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TSB Issues Safety Recommendations Following 2019 CN Derailment Investigation

Written by Marybeth Luczak, Executive Editor
TSB issued two safety recommendations following its investigation of the Jan. 3, 2019 CN train collision and derailment near Portage la Prairie, Manitoba. (Photograph Courtesy of TSB)

TSB issued two safety recommendations following its investigation of the Jan. 3, 2019 CN train collision and derailment near Portage la Prairie, Manitoba. (Photograph Courtesy of TSB)

The Transportation Safety Board of Canada (TSB) is calling for Transport Canada and the Canadian rail industry to expedite the implementation of automated train control systems and to develop and implement formal crew resource management training, following its investigation of the 2019 CN train collision and derailment in Manitoba.

TSB on Aug. 24 released its investigation report (R19W0002) into the collision of eastbound CN freight train 318 with westbound CN freight train 315, just east of Portage la Prairie, Manitoba.

On Jan. 3, 2019, trains 318 and 315 were operating on the Rivers Subdivision, one of CN’s busiest routes, which frequently transports dangerous goods, according to the TSB report (download below).

“Just under 3 hours later, while proceeding on the south track using Trip Optimizer …, train 318 passed a signal at Mile 52.2 indicating to the crew that they should be preparing to stop at the next signal, located at Mile 50.4 at Nattress,” TSB reported. “The conductor called out the signal as required, but did not hear the locomotive engineer (LE) verbally respond and the train continued at track speed.

“Soon after, the head ends on train 318 and train 315 passed each other, and train 318’s conductor reminded the LE of the previous signal. The LE then applied the train brakes. However, as the Stop signal indication at Nattress came into view, the crew recognized that they would not be able to stop in time and applied the brakes in emergency. Shortly after train 318 collided with the side of train 315 at 23 mph (37 km/h), the crew jumped from the train, sustaining minor injuries. The two head-end locomotives on train 318 and eight cars on train 315 derailed as a result of the collision.” While no railcars hauling dangerous goods were involved, “the head-end locomotives on train 318 lost a combined total of about 3,500 imperial gallons of diesel fuel,” TSB reported. “The released diesel fuel was contained locally and cleaned up with no waterways affected.”

Following the accident, CN distributed System Notice No. 904 to all operating employees in Canada, “warning train crews that there was an increase in occurrences where train crews failed to stop at signal indications requiring them to do so, primarily due to a lack of focus on situational awareness,” according to TSB.

Figure S1. Progression of signals encountered by train 318 while approaching Nattress. (Source: TSB)

The TSB accident investigation found that:

  • The “crew on train 318 had formed the expectation that they would continue following behind an earlier eastbound train through to Winnipeg, without stopping at Nattress.”
  • The locomotive engineer “was fatigued due to disrupted sleep periods during the two nights preceding the accident,” and consequently “experienced decreased vigilance due to fatigue and the reduced workload associated with the use of Trip Optimizer, which contributed to his delayed reaction to the signals displayed in the field.”
  • Rail operations “rely predominantly on administrative defenses, such as Canadian Rail Operating Rules and Work/Rest Rules for Railway Operating Employees, and safe train operations are contingent on train crews following the rules. When a train crew does not follow the rules, for whatever reason, the administrative defenses fail. When there is no secondary physical fail-safe defense, such circumstances can result in an accident that otherwise could have been prevented.”
  • The “train 318 crew communication within the cab was ineffective. Due to the difference in the level of experience between the train 318 crew members, the conductor deferred to the LE [locomotive engineer] without questioning the operation of the train and, as a result, the crew’s actions to slow and stop the train were delayed.”
TSB Chair Kathy Fox

TSB reported that the accident “highlights major issues in the rail industry and reinforces TSB’s call for physical fail-safe train controls for over two decades through recommendations R13-01 [on implementation of such controls beginning with Canada’s high-speed rail corridors] and R00-04 [on rail industry implementation of ‘additional backup safety defenses to help ensure that signal indications are consistently recognized and followed’].” 

As a result of its investigation, TSB has issued to Transport Canada two recommendations:

  1. Require all major Canadian railroads to speed implementation of “physical fail-safe train controls on Canada’s high-speed rail corridors and on all key routes.” TSB Chair Kathy Fox said: “The United States has fully implemented a positive train control system on all high-hazard track required by its federal legislation. This includes the U.S. operations of both CN and Canadian Pacific, which have invested significantly in their locomotive fleets and infrastructure. The railway industry must act more quickly to implement a similar form of automated or enhanced train control system on Canada’s key routes to improve rail safety and avoid future rail disasters.”
  2. Require Canadian railways to develop and implement formal crew resource management (CRM) training as part of qualification training for railway operating employees. “The aviation and marine industries experienced significant safety benefits with the introduction of CRM,” Fox said. “This type of training could provide additional tools and strategies to train crews to mitigate inevitable human errors, providing significant safety benefits in the rail industry.”


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