Passenger and Employees refer to health and safety incidents not directly associated with operations.
rates and consequence metrics are lagging indicators of
safety performance. Lagging indicators (losses, incidents,
and near misses) do not allow for a complete picture of
safety performance if not combined with the assessment
of leading indicators (e.g., substandard actions and con-
ditions, deficiencies in the safety management system, its
implementation, and compliance with the system). The
data used in this paper (up to December 31, 2017)
includes TSB data from its Rail Occurrence Database
System (RODS), which is made publicly available
through the TSB website (www.tsb.gc.ca).
TSB Reported Occurrence Types (Incidents and Near
Misses)
Loss incidents and near misses are classified by TSB as
accidents (loss incidents) and incidents (near misses and
substandard practices or conditions). The types and dis-
tribution of incidents according to RODS are shown in
Figure 2. In this period (2014 to 2017), TSB reported
1,381 incidents (25%) and 4,079 accidents (75%). In the
database, main track refers to rail segments used for
train traffic and nonmain track is associated with sidings,
yards, and others used for train and rolling stock han-
dling other than main transport.
(a) TSB incident classification: near misses and sub-
standard practices/conditions.
(b) TSB incident classification: loss incidents.
Although most near misses in Figure 2a are move-
ments exceeding the limits of authority (38.1%), nearly
51
half of reported loss incidents in Figure 2b (48%) are
non-main-track train derailments.
Temporal Safety Performance Trends: TSB Reported
Loss Incidents
The number of reported loss incidents between 2001 and
2017 is shown in Figure 3. Accidents were also normal-
ized per million main-track train-miles, to eliminate the
variability associated with train traffic fluctuation.
Figure 3a shows a decreasing trend in incident frequency.
Loss incident frequencies were dominated by yard work
(normally at low speeds) and trespasser and crossing loss
incidents. Trespasser and crossing incidents include fac-
tors difficult to control by rail operations, such as exces-
sive risk-taking and self-harm by third parties (12).
Incident frequencies on the main track can provide
insight into the risks associated solely with transporta-
tion activities. Figure 3b shows main-track train-loss inci-
dents and incidents per million main-track train-miles,
excluding trespasser and crossing incidents. This figure is
consistent with the overall decreasing trends observed
pre-2012, although the trends have greater short-term
variability. The data, however, suggest an increasing
trend between 2012 and 2017, although another interpre-
tation is that the trend remained consistent between 2009
and 2017. In relation to frequencies over the latter 5 years
analyzed, railway transportation showed 13 to 14 loss
incidents per million main-track train-miles (a total of
1,000 to 1,100 per year). This reduced to between 2.2 and
2.7 loss incidents on main track, per million main-track
52
Figure 3. (a) Loss incidents and (b) loss incidents on main track.
Figure 4. (a) Loss incidents involving DG and those with DG release (b) and loss incidents involving DG normalized to carloads.
Note: DG = dangerous goods.
train-miles (a total of 160 to 200 per year) when exclud-
ing trespasser and crossing incidents.
Figure 4a shows the number of loss incidents involv-
ing DG and the number of incidents with DG release
presenting an increase during the period 2013 to 2015.
Normalized incident frequency by the amount of TDG
provides a means for isolating safety metrics from varia-
tion in the amounts of DG transported. This was done as
number of loss incidents involving DG per carload of
DG generated, Figure 4b (3, 6). This figure reveals a clear
Transportation Research Record 2675(1)
and continuous decreasing trend in the amount of loss
incidents involving DG per amount transported, suggest-
ing a constant improvement in relation to the safety per
carload of DG.
TSB-Reported Fatalities and Serious Injuries
Figure 5a indicates the number of serious injuries, fatal-
ities, and aggregated serious injuries and fatalities. A
generally decreasing trend was observed suggesting a
Sattari et al
Figure 5. (a) Reported fatalities and serious injuries, (b) grouped by employees only, and (c) by intercity train passengers.
continuous improvement in reducing the number of
occurrences with the potential for serious injury. A peak
in 2013 corresponded to the tragic outcome of the Lac-
Mégantic disaster (47 fatalities) (8). This was the first
indication that mitigation of the more frequent limited-
exposure occurrences was being met with some success,
however the potential for low probability, high-
consequence occurrences (e.g., large number of injuries)
requires further analysis and mitigation.
Although the above numbers provide an overall view
of safety performance evolution for people safety, it is
worth evaluating this performance in relation to employ-
ees, passengers, and public safety. Figure 5b shows the
number of serious injuries and fatalities for railway
employees. The annual variability masks any long-term
changes and its evolution suggests between two and three
employee fatalities and 10 to 11 serious employee injuries
each year. This data suggests there is an opportunity to
enhance safety management strategies and target occur-
rences that are more likely to cause serious injuries to
employees. Note Figure 5, b and c, do not include the
fatalities at Lac-Mégantic, which were not employees or
passengers. Figure 5c presents the number of passenger
fatalities and serious injuries. Their reduced number did
not allow for evaluation of any trends on records,
53
however spikes in serious injuries were observed in 2001,
2010, 2012, and 2015. Passenger fatalities occurred in
2006, 2008, 2010, 2014, and 2017. In the following sec-
tion, public safety is addressed as part of a longer-term
historical retrospection.
