Lack of direct supervision and misapplication of safety critical operating procedures contributed to a 2013 fatal rail accident in Saskatchewan
Winnipeg, Manitoba, 22 October 2014 – In its report released today (R13W0260), the Transportation Safety Board of Canada (TSB) identified lack of direct supervision and misapplication of safety critical operating procedures as contributing factors to a November 2013 fatal rail accident in Saskatchewan.
On 18 November 2013, while performing switching operations at Murphys interchange track near Tisdale, Saskatchewan, a Canadian National Railway (CN) freight train struck and seriously injured a conductor trainee who was securing a derail mounted between the rails. The employee was transported by ambulance to hospital but succumbed to injuries during transport.
The investigation found that when conductor trainees work independently, without direct and close supervision, the risk of error increases and can lead to accidents. Additionally, there is a risk of misapplying safety rules and instructions where there is inadequate reinforcement of proper procedures, reduced training periods, and lack of continuity and assessment among trainers.
In December 2013, the TSB sent a Rail Safety Advisory letter to Transport Canada (TC) identifying the potential risks associated with switching operations, specifically concerning the proximity of the conductor to the trainee while supervising tasks. TC indicated that it has identified the issue of trainee supervision in its risk-based business plan for the upcoming year and is developing risk control actions to address it.
For its part, CN has issued a number of safety communications to its operating personnel on the subject within the region and system-wide.
The TSB is an independent agency that investigates marine, pipeline, railway and aviation 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.
For more information, contact:
Transportation Safety Board of Canada
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