Release of investigation report R19W0002 – Nattress

Speaking Notes - R19W0002 (Nattress)

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Introduction - Kathy Fox

Good morning.

On January 3rd 2019, eastbound CN freight train 318 collided with the side of westbound CN freight train 315 near Portage La Prairie, Manitoba. As a result of the collision, both trains derailed. The train 318 crew jumped from the locomotive just after the collision, narrowly avoiding serious injury.

Today we will tell you what happened, why it happened, and what needs to be done to prevent this type of accident from occurring again. Specifically, we are making 2 recommendations to Transport Canada in an effort to improve rail safety. 

First, the Board recommends that Transport Canada require all major Canadian railways to expedite the implementation of physical fail-safe train controls on Canada’s high-speed rail corridors and on all key routes; and

Secondly, that Transport Canada require Canadian railways to develop and implement formal crew resource management training as part of qualification training for railway operating employees.

I will speak in more detail about each of these recommendations. But before I do, I’ll ask Rob Johnston to outline the investigation findings.

The occurrence – Rob Johnston

Thank you, Kathy.

At 0610 am, eastbound train 318 departed Rivers, Manitoba and began following another train on the Rivers Subdivision, enroute to Winnipeg, Manitoba.

At about 0730 am, westbound train 315 departed from Winnipeg on the Rivers Subdivision.

As train 318 approached Portage la Prairie, the crew overheard a rail traffic controller on the radio, clearing the preceding train straight through to Winnipeg. In light of this conversation, the crew expected that they would also continue to Winnipeg without stopping. However, the controller had planned to stop them at Nattress (Mile 50.4) to allow westbound train 315 to pass.

Just after 9 am, train 318 was proceeding at 42 mph on the south track using the Trip Optimizer, a system similar to cruise control in a car, when it passed a Clear to Stop signal indication which indicated to the crew that they should be preparing to stop the train at the next signal. The conductor called out the Clear to Stop signal as required but did not hear the locomotive engineer verbally respond. The engineer appeared to be staring straight ahead and the train continued on the south main track at track speed with Trip Optimizer engaged.

A short time later, as train 315 was transitioning to the north track, the head-ends of train 318 and train 315 passed each other near Mile 51. Subsequently, the train 318 conductor reminded the engineer of the previous Clear to Stop signal. The engineer then disengaged Trip Optimizer and made a full-service brake application. However, as the Stop Signal indication at Nattress came into view, the crew recognized they would not be able to stop in time and avoid a collision with train 315.  

The engineer made an emergency train brake application and the crew exited the locomotive cab, moving to the back of the locomotive platform. While travelling at 23 mph, train 318 collided with the side of train 315. The train 318 crew subsequently jumped from the locomotive platform and sustained minor injuries. As a result of the collision, 2 of the train 318 head-end locomotives, and 8 cars on train 315, derailed.

The TSB investigation determined that:

The train 318 crew had formed the expectation that they would continue following behind the earlier eastbound train through to Winnipeg, without stopping at Nattress.  

They did not respond appropriately to the signal indications displayed in the field (at Mile 52.2 and Mile 50.4), which ultimately led to the collision.

The engineer was fatigued due to disrupted sleep periods during the 2 nights preceding the accident. The fatigue, when combined with the reduced workload associated with the use of trip optimizer, resulted in decreased vigilance. Fatigue management has been an issue of concern on the TSB Watchlist since 2016.

The TSB has previously identified that for various reasons, including fatigue, train crews do not always consistently follow railway signal indications. This increases the risk of a train collision and/or derailment to occur and is why following railway signal indications has been on the TSB Watchlist since 2012.  

Finally, the conductor had only 10 months of experience and limited knowledge of locomotive operations or train braking systems. This resulted in the conductor deferring to the more experienced locomotive engineer without questioning the operation of the train.

In this case, the crew did not clearly communicate within the cab and as a result, the crew’s actions to slow and stop the train were delayed, ineffective and not in accordance with operating rules.

Kathy Fox will now talk about the Board’s recommendations.

Recommendations – Kathy Fox

Thank you, Rob.

The rail transportation system is complex. The defence-in-depth philosophy advocated by safety specialists for complex systems seeks multiple and diverse lines of defence to mitigate the risks of errors. Wherever possible, a combination of rules-based defences, also known as administrative defences, and physical defences should be implemented.  