Analysis of Rail Incidents from a Process
Safety Perspective
The previous section provided an understanding of the
state of the Canadian railway industry in relation to
safety outcomes, as measured by annual frequencies and
trends in loss incidents. Although the industry’s efforts to
enhance the safety of operations was reflected in decreas-
ing incident trends, some potential opportunities for
improvement were highlighted. This section takes a closer
look at these incidents and adopts some concepts and
tools from process safety to further assess areas that
could provide greater benefits as regards safety as a
return on further investment.
Individual Risk 2001 to 2017
Records of passenger and employee fatalities allow esti-
mation of the historic risk to life for these groups. In this
54
Figure 6. Estimated average individual risk to life for rail
employees and intercity train passengers.
Note: HSE = UK Health and Safety Executive.
context, historic risks refer to past performance based on
data between 2001 and 2017. To this end, the average
annual risk to employees was approximated as the ratio
between average employee fatalities per year (2.5 between
2001 and 2017) and the number of employees exposed to
operations, approximately 30,000 in 2017 (RAC, 2018).
The calculated average risk to employees was 8.3 3 10–5.
A worst-case estimate of the risk to life for intercity passen-
gers assumed the most catastrophic passenger incident
(three fatalities in 2006) and calculated the ratio to the total
number of intercity passengers in 2006, 4.3 million (RAC,
2018). The calculated risk to employees was 6.9 3 10–7.
These are shown in Figure 6 together with the mortality
rate and mortality for all accidents in Canada, age stan-
dardized (17), work-related fatalities in the province of
British Columbia per year per full-time employee (18),
and work-related fatalities in the province of Alberta per
year per full-time employee (19). The latter are shown for
benchmark purposes only. The historic (since 2001)
worst-case risk to the average passenger was well below
Canadian mortality statistics for all accidents by more
than two orders of magnitude. The risk to the average
employee was slightly higher than the average work-
related risks reported in Alberta and British Columbia,
and lower than the Canadian mortality statistics for all
accidents. It is worth noting that the provincial statistics
for work-related fatalities include both high- and low-risk
activities (e.g., roofing and administrative office work),
and that the exposure of rail employees to different
hazard levels will vary as a function of their specific task.
Transportation Research Record 2675(1)
Figure 7. Reported accidents and number of fatalities and
serious injuries for employees and passengers for federally
regulated operations (7, 16).
Individual risk criteria suggested by the UK Health
and Safety Executive (HSE) are also plotted in Figure 6
(20). These criteria have been widely adopted by many
industries in multiple countries as a sensible basis for
managing risk, particularly as risk tolerance criteria for
use with layer of protection analysis or other risk analy-
sis methods (21). In these criteria, acceptable risks are
understood as those that society is willing to accept with-
out further action; tolerable risks are those society is will-
ing to tolerate given there is some benefit from incurring
such risks. The area between tolerable and acceptable
thresholds is commonly referred to as ‘‘ALARP’’ (as low
as reasonably practicable). ALARP requires that risk
levels and the costs associated with mitigating risk are
considered, and that risk reduction measures are imple-
mented should the cost of doing so be reasonably prac-
ticable. The HSE criteria suggest that the risk to the
average passenger was within acceptable limits (lower
than 10–6) and the risk to the average rail employee was
well within tolerable limits for workers. Trespasser and
crossing incidents accounted for over 90% of fatalities.
The nature of these incidents (in many instances includ-
ing self-harm and reckless behavior by third parties) and
the difficulties and uncertainty estimating the number of
people exposed to such incidents, prevent adequate esti-
mates of these risks within the scope of this study.
As suggested by Figure 3, the overall trend in the
safety performance of rail transport in Canada has
shown continuous improvement in the last couple
decades. However, this trend does not differentiate
between high- and low-consequence occurrences.
However, railway occurrences with the potential for high
consequences present elevated levels of risk. This can be
illustrated by comparing the changes in annual frequen-
cies of reported railway accidents and the number of seri-
ous injuries for employees and passengers (including
fatalities) (Figure 7). This figure shows that even when
Sattari et al
Table 1. Deadliest Rail Accidents in Canada (23–25)
Year Location
1854 Baptiste Creek, Ontario
1857 Desjardines Canal, Ontario
1864 St-Hilaire, Quebec
1902 Wanstead, Ontario
1910 Spanish River, Ontario
1942 Almonte, Ontario
1947 Dugald, Manitoba
1950 Canoe River, British Columbia
1986 Hinton, Alberta
2013 Lac-Mégantic, Quebec
the overall frequency of accidents showed a sharp
decrease between 2005 and 2009, which was followed by
a general decreasing trend from then on, the average
number of serious injuries per year remained constant at
15. The continued potential for low-frequency, high-
consequence events can also be illustrated with a review
of high-profile railway occurrences in Canada investi-
gated by TSB in the last couple of decades. These occur-
rences indicate an opportunity for optimizing resource
allocation for risk mitigation strategies, targeting the
critical conditions and practices associated with low
probability but high-consequence incidents.
