Communiqués

TSB # R 08/99

(Hull, Quebec, 15 April 1999) - The investigation into the collision between two commuter trains at Union Station in Toronto, Ontario, on the afternoon of 19 November 1997, has revealed several unsafe conditions affecting the operation of GO Transit commuter trains.

In its final report on the investigation, the Transportation Safety Board of Canada made a number of findings: the crew did not clearly communicate critical information necessary to perform the movement; there was an ineffective work plan; the crew was unable to establish intercom communication; there was inadequate crew training; the communications systems were inefficient; there was a lack of standard operating procedures; and the emergency braking systems in the cab car were not readily accessible. All of these factors contributed to the collision.

The stationary train, with more than 800 persons on board, was preparing to leave Union Station when it was hit by a second train, with two crew members on board, that was being pushed into position on the same track. The second train was moving at approximately 12 mph at the time of the collision. Fifty-four passengers and two crew members sustained minor injuries.

Since the accident, a number of changes have been made to improve the safety of the GO Transit system and reduce the probability of collisions:

• The rules for operating crews regarding reversing movements have been changed. The locomotive engineer must now change controlling positions, to either the cab car or locomotive, to operate the train from the leading end of the direction of the train movement. The track on which the accident took place, Depot Track No. 1, must be unoccupied before another train can be allowed on it. Training and qualification of GO Transit train crews have now been formalized, and refresher training will be provided every three years.
• At the time of the accident, the first-aid and trauma kits were locked up and accessible only by crew members. Since the accident, GO Transit has upgraded the kits, provided more flashlights, and made them more accessible. It also provided more emergency flashlights, replaced the glazing in all emergency windows and improved related signage.

During the emergency, the conductor in the cab car was unable to establish intercom communication with the locomotive engineer in order to give warning of the developing situation. This was the first time the conductor had used the intercom of the Integrated Communications Control Unit (ICCU) in an emergency situation. The way the ICCU is designed and installed makes it difficult, in an emergency, to ensure that a crew member is going to get and remain in contact with the person at the other end. Safety-critical information must be easily and reliably conveyed.

It was also determined that employees had not been provided with meaningful instruction and training on how to use the system, particularly during an emergency. The Board has therefore recommended that:

GO Transit review its communication protocol as well as the design and installation of the Integrated Communications Control Unit (ICCU) to ensure that safety-critical information can be reliably transmitted and received. [R99-03]

Once the intercom communication between the conductor and locomotive engineer failed, the conductor in the cab car attempted to apply the emergency brake to prevent the accident. The conductor could not get at the closest emergency brake valve because it was behind the open cab door and the automatic emergency brake valve in the cab control station requires that the operator re-install the handle before it is operable. The inability of the conductor to initiate an emergency stop with either of the two valves illustrates the necessity of designing and locating emergency equipment that can quickly and easily be applied by crew members in an emergency. The Board has therefore recommended that:

GO Transit review the emergency brake valves on all cab cars to ensure that they can quickly and easily be applied in an emergency situation. [R99-04]

The Board has a safety concern about the way in which the cab control station door swings into the aisle toward the end corridor door. The end corridor door is identified as an emergency exit and, although not a primary route of egress, passengers trying to use this door, in an emergency, as the most convenient means of escape may be impeded by the cab control station door if it is secured or jammed in the open position in the aisle way.

The Transportation Safety Board of Canada is an independent agency operating under its own Act of Parliament. 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.

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