The agency called on major passenger and freight railways to invest in an automatic, fail-safe system that would slow or stop trains if the crew misread the track signals.
That safety system could have prevented the Feb. 26, 2012 crash, in which the crew operating the Via Rail train all "misperceived" crucial signals telling them to slow down, the TSB said in its report on the incident.
While that accident proved fatal — three crew members were killed and 45 people were injured — the TSB warned that similar misperception of signals by train crews happens all too often.
"About once a month, somewhere in Canada, there's a disconnect between what the signal displays and the action the crew takes. That's a risk and we need to drive that risk down," said TSB Chair Wendy Tadros.
"We have to look at the benefit to the rail system, we have to look at the benefit to safety and to Canadians."
While she couldn't estimate the cost of implementing such a system across the country, Tadros said the safety mechanism was clearly needed in Canada.
"We lag way behind the rest of the world. Many, many countries have these systems," said Tadros, listing the United States, Britain, Germany, India and China among them.
"Transport Canada needs to sit down with the railways and talk to them about what needs to be done and then there needs to be some agreement on the technology."
The federal transport minister didn't make any commitments on the fail-safe controls — also known as positive train control — being called for by the TSB.
"We are closely monitoring the implementation of positive train control in the United States," said Denis Lebel. "Where there is a clear safety benefit, our government will not hesitate to take action."
The TSB suggested, however, that its recommendations regarding additional defences over the past decade have fallen on deaf ears.
"The industry has implemented more rules and procedures. This hasn't fixed the fundamental problem. And these accidents keep happening," Tadros said. "We need to fix this because if we don't, it will happen again."
Meanwhile, CN Rail (TSX:CNR) said it was working with Transport Canada on examining fail-safe train controls.
However it said the collision-avoidance technology — also known as PTC — is complex and should be further tested before being put in place across the rail industry.
"PTC, as currently being implemented, is a technologically complex system that as of yet has not been proven in any large scale industry implementation," CN said.
The automatic fail-safe mechanism was one of three main recommendations contained in TSB's 75-page report.
The agency also recommended the installation of in-cab cameras in all lead locomotives in mainline operations. It said recordings from such cameras would be key to understanding why accidents happen.
Via Rail has already committed to installing recorders throughout its fleet and expected to complete the process by mid-2014. The Railway Association of Canada also said it was encouraging its members to install the devices.
A third recommendation from the TSB involved ensuring all passenger and freight locomotives meet crash worthiness standards — which improve the crew's chances of survival in a crash.
The recommendations have been submitted to Transport Canada, which has 90 days to respond.
NDP transportation critic Olivia Chow called on the federal government to act on all the recommendations 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."
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.
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 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."
Misperception, where a factual error is typically made, is quite common and happens at various levels, said one expert.
"Our capacity to process information simultaneously is pretty limited," said Susanne Ferber, acting chair of the department of psychology at the University of Toronto.
"The history of what we are familiar with is a very powerful predictor of how we behave in the future. Overiding that takes some extra mental effort."
The TSB noted that since 2007, it had conducted five investigations into train collisions or derailments where misinterpretation or misperception of signals was a cause or contributing factor.Suggest a correction