Rail transportation safety investigation R17W0267
The TSB has completed this investigation. The report was published on 10 June 2020.
Canadian National Railway Company
Remote control locomotive system
Extra yard assignment Y1XS-01
View final report
On , at about 1800 Central Standard Time during hours of darkness, a Canadian National Railway Company (CN) foreman and a helper were performing switching operations at CN’s Melville Yard in Melville, Saskatchewan. The foreman was operating extra yard assignment Y1XS-01 using a remote control locomotive system (RCLS) when the foreman became pinned between the assignment and the lead car of an uncontrolled movement while applying a hand brake. The foreman received fatal injuries. There was no derailment and no dangerous goods were involved.
The movement consisted of 3 open-top hopper cars loaded with ballast. The foreman had kicked these cars up an ascending grade toward a connecting track, but at too slow a speed for them to reach it. Without sufficient speed, the cars stalled on the grade and began to roll back uncontrolled. The foreman ran to and boarded the lead car and applied a hand brake, but the braking efficiency of the hand brake was compromised. As a result, the uncontrolled movement did not stop or slow down, reducing the opportunity and time available for the foreman to get out of harm’s way.
New TSB recommendation aims to reduce frequency of uncontrolled movements in rail yards
Read the news release
TSB to issue safety recommendation and concern following investigation of 2017 uncontrolled movement in Melville, Saskatchewan
Read the media advisory
Map showing the location of the occurrence
Glen Pilon has been with the TSB since 2008 and is a Regional Senior Investigator at the TSB Head Office in Gatineau, Quebec. He has been the investigator-in-charge of seven rail accident investigations, deputy investigator-in-charge of the Lac-Mégantic investigation, and has acted as a train operations expert in many others. Mr. Pilon worked for the Ottawa Valley Railway (OVR) from 1996 to 2008 as a locomotive engineer and safety officer, and with the Canadian Pacific Railway (CP) from 1987 to 1996 in operations, as a trainman and conductor.
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Class of investigation
This is a class 2 investigation. These investigations are complex and involve several safety issues requiring in-depth analysis. Class 2 investigations, which frequently result in recommendations, are generally completed within 600 days. For more information, see the Policy on Occurrence Classification.
TSB investigation process
There are 3 phases to a TSB investigation
- Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
- Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
- Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.
For more information, see our Investigation process page.
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.