TSB calls for Transport Canada and the Canadian railway industry to expedite implementation of automated train control systems
Winnipeg, Manitoba, 24 August 2022 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (R19W0002) into a collision involving two Canadian National Railway (CN) freight trains near Portage la Prairie, Manitoba. As a result of the investigation, the Board is issuing two recommendations to Transport Canada.
First, the Board recommends that Transport Canada require all major Canadian railways to expedite the implementation of physical fail-safe train controls on Canada’s high-speed rail corridors and on all key routes.
“The United States has fully implemented a positive train control system on all high-hazard track required by its federal legislation. This includes the U.S. operations of both CN and Canadian Pacific, which have invested significantly in their locomotive fleets and infrastructure,” said TSB Chair Kathy Fox. “The railway industry must act more quickly to implement a similar form of automated or enhanced train control system on Canada’s key routes to improve rail safety and avoid future rail disasters.”
Second, the Board recommends that Transport Canada require Canadian railways to develop and implement formal crew resource management (CRM) training as part of qualification training for railway operating employees.
“The aviation and marine industries experienced significant safety benefits with the introduction of CRM,” said TSB Chair Kathy Fox. “This type of training could provide additional tools and strategies to train crews to mitigate inevitable human errors, providing significant safety benefits in the rail industry.”
On 3 January 2019, eastbound CN freight train 318 collided with the side of westbound CN freight train 315 just east of Portage la Prairie, Manitoba.
At 0610, train 318 departed Rivers, Manitoba towards Winnipeg, Manitoba. At about 0730, westbound train 315 departed Winnipeg. Both trains were operating on the Rivers Subdivision, one of CN’s busiest routes which frequently transports dangerous goods.
Just under 3 hours later, while proceeding on the south track using Trip Optimizer (a system similar to cruise control on a car), train 318 passed a signal at Mile 52.2 indicating to the crew that they should be preparing to stop at the next signal, located at Mile 50.4 at Nattress. The conductor called out the signal as required, but did not hear the locomotive engineer (LE) verbally respond and the train continued at track speed.
Soon after, the head ends on train 318 and train 315 passed each other, and train 318’s conductor reminded the LE of the previous signal. The LE then applied the train brakes. However, as the Stop signal indication at Nattress came into view, the crew recognized that they would not be able to stop in time and applied the brakes in emergency. Shortly after train 318 collided with the side of train 315 at 23 mph (37 km/h), the crew jumped from the train, sustaining minor injuries. The two head-end locomotives on train 318 and eight cars on train 315 derailed as a result of the collision.
The investigation determined the following:
- The crew on train 318 had formed the expectation that they would continue following behind an earlier eastbound train through to Winnipeg, without stopping at Nattress.
- The LE was fatigued due to disrupted sleep periods during the 2 nights preceding the accident. Consequently, he experienced decreased vigilance due to fatigue and the reduced workload associated with the use of Trip Optimizer which contributed to his delayed reaction to the signals displayed in the field.
- Railway operations rely predominantly on administrative defences, such as Canadian Rail Operating Rules and Work/Rest Rules for Railway Operating Employees and safe train operations are contingent on train crews following the rules. When a train crew does not follow the rules, for whatever reason, the administrative defences fail. When there is no secondary physical fail-safe defence, such circumstances can result in an accident that otherwise could have been prevented.
- The train 318 crew communication within the cab was ineffective. Due to the difference in the level of experience between the train 318 crew members, the conductor deferred to the LE without questioning the operation of the train and, as a result, the crew’s actions to slow and stop the train were delayed.
This accident highlights major issues in the rail industry and reinforces TSB’s call for physical fail-safe train controls for over two decades through recommendations R13-01 and R00-04.
The issues identified in this investigation also highlight two recurring TSB Watchlist issues: following railway signal indications and fatigue management.
Following this occurrence, CN distributed a System Notice throughout its Canadian operations warning train crews that there was an increase in occurrences where train crews failed to stop at signal indications requiring them to do so, primarily due to a lack of focus on situational awareness.
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