Rail transportation safety investigation R18H0039
The TSB has completed this investigation. The report was published on 22 July 2020.
Table of contents
Uncontrolled movement of rolling stock
Canadian Pacific Railway
Remote control locomotive system
Yard assignment T16-13
Mile 195.5, Belleville Subdivision
Toronto Yard
Toronto, Ontario
14 April 2018
The occurrence
On , at about 0215 Eastern Daylight Time, a Canadian Pacific Railway (CP) yard foreman and a CP yard helper were performing switching operations at CP’s Toronto Yard in Toronto, Ontario using a remote control locomotive system (RCLS). The yard foreman was operating yard assignment T16-13 (the assignment) when it began to roll uncontrolled eastward on the Staines connecting track.
Media materials
News release
Training deficiencies and crew inexperience factors in 2018 uncontrolled movement of rail cars in Toronto, Ontario
Read the news release
Backgrounders
Investigation information
Map showing the location of the occurrence
Investigator-in-charge
Glen Pilon has been with the TSB since 2008 as Technical Coordinator and investigator at the TSB Head Office in Gatineau, Quebec. He has been the investigator-in-charge of a number of rail accident investigations and has acted as train operations expert on many others. Mr. Pilon worked for the Ottawa Valley Railway (OVR) from 1996 until 2008 as locomotive engineer and safety officer and with the Canadian Pacific Railway (CP) from 1987 until 1996 in operations as trainman and conductor.
Class of investigation
This is a class 2 investigation. These investigations are complex and involve several safety issues requiring in-depth analysis. Class 2 investigations, which frequently result in recommendations, are generally completed within 600 days. For more information, see the Policy on Occurrence Classification.
TSB investigation process
There are 3 phases to a TSB investigation
- Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
- Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
- Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.
For more information, see our Investigation process page.
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.