Rail transportation safety investigation R18M0037

The occurrence

On 4 December 2018, at approximately 0827 Atlantic Standard Time, a cut of 2 cars loaded with mixed freight rolled uncontrolled westward on the west lead track at Canadian National Railway Company (CN) Edmundston Yard in Edmundston, New Brunswick. The leading car struck a trailing locomotive travelling in the opposite direction. The conductor trainee, who was standing on the northeast footboard of the locomotive, was trapped between the locomotive and the leading car and was fatally injured. No rolling stock derailed, and no dangerous goods were involved.

During switching activities before the occurrence, the cut of 2 cars had been moved approximately 4380 feet without the air brakes having been applied. During winter operations, applying brakes regularly conditions the brakes to prevent snow and ice from building up between the brake shoes and the wheels. To carry out the next movement, the crew had to temporarily leave the cut of cars on the west lead track. The crew considered the cars to be attended and applied the emergency brakes. However, ice contamination during the previous movements had made the brakes less effective, and, as a result, the total retarding force generated by the brakes of the 2 cars was insufficient to prevent the cut of cars from rolling uncontrolled. If the brakes on rolling stock are not properly conditioned in winter conditions, their effectiveness can be compromised, increasing the risk of an uncontrolled movement.

In November 2018, CN had issued a notice regarding train operations in winter conditions that reminded employees of the requirement to regularly condition the brakes on rolling stock. This directive allows some latitude to locomotive engineers, who can adjust some tasks, such as brake conditioning, according to their personal experience. This practice is acceptable as long as in-train forces are not increased and control of the train is not compromised. However, if the various directives, rules, and operating instructions in effect are not properly interpreted and applied, the safety of railway operations could be compromised, increasing the risk of an accident.

When the conductor realized that the cut of cars was rolling uncontrolled, it had already passed the fouling point of switch EA04. Given the speed of the cut of cars, the track gradient in the area, and the presence of snow on the ground, the conductor was unable to take any action to stop the cut of cars. Rule 112 of the Canadian Rail Operating Rules, railway instructions, and employee training do not clearly define the factors and risks that must be taken into account for employees to determine whether they are in close enough proximity to take effective action to stop an uncontrolled movement of equipment.

Safety communications

Media materials

News release

Deployment notice