Historic Societal Risk Performance
Insight into the risks associated with large numbers of
fatalities can be gained by examining previous high-
consequence incidents. It was assumed that high-
consequence incidents involving multiple fatalities (10 or
more) would almost certainly be recorded, therefore the
historic database could extend for longer periods than
the one used to assess individual risk. A list of the dead-
liest rail accidents in Canada is presented in Table 1.
This table indicates 10 incidents causing 10 or more
fatalities have occurred since the 1850s, with five acci-
dents causing over 40 fatalities each, one of which caused
99 fatalities. Most of these accidents involved passenger
trains; Lac-Mégantic involved a freight train. The peri-
odicity of rail accidents (with multiple fatalities) post
1900s is approximately 15 to 20 years decreasing within
the last century.
The historical societal risks associated with rail trans-
port can be estimated by multiplying the frequency of
accidents (in a period) by the number of fatalities fol-
lowed by normalization. Normalization can be applied
per amount of goods transported (gross tons), train traf-
fic (train miles), or spatial unit (to normalize the extent
of operations). This study used spatial normalization to
understand the risk distributed geographically. This
55
Reported no. fatalities Observation
52 Passenger
59 Passenger
99 Passenger
31 Passenger
43 Passenger
39 Passenger
31 Passenger
21 Passenger
23 Passenger and freight
47 Freight—not Class 1 operator
approach helps to reduce redundancy while increasing
consistency between data.
These societal risk estimates for Canadian railroad
were plotted on an F–N plot in Figure 8. This plot pre-
sents the number of fatalities (N on the horizontal axis)
and annual frequency of N or more fatalities (F on the
vertical axis). The societal criteria (tolerable and accepta-
ble thresholds) follow the guidelines provided by the
HSE (20). The area between the tolerable and acceptable
thresholds corresponded to the ALARP region. The tol-
erable and acceptable thresholds for these criteria had a
slope of –1 in the log-log scale. Such lines are the sets of
pairs F–N with the same level of risk, or iso-risk lines.
The uncertainty associated with small statistical sam-
ples was recognized, and Figure 8 was developed by
selecting a range in values constrained between 10 and
100 fatalities (in accordance with the database). The
coordinate for N at 10 fatalities and F at 2.0 3 10–6 was
used as anchor in Figure 8, and the estimate toward a
larger number of fatalities progressively reduced to
reflect the decrease in accidents as the number of fatal-
ities increased. Because only one out of the 10 accidents
had an N near 100, the estimates were reduced by about
one order of magnitude for N at 100. A similar process
was followed for the estimates at the subdivision scale,
maintaining the decrease by an order of magnitude for N
at 100.
The societal risks plotted in Figure 8 are crude, order
of magnitude estimates of past safety performance, how-
ever they can provide valuable insights into evolutionary
trends and gross safety levels. These estimates suggest
that societal risks associated with rail transport would be
considered acceptable according to HSE recommenda-
tions when assessed at the milepost scale (track lengths
of a mile). This scale can be considered adequate for
assessment when compared with the areal extent of other
industries (e.g., power plants, manufacturing facilities).
Societal risks at a subdivision scale were within the
ALARP region (occurrences after 1950), which is
56
Figure 8. Estimated societal risks for rail transport in Canada.
Note: ALARP = area between tolerable and acceptable thresholds; HSE =
UK Health and Safety Executive.
consistent with increasing safety engineering efforts over
the past few decades. This scale is considered adequate
as it represents an operational unit within the industry.
The proximity of the estimated societal risks (at the sub-
division scale) to the HSE-recommended tolerability
thresholds suggests there are further opportunities for
enhancing safety to more acceptable levels. They also
illustrate the imperative for controlling residual risks
once mitigation strategies are in place, through robust
safety management systems. Moreover, the severity of
events with multiple fatalities might require special con-
sideration with regard to consequence mitigation in the
event of an occurrence, a tragic example being the events
at Lac-Mégantic in 2013 (8).
Hierarchy of Incidents
For visualization purposes, the occurrence frequencies
per type were evaluated through an incident pyramid
(Figure 9). The incident pyramid illustrates a direct rela-
tionship between various levels of incident frequency and
severity. Incidents with higher severity are located at the
top of the pyramid and occur less frequently, whereas
incidents with lower severity occur more frequently. The
pyramid indicates that decreasing the frequency of occur-
rences in the lower levels of the pyramid would reduce the
likelihood of high-consequence events, thereby reducing
the frequencies at the top of the pyramid (26). To develop
an incident pyramid for railroads, RODS occurrence
Transportation Research Record 2675(1)
Figure 9. Incident pyramid distribution per occurrence type for
RODS, 2007–2017.
types are classified into five groups and presented in
Figure 9. In addition, Appendix A presents the logic for
classifying these occurrences as per the incident pyramid.
