Following their investigation, the Transportation Safety Board of Canada recommended that Transport Canada work with the railway industry and its labour representatives to identify the underlying causes of uncontrolled movements that occur while switching without air (i.e., without using air brakes on individual rail cars), and develop and implement strategies and/or regulatory requirements to reduce their frequency.
Switching refers to a process of arranging rail cars in the correct order on a train. In certain locations, such as yards, switching can occur without air brakes being used on individual rail cars so that these cars can be arranged more efficiently.
The Transportation Safety Board of Canada identified one safety concern in their report:
Without additional mitigation, inexperienced remote control locomotive system operators will continue to be paired together in yards with a commensurate risk of ongoing adverse outcomes.
The Transportation Safety Board of Canada investigation concluded that the crew’s limited experience likely contributed to a decision to switch three loaded cars at insufficient speed up an ascending grade. It also determined that there was a lack of communication between the two employees.
Ministerial Order pursuant to Section 19 of the Railway Safety Act (MO 20-09)
Railway employees work in a dynamic environment. The majority of uncontrolled movements take place in rail yards where the risk to the public is very low.
Transport Canada has put in place a Ministerial Order that introduces measures to improve rail safety in Canada and reduce the risk of uncontrolled movements.
This Ministerial Order requires the rail industry to work with labour representatives to improve the safety of switching operations by revising the Canadian Rail Operating Rules to address the underlying causes of uncontrolled movements that occur while switching is undertaken.
Addressing uncontrolled movements of rail equipment
Transport Canada has taken many steps to strengthen rail safety, including implementing stricter rules to secure trains and reduce the risk of uncontrolled movement of rail equipment.
The Department revised Rule 112 of the Canadian Rail Operating Rules on train securement, requiring additional physical defences to secure unattended trains. Rule 112 provides uniformity in hand brake application by requiring handbrakes to be applied according to a chart that is based on train tonnage and grade. The Rule also requires an additional means of securement when equipment is left unattended on main track, sidings, subdivision track, and high risk locations
.In April 2020, Transport Canada approved a new Rule 66 of the Canadian Rail Operating Rules, which will help ensure that effective safety procedures are applied to all trains that come to emergency stops on both heavy grades and mountain grades. This change to the Canadian Rail Operating Rules puts into place additional permanent layers of defence to secure attended trains and prevent an uncontrolled movement on both heavy grades and mountain grades.
Remote Control Locomotive Systems
Transport Canada published the Guideline for Remote Control Locomotive Operation, in 2019, which makes recommendations in the area of training and qualification for employees involved in remote control locomotive operations.
The guideline recommends railways establish criteria, such as minimum experience of each crew member and amount of supervision required, for when less experienced remote control operators may work together.
Additionally, Transport Canada is moving forward with revising the Railway Employee Qualification Standards Regulations to address gaps related to training and experience of employees.
Transport Canada monitors the railway’s compliance to rules and regulations made under the Railway Safety Act through a program of risk-based inspections. If non-compliance or a safety concern is found, Transport Canada takes appropriate enforcement action based on the severity of the safety issue and can involve one or more of several compliance and enforcement tools, including Letters of Non-Compliance, Notices, Notices and Orders, Administrative Monetary Penalties and Prosecution.