February 27, 2024
Director General, Rail Safety, Transport Canada
Enterprise Building, 14th floor
427 Laurier Avenue West
Ottawa ON K1A 0N5
TSB occurrence R23V0137
On 23 July 2023, Canadian National Railway Company (CN) freight train G83452-22 (train 834) was proceeding eastward on the Canadian Pacific Railway Company (CPKC) Cascade Subdivision, operating under a Restricting signal.A Restricting signal requires that trains be operated at restricted speed. Restricted speed is defined as a speed that will permit stopping within one-half the range of vision of equipment (train crews must also be prepared to stop the train short of a switch not properly lined) and in no case exceeding slow speed. Slow speed is defined as a speed not exceeding 15 miles per hour. (Transport Canada, Canadian Rail Operating Rules, Rule 436 and Definitions at https://tc.canada.ca/sites/default/files/2022-05/canadian-rail-operating-rules-may-9-2022.pdf [last accessed 13 February 2024]) Approximately 1000 feet past the Restricting signal, train 834 was rounding a curve when the crew observed the tail end of stationary CN train Z11251-23 (train 112) at about Mile 13.1. The brakes on train 834 were applied in emergency, but the train was unable to stop before colliding with the tail-end remote locomotive on train 112 at about 4 mph.
Analysis of the locomotive event recorder data determined that train 834 was being operated in excess of 15 mph as it passed the Restricting signal. Although the collision did not result in serious injuries, the safety risks posed by this occurrence prompted significant TSB follow-up.TSB occurrence R23V0137 is a Class 5 occurrence under the TSB’s Policy on Occurrence Classification.
TSB occurrence R23T0205
On 27 September 2023, CPKC train 112-22 (train 112) was travelling southbound on the CPKC Parry Sound Subdivision when it encountered a Restricting signal. Preliminary investigation determined that both crew members identified and acknowledged the Restricting signal; however, train 112 went by the signal at about 21 mph in an area of track curvature.
Shortly after, the tail end of CPKC train 118-22 (train 118) came into view of the crew and the brakes on train 112 were applied in emergency. However, train 112 was unable to stop and struck the tail end of train 118 at approximately 18 mph.
Sixteen cars on train 118 derailed, several of which came to rest foul of CN Bala Subdivision, located adjacent to, the CPKC main line. Although there were no serious injuries, the safety risks posed by this occurrence prompted significant TSB follow-up.TSB occurrence R23T0205 is a Class 5 occurrence under the TSB’s Policy on Occurrence Classification.
TSB occurrence R23D0108
On 21 November 2023, CN train X37621-20 (CN 376) was travelling southbound on the east track of the St-Laurent Subdivision when it collided with the rear of stationary exo commuter train 1212 (EXO 1212).
Train CN 376, a light engine movementLocomotives travelling alone, not coupled to cars. consisting of 2 locomotives, was travelling southbound on the east track of the St-Laurent Subdivision. Approaching the Montréal-Nord controlled location, the advance signal was displaying a Restricting signal, and the train continued into the next block.The Canadian Rail Operating Rules define a block as “[a] length of track of defined limits, the use of which by a movement is governed by block signals”. (Canadian Rail Operating Rules [CROR], [09 May 2021, effective 01 October 2022, approved by Transport Canada 30 July 2021], Definitions.) EXO 1212 was stopped on the east track in this same block, at the Saint-Léonard-Montréal-Nord exo station platform at Mile 135.8. Approaching the station, train CN 376 was travelling at about 40 mph when the rear of stationary train EXO 1212 came into sight, and the brakes were applied in emergency. Train CN 376 was unable to stop in time and collided with EXO 1212 at a speed of about 32 mph.
The impact derailed train EXO 1212 and pushed it southward approximately 125 feet. Four of the 8 passengers on board the commuter train and the 2 exo crew members were injured. There was significant damage to both CN locomotives on train CN 376, as well as to locomotive EXO 1346 and passenger car EXO 3062.TSB occurrence R23D0108 is the subject of a TSB Class 3 investigation.
TSB occurrence R24C0020
On 16 February 2024, a loaded unit coal train (train 805) travelling westward on the north main track of the CPKC Mountain Subdivision struck the trailing car of a stationary unit grain train (train 301) at about Mile 116.7.
Preliminary investigation has determined that train 805 encountered a Clear to Stop signal indication at Signal 1149N and a Restricting signal indication at Signal 1167N. Train 805 was travelling at about 33 mph approaching the Restricting signal indication when the trailing car of train 301 came into view just beyond the signal. The brakes on train 805 were applied in emergency. Train 805 travelled about 820 feet in emergency and slowed to about 22 mph when it struck the trailing car of train 301. Both crew members of train 805 were taken to a local hospital, one with minor injuries and the other with serious injuries.
As a result of the collision, the 4 head-end locomotives on train 805 derailed and were extensively damaged. An undetermined amount of diesel fuel was spilled and 1 of the locomotives caught fire. The collision impact also derailed 3 loaded grain hopper cars and damaged a 4th car on stationary train 301.TSB occurrence R24C0020 is the subject of a TSB Class 3 investigation.
Defences for trains operating under Restricting signals
Centralized traffic control (CTC) is the primary method of traffic control used by railways on main tracks in Canada. The CTC system uses track circuitry and associated software to display signal indications (lights) in the field. The system displays a combination of red, yellow, and green lights, either constantly illuminated or flashing. Train movements are governed by these signal indications and are supervised from a central office location by a rail traffic controller.
Under a Restricting signal, more than one train can be permitted to operate within the same block at the same time. Therefore, collision avoidance requires that train crews accurately identify signals, strictly follow the requirements of the signals, and maintain situational awareness to be prepared to stop within one-half the range of vision of equipment operating within the same block. However, in a complex system such as rail transportation, even the most rigorous set of rules (i.e., administrative defences) may not cover every contingency or be uniformly interpreted by individuals. Accurate situational awareness and a full understanding of the operating parameters involved in train handling—such as track curvature, track grade, train tonnage, equipment braking characteristics, weather, and visibility—must all be evaluated and assimilated into a dynamic plan when operating under a Restricting signal. In addition, locomotive engineers, no matter how motivated or experienced, are subject to the normal slips, lapses, and mistakes that inherently characterize human behaviour. Sole reliance on the ability of locomotive engineers to achieve this complex task has not proven to be fully effective in preventing main-track collisions for trains operating under Restricting signals.
To reduce the likelihood of collisions when trains operate under Restricting signals in CTC territory and to reduce the risks to train crews and the travelling public, as a priority, Transport Canada should work with the railway industry to address the limitations with the existing administrative defences.
The TSB would appreciate being informed of what action, if any, will be taken in this regard.
Yours sincerely,
Original signed by
Vincenzo De Angelis
Director, Investigations – Rail/Pipeline
cc:
Director, Regulatory Affairs
Transport Canada, Rail Safety
Assistant Vice President, Safety
Canadian National Railway Company
Senior Manager, Regulatory Affairs, Safety
Canadian National Railway Company
Managing Director, Regulatory Affairs
Canadian Pacific Railway Company
Specialist Director, Regulatory Affairs & Safety
VIA Rail Canada Inc.
Director, Regulatory Affairs
Railway Association of Canada