Rail transportation safety investigation R23Q0022
The TSB has completed this investigation. The report was published on 9 May 2024.
Table of contents
Movement exceeds limits of authority
Quebec North Shore and Labrador Railway
Ore train W039
Mile 128.3, Wacouna Subdivision
Mai, Quebec
The occurrence
On 22 February 2023, at approximately 2133 Eastern Standard Time, the empty Tacora Resources Inc. ore train W039, operated by Quebec North Shore and Labrador Railway, was travelling northward on Quebec North Shore and Labrador Railway’s Wacouna Subdivision when it passed a Stop signal without authority at Mile 128.3 at Mai Station, Quebec. There was no collision or derailment, and there were no injuries.
Media materials
News release
TSB report highlights the importance of adequate supervision for newly qualified railway employees
Read the news release
Investigation information
Map showing the location of the occurrence
Investigator-in-charge
Patrick Sirois joined the Transportation Safety Board of Canada (TSB) in 2020 as a Senior Regional Investigator with the Rail/Pipeline Investigations Branch.
Before joining the TSB, Mr. Sirois gained considerable experience in railway operations at Canadian National Railway Company (CN) from 2007 to 2016 holding various positions as a train conductor, locomotive engineer and trainmaster. Mr. Sirois is a member of the Air Brake Association, an educational organization dedicated to the development and improvement of braking systems in the railroad industry. Mr. Sirois also holds a degree in broadcasting from the Cité Collégiale in Ottawa and has several years of experience in the field of electronic media and in the telecommunications industry. He lives in Montréal, Quebec.
Class of investigation
This is a class 3 investigation. These investigations analyze a small number of safety issues, and may result in recommendations. Class 3 investigations are generally completed within 450 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.