Rail transportation safety investigation R18M0037
The TSB has completed this investigation. The report was published on 26 January 2021.
Canadian National Railway Company
Mile 1.03, Pelletier Subdivision
Edmundston, New Brunswick
On , at approximately 0827 Atlantic Standard Time, a cut of 2 cars loaded with mixed freight rolled uncontrolled westward on the west lead track at Canadian National Railway Company (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 northeast footboard of the locomotive, was trapped between the locomotive and the leading car and was fatally injured. No rolling stock derailed, and no dangerous goods were involved.
During switching activities before the occurrence, the cut of 2 cars had been moved approximately 4380 feet without the air brakes having been applied. During winter operations, applying brakes regularly conditions the brakes to prevent snow and ice from building up between the brake shoes and the wheels. To carry out the next movement, the crew had to temporarily leave the cut of cars on the west lead track. The crew considered the cars to be attended and applied the emergency brakes. However, ice contamination during the previous movements had made the brakes less effective, and, as a result, the total retarding force generated by the brakes of the 2 cars was insufficient to prevent the cut of cars from rolling uncontrolled. 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.
In November 2018, CN had issued a notice regarding train operations in winter conditions that reminded employees of the requirement to regularly condition the brakes on rolling stock. This directive allows some latitude to locomotive engineers, who can adjust some tasks, such as brake conditioning, according to their personal experience. This practice is acceptable as long as in-train forces are not increased and control of the train is not compromised. However, if the various directives, rules, and operating instructions in effect are not properly interpreted and applied, the safety of railway operations could be compromised, increasing the risk of an accident.
When the conductor realized that the cut of cars was rolling uncontrolled, it had already passed the fouling point of switch EA04. Given the speed of the cut of cars, the track gradient in the area, and the presence of snow on the ground, the conductor was unable to take any action to stop the cut of cars. Rule 112 of the Canadian Rail Operating Rules, railway instructions, and employee training do not clearly define the factors and risks that must be taken into account for employees to determine whether they are in close enough proximity to take effective action to stop an uncontrolled movement of equipment.
Train securement practices led to December 2018 fatal uncontrolled train movement
Read the news release
TSB deploys a team of investigators to the site of a railway accident at Edmundston Yard in Edmundston, New Brunswick
Gatineau, Quebec, 4 December 2018 — The Transportation Safety Board of Canada (TSB) is deploying a team of investigators to the site of a Canadian National Railway fatal accident at Edmundston Yard in Edmundston, New Brunswick. The TSB will gather information and assess the occurrence.
Map showing the location of the occurrence
Luc Régis joined the Transportation Safety Board of Canada (TSB) in 2019 as a Senior Regional Investigator with the Rail/Pipeline Investigations Branch.
Before joining the TSB, Mr. Régis gained considerable experience in the construction and maintenance of railway infrastructure, holding various supervisory positions within the Engineering Department at Canadian National Railway Company (CN) from 2009 to 2014. From 2014 to 2019, he worked at Transport Canada as a Railway Safety Inspector in the Quebec Region, and at Transport Canada’s Emergency Situation Centre (SitCen) as rail safety expert. He lives in Montreal, Quebec.
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.
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