News release

The Transportation Safety Board of Canada (TSB) released today its investigation report (R16W0242) into a November 2016 uncontrolled train movement, collision and derailment in Estevan, Saskatchewan.

On 29 November 2016, at about 0515 Central Standard Time, a southbound Canadian Pacific Railway (CP) ballast train rolled uncontrolled in the siding at Estevan, Saskatchewan, and struck the side of a northbound CP freight train that had just stopped on the main track. The ballast train locomotive sustained damage and a freight car on the northbound train derailed and sustained minor damage. No dangerous goods were involved and there were no injuries.

The investigation determined that, while the two crew members from the ballast train were performing a passing train inspection of the northbound train, the locomotive engineer (LE) left his position on the ground and entered the locomotive cab of his train. While in the cab, the LE inadvertently moved the automatic brake handle to the release position. Without realizing that the automatic air brakes were releasing, the LE returned outside to complete the passing train inspection.

The investigation also found that, due to a build up of ice and snow on the locomotive brakes of the ballast train, the effectiveness of these brakes alone had been reduced, resulting in a retarding force that was insufficient to hold the train. Upon recognizing that the train was moving, the LE immediately boarded the locomotive, entered the cab and initiated an emergency brake application. However, the ballast train continued to move at a speed of less than 1 mph until the locomotive struck the side of the northbound train, which had by then stopped on the main track.

In accordance with Rule 112 of the Canadian Rail Operating Rules, railways are permitted to use the reset safety control (RSC) system with roll-away protection as a secondary method of train securement for an unattended train. However, the roll-away protection feature on the ballast train did not activate to stop the train, as the uncontrolled train did not reach the pre-set activation speed of 2.5 mph. This occurrence highlights the risk that using the locomotive's RSC system equipped with roll-away protection as a secondary method of train securement may not always prevent an uncontrolled movement.

From 2008 to 2017, 541 occurrences related to unplanned/uncontrolled movements were reported to the TSB. Over this 10 year period, there were 21 occurrences involving loss of control, of which 14 affected the main track. Uncontrolled movements are low frequency–high-risk events that can occur due to loss of control, switching without air, or insufficient securement. Uncontrolled movements that affect the main track will typically present the greatest risk of adverse outcomes, particularly if dangerous goods are involved.

This investigation has also raised three TSB Watchlist issues:

• Safety management and oversight: a railway must have processes for ensuring compliance with regulations and rules. Because crew members of the ballast train had been on duty for about 13 hours by the time the train was secured after the incident, which exceeded the maximum on-duty time of 12 hours as specified in the work/rest rules, CP should have filed a report in order to meet regulatory requirements.
• On-board voice and video recorders: valuable data are going unrecorded, hindering the progress of TSB safety investigations and affecting the capability of railways to improve safety management systems.
• Fatigue management systems for train crews: although both crew members were fatigued at the time of the occurrence, it could not be determined if any significant performance decrements had occurred. Fatigue continues to pose a risk to the safe operation of trains, particularly freight trains, which move 70% of the country's surface goods.

Following this occurrence, the TSB issued a Rail Safety Advisory (RSA) relating to the roll-away protection activation of the RSC device on some CP locomotives. In December 2016 and January 2017, CP issued two System Bulletins indicating that the RSC with roll-away protection is not to be used as a physical securement or mechanical device when operating certain series of locomotives.