To provide further details of the number of occurrence
types per level in the incident pyramid for 2007 to 2017,
Figure 10 was plotted, providing some insight into the
severity associated with each occurrence type according
to records:
Detail I: Trespasser and crossing accidents account
for most fatal occurrences, as known from previous
analyses (6, 8). It is interesting to note, however, that
trespasser injuries are mostly fatalities or serious inju-
ries, with a small proportion of minor injuries, high-
lighting the severity of such accidents. Fatalities and
serious injuries account for more than half of the
crossing accidents with injuries. Occurrence types
associated with transport and handling with the great-
est number of fatal occurrences are main-track derail-
ments (4), but passenger incidents account for most
occurrences involving serious incidents (12).
Detail II: Occurrences with material damage or
time loss are dominated by non-main-track train
derailments (6,319). On the other hand, near misses
are dominated by movements exceeding limits of
authority (1,285).
Sattari et al
Figure 10. Details in incident pyramid distribution per occurrence type for RODS, 2007–2017.
Detail III: Substandard conditions and practices are
dominated by main-track switches in abnormal posi-
tion (27) and a signal less restrictive than required
(18). The reported near misses and substandard condi-
tions and practices have lower frequencies compared
with the upper levels of the pyramid. This is a result of
RODS only including a subset of these substandard
conditions and practices and, as a result, TSB is effec-
tively blinding itself to the insights gleaned from
57
analyzing the root causes and preventing the occur-
ence of loss events (colloquially referred to as ‘‘mining
the diamond’’, which recognizes that only a small frac-
tion of these conditions and practices could result in
an incident) (26).
Moreover, the incident pyramid levels were modified
to Figure 11 to better suit a classification of RODS
that involved TDG and the potential severity of these
58 Transportation Research Record 2675(1)

Detail IV: Fatalities associated with TDG correspond

to one main-track train derailment, with 47 fatalities,
highlighting the potential for high consequences given
this type of occurrence. All minor injuries associated
with TDG were leakers (8).
Detail V: DG leakers account for 731 occurrences of
764 occurrences with dangerous goods released.

Reported near misses were all uncontrolled move-

Figure 11. Incident pyramid distribution per occurrence type for
RODS involving DG, 2007–2017.
occurrences as they relate to the goods they are
transporting.
Figure 12 provides more details including the follow-
ing insights:
ments of rolling stock. This low frequency suggests that
near misses are being underreported. RODS did not
include any substandard conditions or practices. Again,
by not including substandard conditions or practices,
root cause analysis and the identification of preventative
measures is being impeded.
With respect to DG leakers, eight out of 731 occur-
rences between 2007 and 2017 were associated with
minor injuries. This corresponds to a ratio of 1.09%
minor injuries per DG Leaker, 0.73 DG leakers with inju-
ries each year, and 1.36 minor injuries associated with
DG leakers each year. These statistics suggest reduced
levels of risk; however, the nature of the incidents indi-
cate that major injuries are likely. Appendix B presents
the summary description of occurrences with dangerous
goods leaking, as presented in RODS, and for those DG
leakers that involved minor injuries.
Furthermore, a measure of past severity of occur-
rences involving DG released cars involved and derailed

Figure 12. Details in incident pyramid distribution per occurrence type for RODS involving DG, 2007–2017.
Note: DG = dangerous goods.
Sattari et al
Figure 13. Occurrences with DG released cars per occurrence
type.
Note: DG = dangerous goods.
Figure 14. A generic incident pyramid.
are shown in Figure 13. The severity as measured by the
number of DG cars released in this figure can provide fur-
ther insight into those occurrences with the potential for
larger consequences after the release of DG. These occur-
rences are mostly main-track and non-main-track derail-
ments, followed by collisions and crossing accidents.
Analysis of Rail Incident Causes from a
Process Safety Management Perspective
Process safety management (PSM) involves different
aspects of working with DG in the process industries:
59
handling, usage, storage, transportation, and manufac-
turing (28). Therefore, the decision-making process for
safety requires the involvement of several team players
such as politicians, the general public, and experts, as
well as consideration of issues such as congestion, the
economy, and the environment (29). The goal of PSM is
to reduce the risk of hazardous chemicals being released
by preventing unplanned loss of containment. When
applied to transportation, PSM implements a framework
for managing TDG. According to the Occupational
Safety and Health Administration (2000), this guideline
should contain information pertaining to the hazards of
the chemicals in the process, the technology of the pro-
cess, and the equipment used in the process. There are
many ways to prevent process safety incidents: by work-
ing to educate individuals, we can learn from previous
incidents (30), assess hazards and risks associated with
hazardous chemicals (31), implement other administra-
tive controls such as improvement in safety norms (32),
and analyze and evaluate the causes of accidents for
rational allocation of resources by the most efficient
approach possible (33).
