TSB has completed this investigation. The report was published on 18 September 2024.
Safety issue investigation (SII)
Factors contributing to seasonal variations in train–motor vehicle accidents at grade crossings
In May 2021, the Transportation Safety Board of Canada (TSB) launched a safety issue investigation (SII) into the factors contributing to an increase in the rate of railway crossing accidents involving motor vehicles during winter months in Canada.
An SII is broad in scope and involves looking at multiple occurrences in order to identify the underlying safety issues. The Board may make recommendations to address any identified systemic deficiencies. The TSB will communicate its findings once the investigation is complete.
Purpose
Every year, approximately 23 people are killed and another 28 seriously injured in railway crossings in Canada. In 2019, 29% of crossing accidents resulted in fatal or serious injuries, making them one of the deadliest types of rail accidents. To improve transportation safety in Canada and internationally, it is important for the TSB to identify and communicate safety deficiencies that contribute to these accidents so that effective safety defenses can be developed. This SII aims to augment results of prior analyses (see Figure 1) demonstrating a seasonal pattern in level crossing accidents involving motor vehicles by statistically comparing the factors contributing to level crossing accidents in winter months to those contributing to accidents in non-winter, non-vacation months.
Scope
The SII will compare the factors contributing to level crossing accidents that happen in non-vacation winter months (January – February) to those contributing to accidents that take place in non-vacation non-winter months (May, June, September) that are comparable in terms of physical crossing characteristics (such as warning protection type) and location (rural vs. urban vs. industrial). Drivers and eyewitnesses to recent accidents at level crossings will be interviewed by TSB investigators so that firsthand accounts can be documented. Those accounts, as well as data from other sources, will be compiled and compared statistically to identify and better understand the underlying causal factors to these occurrences
Research outcomes will be communicated in a final TSB report, which will provide findings and, potentially, recommendations for improving road-rail level crossing safety, especially during winter months. This could include, for example, safety defenses relating to snow clearance practices around crossings, improving traction on snow- or slush-covered approach roads, and the development of targeted driving strategies to improve driver perception and decision making in winter conditions.
Methodology
The SII will compare a sample of winter motor vehicle crossing accidents to non-winter crossing accidents. These will be explored using various approaches that will continue to evolve as the investigation progresses.
Media materials
Investigation information
Investigator-in-charge
Ms. Gauthier joined the TSB Human Factors and Macro Analysis group as a Senior Human Factors Investigator in 2016 and since then has been involved in numerous investigations into air, marine, pipeline, and rail transportation occurrences and human factors safety studies.
Ms. Gauthier has over 17 years’ experience providing human factors and safety management analysis and support in aircraft airworthiness and maintenance, airline operations, and in the marine, rail, first responders, military, and energy sectors. Ms. Gauthier has applied her skills and experience in a variety of human factors and safety programs including training needs analysis, human performance measurement, system requirements analysis and definition, user interface design, human factors investigations, fatigue analysis, error and human reliability analysis, and cognitive workload analysis.
Ms. Gauthier received her MA in Psychology specializing in Human–Computer Interaction in 2005 from Carleton University.
Download high-resolution photos from the TSB Flickr page.
Class of investigation
This is a class 1 investigation. These investigations—also known as safety issue investigations (SII)—analyze a series of occurrences with common characteristics that have formed a pattern over a period of time. These investigations, which may result in recommendations, are generally completed within 730 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.