TSB reiterates the need for additional physical safety defences after a passenger train passed a Stop indication in Drummondville, QC
Dorval, Quebec, 16 September 2020 — The Transportation Safety Board of Canada (TSB) released today its investigation report (R18D0096) into an incident where a passenger train proceeded past a Stop signal indication in Drummondville, Quebec, in 2018. The incident occurred a few seconds after another passenger train had cleared the main track.
On 31 October 2018, around 19:35, a VIA Rail Canada Inc. (VIA) passenger train (VIA 29) was proceeding west to Montréal on the Canadian National (CN) Drummondville Subdivision at approximately 32 mph (51 km/h) when it passed a signal (Signal 991) that was displaying a Stop indication. CN’s Drummondville Subdivision is a single main track with several sidings where trains can meet and pass each other. A few seconds earlier, another passenger train (VIA 28) travelling eastbound had just cleared the same main track into a siding. There was no collision, and no injuries were reported.
The investigation found that VIA 29’s crew members were unaware that they had passed a Stop indication, or that VIA 28 had only just cleared the main track when they continued westward toward Montréal. The investigation determined that the head end of the locomotive on VIA 29 and the tail end of the last passenger coach on VIA 28 were approximately 377 feet and 8 seconds apart when the last coach on VIA 28 was completely in the siding, off the main track.
When VIA 29 travelled through the switch, the rail traffic controller (RTC) in Montréal received an alarm (Rule 439) indicating that rolling stock had passed a Stop signal indication. The RTC did not immediately investigate the cause of the alarm and associated it with a track vehicle working in the area. That assumption was made based on factors such as numerous recent nuisance/false alarms. If Rule 439 alarms are not fully investigated by RTCs, an urgent situation could go unnoticed, increasing the risk of accidents.
This occurrence highlights once again that wayside signals and administrative defences, such as the requirement for train crews to follow signal indications, although usually effective, are not always consistently applied. If train control systems rely only on administrative defences to ensure the safe operation of trains, signal recognition errors will continue to occur, increasing the risk of train collisions and derailments.
Following railway signal indications is identified as one of the key safety issues that needs to be addressed and has been on the TSB Watchlist since 2012. The TSB has investigated similar occurrences and issued two recommendations (R13-01 and R00-04) calling for the implementation of physical train controls and additional backup safety defences to mitigate the risks of normal human errors and ensure that signal indications are consistently followed.
Following the occurrence, Transport Canada conducted an inspection and issued a letter of non-compliance to VIA for violations of the Canadian Rail Operating Rules (CROR). VIA also took several actions, including discussions between management and crews to raise awareness about the risks related to radio communications with locomotive engineers on non-urgent subjects and their possible distraction. At CN, the RTC screen was modified to include a visual cue (red square) at a location where a CROR Rule 439 alarm occurs, and management at the Montreal rail traffic control centre reviewed this occurrence with other RTCs with emphasis on following procedures when a CROR Rule 439 alarm occurs.
See the investigation page for more information.
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.
For more information, contact:
Transportation Safety Board of Canada
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