Training deficiencies and crew inexperience factors in 2018 uncontrolled movement of rail cars in Toronto, Ontario
Gatineau, Quebec, 22 July 2020 — In its investigation report (R18H0039) released today, the Transportation Safety Board of Canada (TSB) determined that unfamiliarity with areas of the yard, deficiencies with crew training and the pairing of inexperienced operators led to an uncontrolled movement of a yard assignment at the Canadian Pacific Railway (CP) Toronto Yard in Toronto, Ontario, in 2018.
On 14 April 2018, a foreman and yard helper were performing switching operations at CP’s Toronto Yard using a remote control locomotive system (RCLS). After coupling the locomotives onto the freight cars in track F-11, the foreman was not able to connect the air brake hoses between the locomotives and the lead car in the track because the hose on the lead car was not properly aligned. Consequently, the foreman decided to move all 88 freight cars, which had a total weight of 6400 tons, on a descending grade without operative freight car air brakes. The foreman did not communicate the plan to anyone else.
As the 88 cars pulled eastward out of track F-11, the foreman disembarked near the L4 switch, but was unable to control the movement on the descending grade of the Staines connecting track using only the locomotive brakes. The cars began to roll eastward, uncontrolled, down a 0.88% descending grade, where they then passed a stop signal and entered the main track of the CP Belleville Subdivision. The cars continued for about three miles on the main track, reaching speeds of up to 17 mph before traversing a public crossing. After the helper riding the assignment applied handbrakes on the two locomotives and the first car, and as the assignment encountered an ascending grade, it came to a stop. There was no derailment or collision, and there were no injuries.
The investigation found that the foreman believed the use of air brakes was required only when the assignment was kicking cars westward into the yard. Although the foreman had previously proceeded without any air brakes available to freight cars in this area of the yard, he had never handled as many cars as the assignment had that day. The foreman was also unaware of the risks associated with proceeding on the descending grade of the connecting track without operative freight car air brakes. Despite his training and previous experience in this task, the foreman lacked the knowledge to safely handle long, heavy cuts of cars on a descending grade in this area of the yard.
In this occurrence, both crew members had less than one year of service with the company. Despite the relative inexperience of both the foreman and the helper, the yard foreman was designated as such because he had the most seniority of the two. If experience with the task involved is not specifically considered when the roles are assigned, inexperienced employees can be scheduled to work together or can be put in charge of unfamiliar tasks, increasing the risk of error. Since 2007, the TSB has completed seven investigations (including this one) that highlight the risks associated with pairing crew members with low levels of experience to carry out yard assignments. The Board has also expressed concern that, without additional mitigation, inexperienced RCLS operators will continue to be paired together in yards, with a commensurate risk of ongoing adverse outcomes.
Since the accident, CP has issued an operating bulletin requiring that for every 3000 tons, at least five cars must have operating air brakes when moving cars from the east or west of the Toronto Yard. The company also made changes to its RCLS procedures and integrated RCLS training into the knowledge management program that is part of its safety management system. As well, Transport Canada performed several crew performance inspections to verify compliance with the CP operating bulletin.
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