News release

In its investigation report (R16E0051) released today, the Transportation Safety Board of Canada (TSB) found that proceeding past a restricted speed signal led to two trains colliding near Carvel, Alberta, in June 2016. The report highlights a number of safety risks, including the absence of physical fail-safe defences to ensure that signals are consistently recognized and followed.

On 4 June 2016, CN train 112 was proceeding eastward from Edson to Edmonton, Alberta, when it collided with the tail end of eastbound train 302, which had stopped near Carvel to allow a westbound train to pass. No cars derailed as result of the collision. The crew of train 302 did not feel the impact as their train was in a stretched state with the brakes released. After the collision, the crew of train 112 conducted a visual inspection of the tail end of train 302, but did not see that one empty hopper car had sustained minor damage, and did not report the incident. The collision was subsequently confirmed by remotely downloading information from the locomotive event recorder and a forward-facing video camera.

The investigation found that, after correctly identifying a signal calling for reduced speed, the crew of train 112 passed the signal at a speed that exceeded the limit. As such, they were unable to stop in time to avoid the collision with train 302. Upon entering a curve at 27 mph, they saw train 302 stopped about 840 feet ahead whereas they had assumed it was further away. The emergency brake was applied, slowing the train to about 18 mph prior to the collision.

This occurrence once again highlights the systemic risks of not following railway signal indications, a TSB Watchlist issue. If existing signal systems do not include physical fail-safe capabilities, signal recognition or application errors by crew members may not be detected, increasing the risk of train collisions and derailments. Since 1998, the TSB has investigated 13 other similar occurrences and issued two recommendations (R13-01 and R00-04) calling for implementation of physical train controls and additional backup safety defences to help ensure that signal indications are consistently followed. Despite significant work on research initiatives, there still remains no short-term plan to address the risk of train collision or derailment in the absence of additional backup safety defences. Transport Canada responses to both recommendations have been assessed as Satisfactory in Part.

In addition, the crew of train 112 did not follow the requirements for reporting contraventions and safety hazards. If relevant safety data, including incident or rule violation reports, are not available to help identify safety issues, emerging trends involving unsafe events may not be identified in a timely manner, increasing the risk of accidents. In this occurrence, the decision not to report the collision resulted in only a cursory inspection of both trains, rather than the required thorough inspections.

Although the crew of train 112 met established rest requirements, the unpredictability of train schedules and call times may lead to cumulative sleep deficit, which can increase the risk of fatigue. This is why fatigue management for freight train crews has been on the TSB Watchlist since 2016.