Our identification of key occurrence types for rail
transport safety and TDG corresponded to an analysis
of frequency and severity associated with the different
occurrence types. This analysis required classifying
RODS following use of process safety tools (Figure 14)
to examine the relative frequency of occurrence types.
Based on this analysis, it appeared that near misses and
substandard practices and conditions were being under-
reported. By examining such leading indicators, railway
operators and regulators are equipped to identify root
causes and prevent more serious occurrences. From this
analysis, key occurrences with the highest severity associ-
ated with TDG and rail transport in general were identi-
fied (trespasser and crossing accidents not included) as
immediate cause and near misses, substandard condi-
tions, and substandard practices.
Immediate Causes: Incidents Involving Dangerous
Goods Release
The review of the RODS database suggests that historical
and, as suggested by the incident descriptions, immediate
causes are critical to reducing the potential for serious
incidents associated with the TDG. These causes can be
categorized as (i) main-track train derailments and colli-
sions, (ii) non-main-track train derailments and colli-
sions, and (iii) DG leakers.
In a study undertaken by Liu et al., the most com-
mon type of main-track railroad accident (in the
United States) was train derailment causing service dis-
ruption and property damage (34). In the current
study, main groups and subgroups of causes reported
60
Figure 15. Frequency of causes (cause group in dark bars, subgroup in lighter bars) for main-track train derailments.
for main-track train derailments are shown in Figure
15. Cause groups are led by track, roadbed, and struc-
tures, then mechanical and electrical failures, which are
closely followed by train operations—human factors.
At the subgroup level, the top causes are associated
with rail brakes, track geometry, train handling, and
makeup, followed by several subgroups including axle
and wheel breaks, environmental conditions, roadbed,
draft, and brakes. The data suggest that besides the top
three causes, several causes have similar orders of mag-
nitude for frequencies.
Main groups and subgroups of causes reported for
non-main-track train derailments are shown in Figure
16. Groups of causes are led by train operation—human
factors—followed by track, roadbed, and structures. The
leading subgroups are related to the use of switches (fail-
ure to apply or remove, passed couplers, shoving move-
ments failure to control, improperly aligned), track
geometry (wide gauge) and environmental conditions
(particularly ice or earth materials on the track).
Another critical cause underlying the potential for
serious incidents associated with TDG is related to main-
track train collisions. According to results provided by
Figure 17a, the main causes for these kinds of accidents
are dominated by train operation: human factors
Transportation Research Record 2675(1)
(particularly those related to speed), violations of author-
ity, train handling, and the use of brakes. In a similar
study conducted in the UK, about 75% of the total num-
ber of accidents between 1942 and 2012 were related to
human factors such as poor performance by train driv-
ers/operators (27). On the other hand, issues with man-
way cover bolts and gaskets (over 50%) are reported as
leading factors for DG leakers, Figure 17b.
Near Misses, Substandard Conditions, and
Substandard Practices
Occurrences with the potential to cause derailments and
collisions can be categorized as (i) movement exceeds the
limits of authority, (ii) main-track switch in abnormal
position, (iii) uncontrolled movement of rolling stock,
and (iv) unprotected overlap of authorities.
Figure 18 illustrates that the main causes reported for
accidents resulting when movement exceeds the limits of
authority. These causes are dominated by violations of
main track authorities (train operators-human factor)
followed by those related to flagging and signals.
The next occurrences with the potential to cause
derailments and collisions are presented in Figure 19a
Sattari et al
Figure 16. Frequency of causes for non-main-track train derailments.
showing the main groups and subgroups of causes
reported are main-track switches in abnormal position.
These are dominated by issues associated with the use of
switches (improperly aligned), followed by main track
authorities. Figure 19b indicates the causes reported for
uncontrolled movement of rolling stock. These are domi-
nated by the improper use of brakes followed by envi-
ronmental conditions and switching rules.
Another cause of derailments and collisions is illu-
strated in Figure 20: unprotected overlap of authority. In
this division, errors in communications; preparations of
train orders, warrants, and other directions; and other
human errors and main-track authority violations not
specified are the leading causes.
Dealing with serious low-frequency railroad DG acci-
dents requires more advanced methods such as risk anal-
ysis to identify the most effective options (35). The
importance of the detailed evaluation of causes presented
here for the key occurrence types is the insights this
affords for developing the process models for identifying
key leading indicators. Based on the assessment and the
authors’ experience, it was envisioned that leading indi-
cators would be a subset of the following (36):
61
 Job safety analysis development
 Contractor and subcontractor safety audits
 Workforce engagements and monitoring
 Contractor project manager, client, and safety rep
engagements
 Nonroutine safety actions
 Stop Work Authority enacted, and
 Corrective action item.
