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News release

Associated links (R23Q0022)

TSB report highlights the importance of adequate supervision for newly qualified railway employees

Dorval, Quebec, 9 May 2024 — Today, the Transportation Safety Board of Canada (TSB) released its investigation report (R23Q0022) into an incident where an ore freight train passed a Stop signal indication at Mai Station, Quebec, in 2023. The incident occurred as another train was proceeding towards Mai in the opposing direction. There was no collision or derailment, and there were no injuries.

On February 22, 2023, a train operated by Quebec North Shore and Labrador Railway (QNS&L) was proceeding on the Wacouna Subdivision heading for a crew change at Mai Station, Quebec. As the train was pulling towards the station camp, it passed a signal displaying a Stop indication. Despite the signal being visible 0.75 miles away, the locomotive engineer (LE) did not undertake the braking manoeuvres required to stop before the signal. About 50 feet from the signal, the LE realized that it was displaying a Stop indication and applied full dynamic braking and the emergency brakes.

The investigation determined that the LE’s mental model was likely affected due to routinely stopping the lead locomotive of his train in front of the camp located after the signal. Furthermore, the LE had developed a habit of not always broadcasting Stop signal indications on the railway radio as required by the Canadian Rail Operating Rules.

The investigation also found that there have been 12 occurrences, including this one, of QNS&L trains passing Stop signals in the last 10 years. Human performance and experience were considered as factors in all these occurrences. On September 7, 2023, the TSB sent a safety information letter to QNS&L on the supervision of newly qualified LEs. As a result, QNS&L made changes to its evaluation program for apprentice LEs and increased the frequency of evaluations by supervisors in the field for LEs with less than two years of experience.

Following railway signal indications is a TSB Watchlist issue. As this occurrence demonstrates, railway signals are not consistently recognized and followed, which in the absence of physical fail-safe defences, poses a risk of train collisions or derailments that can have catastrophic consequences.

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