Safety communications related to TSB investigation R17W0267 – December 2017 employee fatality in Melville, Saskatchewan
On 22 December 2017, 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.
Recommendation made on 10 June 2020
In this occurrence, a foreman was controlling a yard assignment using an RCLS while switching without air in Melville Yard. During switching operations, the foreman became pinned between the assignment and the lead car of an uncontrolled movement while attempting to stop the movement by applying a hand brake. As a result, the foreman received fatal injuries.
Uncontrolled movements generally fall into 1 of 3 broad causal categories: loss of control, switching without air, and securement. Since 2016, the TSB has completed 3 investigations,Footnote 1 including this one, involving uncontrolled movements that occurred in yards while switching without air.
Switching without air occurs when a movement is switching with the use of the locomotive independent brakes, only with no air brakes available on the cars being switched or kicked. The vast majority of these incidents occur in yards.
Similar to this occurrence, TSB occurrence R16W0074 involved relatively inexperienced operators who were conducting switching operations without air in Canadian Pacific Railway (CP)’s Sutherland Yard in Saskatoon, Saskatchewan. The investigation determined that, despite Transport Canada (TC) and industry initiatives, the desired outcome of significantly reducing the number of uncontrolled movements had not yet been achieved. Consequently, the Board was concerned that the current defences were not sufficient to reduce the number of uncontrolled movements and improve safety.
Between 2009 and 2018, 562 unplanned/uncontrolled movements occurred. There has been an upward trend during this 10-year period. The average increase per year for all categories was 1.67 occurrences, with 86% of the overall increase associated with switching without air. Of the 185 occurrences involving switching without air, 70 (38%) occurred as a result of rollbacks and 56 (30%) involved dangerous goods. The major outcomes of these occurrences were collisions (134, or 72%) and derailments (76, or 41%). Two of the occurrences (1%), including this occurrence, involved an employee fatality.
While switching without air is routine and occurs every day in the railway industry, the practice has some inherent risks that can result in serious consequences. If effective strategies are not taken to improve safety while switching without air, uncontrolled movements will continue to occur, increasing the risk and severity of adverse outcomes.
The railway industry is responsible for having rules, instructions, procedures, and processes in place to safely manage operations. Railway employees who are directly involved in these operations have the greatest knowledge of how the work actually gets done and are the most affected when accidents occur. However, the regulator also has a responsibility to have adequate regulations, rules, and enforcement in place in order to provide effective regulatory oversight to ensure safe operations.
Safety action taken by TC and the railway industry to date has focused on securement practices. However, the desired outcome of significantly reducing the number of uncontrolled movements has not yet been achieved.
The underlying causes of uncontrolled movements that occur while switching without air can vary greatly. Consequently, developing a comprehensive strategy to deal effectively with all of the underlying factors and associated risks in order to reduce the number of such uncontrolled movements is proving to be difficult. Therefore, the Board recommends that
The Department of Transport work with the railway industry and its labour representatives to identify the underlying causes of uncontrolled movements that occur while switching without air, and develop and implement strategies and/or regulatory requirements to reduce their frequency.
TSB Recommendation R20-01
Pairing of inexperienced remote control locomotive system operators
In the railway industry, conductors are assigned the task of being RCLS operators, particularly in rail yards across the country. Conductors are generally unionized positions that are governed by collective agreements between the employer and the union. In most cases, local yard assignments are posted for bidding each week. After the employees submit their bids, the positions are awarded based on seniority in accordance with the collective agreement.
Some of the posted positions are favoured owing to the rate of pay, days off, and hours of work. Typically, the evening shifts and the night shifts are considered the least desirable, and yard positions in particular are normally regarded as the least desirable because the pay rates for these positions are the lowest. If no bids are received for a specific position, the position is awarded to the employee with the least seniority.
As extensive employee turnover has been occurring in the railway industry in the past few years, it is not unusual for the 2 most junior, and least experienced, employees at a terminal to be working together in yards, particularly during the evening and night shifts. The pairing of inexperienced crew members is not uncommon in the Canadian railway industry.
Since 2007, the TSB has completed 6 investigations (including this occurrence) that highlight the risks associated when conductors with low levels of experience are paired together to carry out yard assignments (Appendix C). The TSB determined that the relative inexperience of the RCLS operators (conductors) contributed to these occurrences through insufficient knowledge to make effective decisions with respect to planning and train handling. Further, the TSB determined that the practice of pairing junior employees together for yard assignments meant that the coaching and mentoring needed to develop effective judgment for train handling were not being provided.
While an operating employee must demonstrate the competencies required to perform work as a qualified foreman, there is no company or regulatory requirement outlining the time or experience required before a conductor assumes the role of yard foreman. These roles are tied to a collective agreement for unionized staff. Consequently, the crew member with more seniority at the railway would typically be assigned the role of foreman, regardless of the employee’s experience with the task.
Furthermore, because railway scheduling systems will typically assign operating employees to yard positions based on seniority, it is possible for yard foremen to have limited operational and RCLS experience. If the role of yard foreman has no requirements relating to experience with the tasks involved, the scheduling system used to fill the positions can result in inexperienced employees being put in charge of unfamiliar tasks, which increases the risk of errors and accidents.
Given the ongoing employee turnover in the railway industry and the potential adverse outcomes when inexperienced RCLS operators are paired together working in yards, the Board is concerned that, without additional mitigation, inexperienced RCLS operators will continue to be paired together in yards with a commensurate risk of ongoing adverse outcomes.
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