It is notable that human factors is one of the leading
components of these occurrences. In research carried
out by Kyriakidis et al., distraction/loss of concentra-
tion, safety culture, proper communication between
employees, workload, training, and stress have been
determined to be the most significant contributions to
the operators’ performance (37). As a result, there is a
significant opportunity for future research to control
human performances by using PSM tools such as layer
of protection analysis and bow tie diagrams. The appli-
cation of these tools requires a more detailed data anal-
ysis method that results in identifying and determining
the risks as well as some useful mitigation and preven-
tion strategies (38).
62 Transportation Research Record 2675(1)

Figure 17. Frequency of causes for main-track train: (a) Main-track train collisions and (b) DG leakers.

Figure 18. Frequency of causes for movements exceeding limits of authority.

Sattari et al 63

Figure 19. Frequency of causes for (a) main-track switch in abnormal position and (b) uncontrolled movement of rolling stock.

Figure 20. Frequency of causes for unprotected overlap of authorities.

1
Or timetable authority, failure to comply.
2
Track bulletins, radio, error in preparation, transmission, or delivery.
64
Figure 21. Railway fatality risk compared across a selection of
countries worldwide, 2012–2016 (39).
The results presented in this section indicated that the
performance of currently reported lagging indicators is
adequate, including derailments and collisions (main and
nonmain track), serious injuries (including fatalities), DG
leakers, and releases as per the UK HSE. However, it can
be added that tolerability strategies for leading indicators
should focus on a subset of indicators that represent the
overall safety levels for TDG, based on the criticality of
the different occurrence types.
Although the industry’s efforts to enhance the safety
of operations is reflected in decreasing incident trends,
the data provided in this section highlighted some potential
opportunities for improvement. Figure 21 illustrates
Canada’s rail fatality risk is the highest among the countries
compared (39). As a result, the reduction of fatality risk on
Canada’s railways should be considered a subject of great
interest, and one that requires decisive action among
Canadian researchers.
On the other hand, as regards the passenger fatality
risk, Canada places second compared with other coun-
tries (Figure 22).
It can be concluded that there is an opportunity to
optimize resource allocation for risk mitigation strate-
gies, targeting the most critical conditions and practices
that have the potential to lead to incidents. To achieve
this goal, this work has presented a detailed analysis of
the reported causes of the key occurrences associated
with TDG. The analysis identified a list of causes that
were most recurrent for the key occurrence types, as
reported in RODS. The list identifies several subcauses,
which are presented in Appendix C. This list is consistent
with expectations; however, the report provides justifica-
tion for focusing on these occurrence types for further
assessment and evaluation. Further, the details in the
appendix provide the necessary information to evaluate
Transportation Research Record 2675(1)
Figure 22. Passenger fatality risk compared across a selection of
countries worldwide, 2012–2016 (39).
potential leading safety indicators in subsequent tasks
for this research. The list of prevalent causes follows:
 Broken rails (critical in relation to derailments)
 Mechanical failures: brakes, wheels, axles, draft
system (critical in relation to derailments)
 Track geometry, particularly sun kinks (critical in
relation to derailments)
 Switching rules and operation of switches
 Train handling and makeup
 Main track authority violations, many related to
communication issues, and
 Use of brakes.
Moreover, analyzing the reported causes of DG leakers
as potentially high-consequence occurrences identified
further insights into the failure of manway cover bolts
and gaskets.
Conclusion
The number of rail accidents reported by TSB indicated
a consistent decreasing trend, which suggests a continued
increase in the general safety of rail transport. Similarly,
accidents involving DG and accidents with releases of
DG showed overall decreasing trends. This study pre-
sented a detailed analysis of the reported causes for the
key occurrences associated with TDG. The analysis iden-
tified a list of causes that were most recurrent for the key
occurrence types, as reported in RODS.
With regard to the safety of people, overall fatalities
and injuries showed a decreasing trend; however, trends
remained steady for employees, which suggests an oppor-
tunity to enhance safety management strategies. An eva-
luation of individual risks, according to the criteria
Sattari et al
suggested by the HSE, indicated that these were within
tolerable thresholds for employees and within acceptable
thresholds for passengers. However, such an evaluation
would be challenging for trespasser and crossing acci-
dents and was outside the scope of this study.
An evaluation of historic societal risks in relation to the
likelihood of events with large number of fatalities (over
10 per event) suggested rail transport was within tolerable
thresholds, however, there is scope for improvement.
After data analysis, it was noted that human factors
was one of leading causes in occurrences in rail transpor-
tation. Managing risk through human factors can take
many forms: redesigning equipment to enhance user per-
formance, accounting for poor worker performance
when designing systems, and preventing risk to workers
caused by changes at the organizational level. It is also
important to realize that dealing with risk in transporta-
tion is a multidisciplinary field requiring cooperation
between different human factors. Recognizing this, it
would be beneficial to optimize systems by having an
integrated team and preventing duplication of effort.
