Backgrounder

TSB investigation findings into the July 2016 crossing accident in Moncton, New Brunswick (R16M0026)

Investigations conducted by the Transportation Safety Board of Canada (TSB) are complex – an accident is never caused by just one factor. The July 2016 crossing accident in Moncton, New Brunswick was no exception. There were many factors that caused this accident, the details of which are contained in the 7 findings as to causes and contributing factors. Furthermore, there were 4 findings as to risk as well as 2 other findings.

Findings as to causes and contributing factors

  1. The accident occurred when the pedestrianNote de bas de page 1 using a motorized wheelchair became immobilized at the crossing and was struck by the train.
  2. The asphalt at the crossing did not cover the entire width of the east sidewalk, leaving a void.
  3. The wheelchair had likely been steered towards the east reflective line on the sidewalk to avoid striking the post of the grade crossing warning system.
  4. The edge of the sidewalk led directly towards the void in the asphalt.
  5. Without reflective line markings on the newly asphalted portion of the sidewalk, the crossing lacked effective visual cues for the pedestrian to safely navigate at night.
  6. After the wheelchair's right caster wheel dropped into the void in the sidewalk, the wheelchair became stuck in the ballast, immobilizing the pedestrian.
  7. The performance capabilities of the wheelchair were adversely affected and did not allow the pedestrian to reverse out of the ballast and back onto the asphalt surface of the crossing.

Findings as to risk

  1. If crossings have uneven surface conditions, particularly if they intersect the railway tracks at an angle other than 90 degrees, swivel caster wheels on assistive devices can inadvertently rotate and drop into the flangeway gap and immobilize the assistive device, increasing the risk of a crossing accident.
  2. If pedestrians who use assistive devices are not aware of the specific hazards inherent to railway crossings, the necessary safety precautions may not be taken when traversing a crossing, increasing the risk of a crossing accident.
  3. If comprehensive inspections are not conducted after crossing surface maintenance work is completed, potential unsafe conditions for crossing users, particularly pedestrians using assistive devices, may not be identified and corrected in a timely manner, increasing the risk of a crossing accident.
  4. Until all crossings designated for persons using assistive devices are identified by road authorities and shared with the railways, the required improvements and related countermeasures for these crossings may not be implemented in a timely manner, and the risk to persons using assistive devices will persist.

Other findings

  1. Within Transport Canada's Grade Crossings Regulations, there are no regulatory requirements relating to the use of visibility markings along the sidewalks and roadways at crossings, including requirements on how to clearly mark where pedestrians are to cross.
  2. It could not be determined why the pedestrian did not make an emergency call while immobilized on the crossing, or if there had been sufficient time to do so. However, the pedestrian could have been out of position in the wheelchair after being jostled when the right caster wheel dropped into the void in the sidewalk, affecting the pedestrian's ability to initiate a call.

TSB investigation findings into the July 2016 crossing accident in Moncton, New Brunswick (R16M0026)

Investigations conducted by the Transportation Safety Board of Canada (TSB) are complex – an accident is never caused by just one factor. The July 2016 crossing accident in Moncton, New Brunswick was no exception. There were many factors that caused this accident, the details of which are contained in the 7 findings as to causes and contributing factors. Furthermore, there were 4 findings as to risk as well as 2 other findings.

Findings as to causes and contributing factors

  1. The accident occurred when the pedestrianNote de bas de page 1 using a motorized wheelchair became immobilized at the crossing and was struck by the train.
  2. The asphalt at the crossing did not cover the entire width of the east sidewalk, leaving a void.
  3. The wheelchair had likely been steered towards the east reflective line on the sidewalk to avoid striking the post of the grade crossing warning system.
  4. The edge of the sidewalk led directly towards the void in the asphalt.
  5. Without reflective line markings on the newly asphalted portion of the sidewalk, the crossing lacked effective visual cues for the pedestrian to safely navigate at night.
  6. After the wheelchair's right caster wheel dropped into the void in the sidewalk, the wheelchair became stuck in the ballast, immobilizing the pedestrian.
  7. The performance capabilities of the wheelchair were adversely affected and did not allow the pedestrian to reverse out of the ballast and back onto the asphalt surface of the crossing.

Findings as to risk

  1. If crossings have uneven surface conditions, particularly if they intersect the railway tracks at an angle other than 90 degrees, swivel caster wheels on assistive devices can inadvertently rotate and drop into the flangeway gap and immobilize the assistive device, increasing the risk of a crossing accident.
  2. If pedestrians who use assistive devices are not aware of the specific hazards inherent to railway crossings, the necessary safety precautions may not be taken when traversing a crossing, increasing the risk of a crossing accident.
  3. If comprehensive inspections are not conducted after crossing surface maintenance work is completed, potential unsafe conditions for crossing users, particularly pedestrians using assistive devices, may not be identified and corrected in a timely manner, increasing the risk of a crossing accident.
  4. Until all crossings designated for persons using assistive devices are identified by road authorities and shared with the railways, the required improvements and related countermeasures for these crossings may not be implemented in a timely manner, and the risk to persons using assistive devices will persist.

Other findings

  1. Within Transport Canada's Grade Crossings Regulations, there are no regulatory requirements relating to the use of visibility markings along the sidewalks and roadways at crossings, including requirements on how to clearly mark where pedestrians are to cross.
  2. It could not be determined why the pedestrian did not make an emergency call while immobilized on the crossing, or if there had been sufficient time to do so. However, the pedestrian could have been out of position in the wheelchair after being jostled when the right caster wheel dropped into the void in the sidewalk, affecting the pedestrian's ability to initiate a call.