What happened? In its final report on the Feb. 16, 2024, accident (download below), TSB said that CPKC train 805 was traveling on the north main track of the Mountain Subdivision when it collided with the trailing car of CPKC train 301 that was waiting on the same track (see maps, above and top). As a result of the collision, it said, four head-end locomotives of train 805 derailed, with one catching fire, and leaking approximately 17,500 liters of diesel fuel; four cars from train 301 derailed, with one catching fire, and spilled about 400 tons of grain. Both crew members on train 805 sustained injuries, according to TSB, an independent agency in Canada that investigates air, marine, pipeline, and rail transportation occurrences and whose sole aim is “the advancement of transportation safety”; it is does not assign fault or determine civil or criminal liability.
“The investigation found that train 805 missed a Clear to Stop indication—meaning it had to be prepared to stop at the next signal—due to the crew receiving a call from the rail traffic controller [“providing some accurate and some erroneous cold wheel information for their train”] which diverted their focus away from the signal,” TSB reported. “Therefore, the crew mistakenly believed they were operating on a Clear indication and were ultimately unprepared to stop. Train 805 ended up passing the next signal. When the flashing light at the tail end of stationary train 301 came into view, the locomotive engineer on train 805 made an emergency brake application; however, there was not enough distance to avoid the collision.”
TSB said that shortly after the accident, it sent a rail safety advisory letter to Transport Canada “drawing their attention to this collision and three others where trains operated under restricting signal indications.” It also sent a rail safety advisory letter to CPKC “informing the company that, in the absence of backup physical defenses to prevent collisions, it may wish to review its procedures for avoiding distraction in critical operating situations.” According to TSB, both letters highlighted “the continuing absence of physical fail-safe train controls and the absence of effective interim measures to help ensure the success of administrative defenses for trains operating under restricting signals.”
“The absence of physical fail-safe defenses capable of intervening by slowing or stopping a train when operating in CTC [centralized traffic control system] territory and the absence of a passive warning system to alert crew members when they approach their limits of authority have been raised by the TSB in its investigation reports since 1995,” TSB pointed out in its investigation report. “Inadequate defenses against misapplied or misinterpreted signal indications have been cited as a cause or contributing factor in numerous investigations conducted by the TSB, and this issue has been on the TSB Watchlist since 2012.
“While the introduction of additional administrative defenses such as CRZ [cab red zone] and CFZ [critical focus zone] can support existing defenses, to be effective, crews must recognize that they are in a CRZ or CFZ. Therefore, they are subject to the same limitations as the other administrative defenses that are in place. One recent example of this limitation is the near-miss collision between a CN freight train proceeding eastward on the south track of the Kingston Subdivision and a VIA [Rail Canada] passenger train proceeding westward on the south track, where it was lined to cross over to the north track, approaching Wesco, Ontario. The CN crew missed a Clear to Stop indication while operating in a CFZ as they were focused on preparing for a future task not related to the train’s immediate operation. The crew were therefore not prepared to stop at the next signal displaying a Stop indication. The CN train came to a stop approximately 1,786 feet past the Stop signal and about 1,100 feet from the stopped VIA passenger train.”
TSB noted in its report that U.S. lawmakers mandated the development and implementation of physical fail-safe train controls—Positive Train Control (PTC)—following a 2008 head-on collision between a freight train and a passenger train in Chatsworth, Calif., that resulted in mass casualties. PTC, which is designed to prevent train-to-train collisions, overspeed derailments, incursions into work zones, and movement of a train through a switch left in the wrong position, has been in operation in the U.S. since December 2020 on all 57,536 required freight and passenger railroad route miles, TSB pointed out.
TSB reported that it has made three recommendations (R00-04, R13-01, R22-04) related to “physical fail-safe train controls,” and since 2013 Transport Canada and the railway industry have been “discussing the framework needed to address the issue, yet the work is not sufficiently advanced to indicate when additional physical safety defenses will be implemented.”
“Although the probability of a missed signal leading to a train collision or derailment may be low,” TSB said, “the consequences of such an accident could be catastrophic for people, property, and the environment.”
Since the accident, TSB reported that CPKC has taken the following safety actions:
- In February 2024, “it implemented a module on situational awareness as part of the conductor training. This module builds on the concepts of crew resource management and is tailored to the specific needs of the railway industry. This training reminds employees that it is each crew member’s responsibility to develop and maintain situational awareness in order to contribute to a safe working environment.”
- On March 8, 2024, “it installed software that provides a message to mechanical support personnel when a report from a wheel temperature detector (WTD) on the Mountain Subdivision includes a car that would not be on a unit train subject to WTD inspection.”
- On March 21, 2024, “mechanical support personnel began creating a master list to verify that car numbers on cold car reports are correct for unit trains subject to the exemptions granted by TC [Transport Canada] for coal, sulfur, potash, and grain trains.”
- On May 17, 2024, “it created a job aid intended for the mechanical support personnel, which provides instructions to verify that the cars with cold wheels listed in WTD reports are the proper series. If the report contains a car number from another train, the car number must not be provided to the train crew of the unit train identified on the report. This process reduces the time it takes a train crew to obtain accurate information on cars with cold wheels.”
- In October 2024, “it incorporated in its training program a module about respecting signal indications. This module highlights the importance of signal recognition and compliance. It discusses the need to positively identify signals and to check that a called signal indication is correct before repeating it. The module also provides guidance on avoiding distractions, such as stopping conversation, keeping eyes forward, and not engaging in non-urgent activities at critical times.”
- From Sept. 16 to Oct. 16, 2024, “it conducted a blitz to ensure that all train and engine employees watched a new Respect the Signal video and discussed its content. This 5-minute video demonstrates what can happen if employees lose situational awareness and fail to respect the signals.”