In addition, further research employing machine
learning (ML) and artificial intelligence could be benefi-
cial to identify and prioritize the best strategies for reduc-
ing incident rates in the organization. ML could be
applied to classify the incidents into different groups
based on their causes or occurrences, then a unique ana-
lytical approach such as Bayesian network could be
applied to determine the network and dependencies
between these groups. This information would help a
company maximize the utilization of their resources as
well as reduce the number of incidents taking place.
Acknowledgments
Transport Canada’s Railway Research Advisory Board of
Canada, Canadian National Railway, and Canadian Pacific
Railway provided valuable discussion and feedback during the
development of the study.
Author Contributions
The authors confirm contribution to the paper as follows: study
conception and design: FS, RM, LL; data collection: FS; analy-
sis and interpretation of results: FS; draft manuscript prepara-
tion led by: FS. All authors reviewed the results and reviewed
and approved the final version of the manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
65
Funding
The author(s) disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this
article: Canadian Rail Research Lab at the University of
Alberta and Transport Canada.
Supplemental Material
Supplemental material for this article is available online.
References
1. Council of Ministers, and Task Force on Transportation
and the Economy. Transportation & the Economy: Final
Report of the PPSC Task Force on Transportation and
the Economy. Council of Ministers Responsible for Trans-
portation and Highway Safety, Ottawa, ON, 2014.
www.comt.ca. Accessed March 7, 2019.
2. Transport Canada. Transportation in Canada 2016 –
Comprehensive Report. Minister of Transport, 2017.
www.tc.gc.ca. Accessed March 7, 2019.
3. Railway Association of Canada. Railways 101. 2016.
www.railcan.ca. Accessed March 8, 2019.
4. Miller-Hooks, E., and H. S. Mahmassani. Optimal Rout-
ing of Hazardous Materials in Stochastic, Time-Varying.
Transportation Research Record: Journal of the Transporta-
tion Research Board, 1998. 1645: 20–25.
5. Minister of Justice. Transportation of Dangerous Goods
Act, 1992 (Consolidation). Current to February 14, 2019.
2017. www.laws-lois.justice.gc.ca. Accessed March 11, 2019.
6. Railway Association of Canada. Rail Trends 2018. 2018.
www.railcan.ca. Accessed March 11, 2019.
7. Transportation Safety Board of Canada. Railway Investi-
gation Report R05E0059: Derailment Canadian National
Freight Train M30351-03 Mile 49.4, Edson Subdivision,
Wabamun, Alberta, 03 August 2005. 2007. www.tsb.gc.ca.
Accessed March 11, 2019.
8. Transportation Safety Board of Canada. Railway Investi-
gation Report R13D0054: Runaway and Main-Track
Derailment – Montreal, Maine & Atlantic Railway Freight
Train MMA-002 Mile 0.23, Sherbrooke Subdivision Lac-
Mégantic, Quebec 06 July 2013. IS. 2014. www.tsb.gc.ca.
Accessed March 11, 2019.
9. Macciotta, R., S. Robitaille, M. Hendry, and C. D. Mar-
tin. Hazard Ranking for Railway Transport of Dangerous
Goods in Canada. Case Studies on Transport Policy, Vol.
6, No.1, 2018, pp. 43–50.
10. Rahbar, M., and M. Bagheri. Risk Assessment Framework
for the Rail Transport of Hazardous Materials. Transpor-
tation Research Record: Journal of the Transportation
Research Board, 2014. 2411: 90–95.
11. Railway Safety Act Review Panel. Enhancing Rail Safety in
Canada: Working Together for Safer Communities. Minis-
ter of Transport, Government of Canada, Rail Safety Act
Review, Ottawa, ON, 2018.
66
12. CaRRL. Canadian Rail Research Laboratory: Report on
Enhanced Train Control. Prepared for Transport Canada.
Faculty of Engineering, University of Alberta, 2018.
13. Crowl, D. A., and J. F. Louvar. Chemical Process Safety:
Fundamentals with Applications, 4th ed. Prentice Hall, NJ,
2019.
14. Kononov, J., and B. K. Allery. Explicit Consideration of
Safety in Transportation Planning and Project Scoping.
Transportation Research Record: Journal of the Transporta-
tion Research Board, 2004. 1897: 116–125.
15. Canadian Association of Petroleum Producers. Process
Safety Event [PSE] Reporting. 2019. https://www.capp.ca/
wp-content/uploads/2019/11/Process_Safety_Event_PSE_
Reporting_Gui-334210.pdf.
16. Transportation Safety Board of Canada Statistical Sum-
mary – Railway Occurrences 2017. 2018. www.tsb.gc.ca.
Accessed January 29, 2019.
17. Statistics Canada. Statistics Canada Mortality, Summary
List of Causes 2009. Catalogue no. 84F0209X. 2012.
18. WorkSafeBC. WorkSafeBC 2015 Statistics. 2016. www
.worksafebc.com. Accessed May 5, 2017.
19. Alberta Labour. Alberta Labour 2015 Workplace Injury,
Disease and Fatality Statistics Provincial Summary. 2016.
www.work.alberta.ca. Accessed May 5, 2017.
