BURLINGTON, Ont. -- The operating crew of a Via Rail train that derailed west of Toronto last year "misperceived" crucial signals telling them to slow down before the fatal crash, the Transportation Safety Board said Tuesday.
In its detailed analysis of the Feb. 26, 2012, crash, the agency recommended an automatic, fail-safe mechanism -- which would slow or stop trains if a signal isn't followed -- be implemented across Canada's rail network.
It's one of three major recommendations made in the board's 75-page report released in Burlington, Ont., where the deadly derailment took place.
TSB chair Wendy Tadros said she hoped the recommendation would be implemented because it could save lives.
"These things are happening over and over again, not always with the consequences of Burlington, but they are happening about once a month," said Tadros.
"In order to be robust safety systems, you need another defence in place. And this is the defence we're recommending."
The TSB pointed out that other countries, including the United States, are already working on implementing similar fail-safe mechanisms across their rail networks.
"We lag way behind the rest of the world, many many countries have these systems," said Tadros, who didn't provide a cost estimate for implementing the recommendation.
The train at the centre of the TSB report was travelling at more than 100 kilometres per hour when it went off the tracks just east of Aldershot station in Burlington, Ont., killing three engineers and injuring 44 passengers and a Via Rail employee.
The speed limit while changing tracks at that particular switch was 24 kilometres per hour.
The crew had not properly responded to signals requiring a slowdown, the TSB found, adding that several factors could have been responsible for their actions.
The report said the accident took place at a point in the route where the crew would normally go straight ahead at track speed but the train was diverted to the switch due to the unexpected presence of a work crew on the tracks.
"This crew expected to go straight ahead, they'd gone straight ahead 99 per cent of the time and expectation is a very powerful thing," Tadros said.
"It's quite possible to misperceive."
The TSB is also recommending the installation of in-cab video cameras in all lead locomotives in mainline operations. The agency says recordings from such cameras would be key to understanding why accidents happen.
A third recommendation from the TSB involves applying crash worthiness standards to rebuilt passenger and freight locomotives as well as new locomotives to improve crew survivability.
"These accidents keep happening," said Tadros.
"I think that Canadians are growing weary of train derailments and they want to see everything possible done to bring those numbers down even further."
The TSB's recommendations have been submitted to the federal Transport Minister, who has 90 days to respond.
NDP transportation critic Olivia Chow is calling on the federal government to act on them immediately.
"Safety really should come first," Chow said in Ottawa. "All it takes is political will and to make it mandatory that there would be voice recorders and video recorders, plus automatic breaking systems in all trains."
