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News release

Associated links (R22T0045)

Inadequate securement of rolling stock led to uncontrolled movement in Toronto Yard, Ontario

Richmond Hill, Ontario, 16 May 2024 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (R22T0045) into the 2022 uncontrolled movement and derailment of several rail cars in Canadian Pacific Railway Company’s (CP) Toronto Yard, located in Toronto, Ontario.

On 13 March 2022, 103 rail cars ran uncontrolled for about 3200 feet down a descending grade of a track in Toronto Yard. The seven leading cars derailed, three of which were loaded with sulphuric acid. There were no leaks, and no one was injured.

The investigation determined that a CP train crew initially secured the cars using six hand brakes, and then performed a hand brake effectiveness test to confirm that there was sufficient brake force to keep the rolling stock from moving on its own. After judging the test to be successful, the crew applied the emergency air brakes. The following morning, the air brakes were released in preparation for switching. When the air brakes on the last car were released, all 103 cars began to roll uncontrolled with the six handbrakes still applied.

The investigation found that the force applied during the hand brake test was insufficient and not enough time was allowed for the slack between the cars to fully adjust before the emergency air brakes were applied. Consequently, the hand brake effectiveness test was incomplete, and the crew were unaware that the number of hand brakes used to secure the cars was insufficient for the descending grade. In this occurrence, the crew applied a greater number of hand brakes than CP’s practice required and were confident that the cars were secured based on the results of the hand brake effectiveness test. CP’s instructions to crews did not provide location-specific guidance; therefore, crews had to rely on their knowledge, experience, and judgment when securing rolling stock in the yard.

Four significant uncontrolled movements have taken place in Toronto Yard over the past five years including this one. As a result, the TSB issued a Rail Safety Advisory Letter (03/23) to Transport Canada (TC) in March 2023. The advisory letter stated that TC might wish to audit CP’s switching and car securement practices for the yard to ensure that adequate procedures are in place to prevent uncontrolled movements.

TC subsequently conducted inspections and issued a Notice under Section 31 of the Railway Safety Act, prompting CP to take safety actions. CP introduced a revised operating bulletin to be used when securing rail equipment in the yard, as well as conducting further education, training, and safety blitzes for employees working at the yard.

Unplanned/uncontrolled movements of rail equipment is a Watchlist issue. 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
Media Relations
Telephone: 819-360-4376