However, today’s railway operations still rely predominantly on crews following the rules. Consequently, safe train operations are contingent on train crews observing each signal indication, broadcasting it, and then taking the appropriate actions.

When a crew does not follow a signal indication, the administrative defence fails. In the absence of a physical defence there is no automatic intervention to slow or stop a train – as was the case in this accident.

To put the potential risk in Canada into perspective, from 2004 to 2021, there was an annual average of 35 reported occurrences in which a train crew did not respond appropriately to a signal indication. Those trains may be carrying dangerous goods such as flammable liquids and more and more oil, along tracks that run beside our rivers and lakes, and through our cities. In failing to address the need for a physical defence system to automatically slow or stop a train, the Canadian public and the environment continue to be put at unnecessary risk.

The United States has addressed this issue. Following a serious train collision in Chatsworth, California in 2008, the United States mandated the implementation of a physical fail-safe train control, known as positive train control (or PTC), for railways operating on high-hazard routes, which includes both CN and CP.

PTC automatically intervenes to slow or stop a train when a crew does not respond to signal indications displayed in the field. It can also protect against: overspeed derailments, incursions into work zones, and main track switches left in the wrong position. As of December 31 2020, PTC was fully implemented on all of the required tracks, or about 41% of the nearly 140 000 route-miles of the U.S. rail network.

Canada has adopted the term “enhanced train control” to describe such train control systems. Over the past 22 years, despite 2 previous Board recommendations, issued in 2000 and 2013 respectively, there is still no requirement for railways operating in Canada to install enhanced train control.

In response to these recommendations, Transport Canada and industry began to study the issue in 2014. However, in the time it took to study the issue, positive train control had been fully implemented in the U.S. on all of the high-hazard trackage required by legislation.

In Canada, the equivalent to the U.S. high-hazard trackage is referred to as a “Key Route” which accounts for about 42% of the Canadian rail network. This accident occurred on the CN Rivers Subdivision, a “Key Route” on which a significant quantity of dangerous goods is carried annually, and one of the busiest subdivisions in Canada. If an accident occurs on a key route, a key train or trains may be involved, increasing the risk of a dangerous goods release and potential adverse consequences. If Transport Canada and the railway industry do not act more quickly to implement physical fail-safe defences to reduce the consequences of inevitable human errors, the risk of collisions and derailments will persist, with a commensurate risk for people, property or the environment.

Therefore, the Board recommends that Transport Canada require major Canadian railways to expedite the implementation of physical fail-safe train controls on Canada’s high-speed rail corridors and on all key routes.

The second recommendation deals with Crew Resource Management.

When a train encounters a signal, 1 crew member must communicate the indication aloud within the locomotive cab to the other crew member who is then required to repeat the message back. There is no requirement for the original sender to confirm that the message was received accurately or understood. As a result, this communication can fail.

When there is a difference in experience between operating crew members, an authority gradient may develop and a less experienced crew member may not always intervene to ensure compliance with all of the rules. Consequently, there is a danger that safety-compromising behaviour will be overlooked because a less experienced employee may be reluctant to question the actions of a more senior employee, or intervene in the operation of the train, even when it may be critical to do so.

All of these factors were present in this accident. [pause]

Since 1996, the TSB has investigated 8 other rail occurrences in which ineffective crew resource management (CRM) practices were identified as a factor that contributed to the accidents.^{Footnote 1}

CRM includes aspects of crew communication, situational awareness, problem solving, and reinforces that operating crews need to remain vigilant for loss of situational awareness by oneself and by other crew members.

The aviation and marine industries have benefitted from the introduction of CRM. Given the prevalence of human factors issues in rail accident statistics, 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. 

CRM training reinforces that operating crews approach their activities from a team perspective. If operating crew members do not receive enhanced initial and recurrent CRM training to develop skills in crew communication, decision-making and dealing with authority gradients, there is an increased risk that inadequate crew communication will lead to unsafe operations.

Therefore, the Board recommends that Transport Canada require Canadian railways to develop and implement modern initial and recurrent crew resource management training as part of qualification training for railway operating employees.

Conclusion – Kathy Fox

The safety issues highlighted throughout the course of our investigation are not new. This accident highlights major issues in the rail industry and reinforces what the TSB has been saying for more than two decades; that physical fail-safe train controls are vital to improving rail safety in Canada and avoiding future rail disasters.

We now welcome your questions.