20. United Kingdom Health and Safety Executive. Reducing
Risk, Protecting People, HSE Decision-making Process.
HM Stationary Office, London, 2011.
21. Baybutt, P. The ALARP Priciple in Process Safety. Process
Safety Progress, Vol. 33, No. 1, 2014, pp. 36–40.
22. Transportation Safety Board of Canada. Railway Investi-
gation Report R12T0038: Main-Track Derailment Via Rail
Canada Inc. Passenger Train No. 92 Mile 33.23, Canadian
National Oakville Subdivision Aldershot, Ontario 26 Feb-
ruary 2012. 2013. www.tsb.gc.ca. Accessed March 11, 2019.
23. Canadian Broadcasting Company. Rail Accidents and
Disasters in Canada. 2012. www.cbc.ca/news/canada/
rail-accidents-and-disasters-in-canada-1.1149829. Accessed
February 27, 2012.
24. Maclean’s. Maclean’s 10 of Canada’s Worst Train Acci-
dents. 2013. www.macleans.ca/society/life/10-of-canadas-
worst-train-accidents.
25. Historica Canada. The Canadian Encyclopaedia - Railway
Disasters. 2015. www.thecanadianencyclopedia.ca/en.
26. Goldenhar, L. M., P. Amadee, T. Barsotti, R. Brown, and
O. B. Mills. Safety Culture and Safety Climate in Construc-
tion: Bridging Research and Practice. Proc., ASSE Profes-
sional Development Conference and Exposition, American
Society of Safety Engineers, Dallas, TX, 2015.
27. Kyriakidis, M., K. T. Pak, and A. Majumdar. Railway
Accidents Caused By Human Error: Historic Analysis of
UK Railways, 1945 to 2012. Transportation Research
Record: Journal of the Transportation Research Board,
2015. 2476: 126–136.
Transportation Research Record 2675(1)
28. Occupational Safety and Health Administration. Process
Safety Management (OSHA 3132). Occupational Safety
and Health Administration, 2000.
29. Cafiso, S., and C. D’Agostino. Reliability-Based Assess-
ment of Benefits in Roadway Safety Management. Trans-
portation Research Record: Journal of the Transportation
Research Board, 2015. 2513: 1–10.
30. Ness, A. Lessons Learned from Recent Process Safety Inci-
dents. Chemical Engineering Progress, Vol. 111, No. 3,
2015, pp. 23–29.
31. Sanni-Anibire, M. O., A. S. Mahmoud, M. A. Hassanain,
and B. A. Salami. A Risk Assessment Approach for
Enhancing Construction Safety Performance. Safety Sci-
ence, Vol. 121, 2020, pp. 15–29. https://doi.org/10.1016/
j.ssci.2019.08.044.
32. Rubin, M., A. Giacomini, R. Allen, R. Turner, and B.
Kelly. Identifying Safety Culture and Safety Climate Vari-
ables that Predict Reported Risk-Taking Among Austra-
lian Coal Miners: An Exploratory Longitudinal Study.
Safety Science, Vol. 123, 2020, p. 104564. https:
//doi.org/10.1016/j.ssci.2019.104564.
33. Liu, X., M. R. Saat, and C. P. L. Barkan. Analysis of
Causes of Major Train Derailment and their Effect on
Accident Rates. Transportation Research Record: Journal
of the Transportation Research Board, 2012. 2289: 154–163.
34. Liu, X., M. Saat, and C. Barkan. Safety Effectiveness of
Integrated Risk Reduction Strategies for Rail Transport of
Hazardous Materials. Transportation Research Record:
Journal of the Transportation Research Board, 2013. 2374:
102–110.
35. Barkan, C. P. L., C. Tyler Dick, and R. Anderson. Rail-
road Derailment Factors Affecting Hazardous Materials
Transportation Risk. Transportation Research Record:
Journal of the Transportation Research Board, 2003. 1825:
64–74.
36. Salas, R., and M. Hallowell. Predictive Validity of Safety
Leading Indicators: Empirical Assessment in the Oil and
Gas Sector. Journal of Construction Engineering and Man-
agement, Vol. 142, No. 10, 2016.
37. Kyriakidis, M., A. Majumdar, G. Grote, and W. Y.
Ochieng. Development and Assessment of Taxonomy for
Performance-Shaping Factors for Railway Operations.
Transportation Research Record: Journal of the Transporta-
tion Research Board, 2012. 2289: 145–153.
38. Scaife, R. Human Factors in the Chemical and Process
Industries. 2016. https://doi.org/10.1016/B978-0-12-803
806-2.00006-6.
39. European Railway Agency. Report on Railway Safety and
Interoperability in the EU 2018. 2018, pp. 19–21. https://
www.era.europa.eu/sites/default/files/library/docs/safety_
interoperability_progress_reports/railway_safety_and_int
eroperability_in_eu_2018_en.pdf.