Train securement practices led to December 2018 fatal uncontrolled train movement
Dartmouth, Nova Scotia, 26 January 2021 — In its investigation report (R18M0037) into a fatal uncontrolled train movement released today, the Transportation Safety Board of Canada (TSB) identified that the safety of railway operations could be compromised if the various directives, rules, or operating instructions in effect are not properly interpreted and applied.
On 4 December 2018, at approximately 0827 Atlantic Standard Time, a cut of two cars ran uncontrolled westward on the west lead track at Canadian National (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 footboard of the locomotive was trapped between the locomotive and the leading car and was fatally injured. There was no derailment and no dangerous goods were involved.
The two cars had been temporarily left on the west lead track with only the emergency brakes applied, as the crew considered them to be “attended” as per Rule 112 of the Canadian Rail Operating Rules (CROR). If the cars had been considered to be “unattended”, the employees would have been required to secure them by applying hand brakes to both cars, and conducting a brake effectiveness test. The investigation found that the CROR Rule 112, railway company instructions and employee training do not clearly define the factors and risks that employees must consider to determine whether they are in close enough proximity to take effective action to stop the equipment should it move unintentionally.
Additionally, the investigation found that the brake effectiveness of the two cars had been reduced due to ice contamination during the previous moves inside the yard, and consequently, the total retarding force generated by the brakes of the two cars became insufficient to prevent the cut from rolling uncontrolled. During winter operations, regularly applying brakes serves to condition the brakes in order to prevent snow and ice from accumulating between the brake shoes and the wheels. 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.
Unplanned/uncontrolled movement of rail equipment is on the TSB Watchlist 2020 as one of the key safety issues that need to be addressed to make Canada’s transportation system even safer.
Four days following the occurrence, on 8 December 2018, CN issued two bulletins regarding cars left unattended in Edmundston Yard.
In March 2019, the TSB sent a Rail Safety Advisory (RSA 02/19) entitled “Securement of cars that are considered ‘attended’ during yard switching operations” to Transport Canada (TC), with a copy to Canadian National (CN), Canadian Pacific Railway (CP) and the Railway Association of Canada.
CN responded to the RSA stating that CROR Rule 112 was sufficiently clear, and that special instructions were already in place with regards to sections (i) and (iv). As for CP, the company’s response indicated that the definition of “unattended” of CROR Rule 112 was clear, and indicated that employees involved in the four uncontrolled movements of cars in CP yards in 2018 had been re-educated on CP’s rules and procedures.
TC, in its response to the RSA, and following its own investigation into this occurrence under Part II of the Canada Labour Code, indicated that it considered the cars to be unattended, and noted it had issued a letter of non-compliance to CN. In addition, TC stated its intention to further engage with industry to ensure there is accurate understanding of unattended equipment and to determine whether additional guidance is required.
See the investigation page for more information.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
For more information, contact:
Transportation Safety Board of Canada
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