Absence of risk assessment, fatigue, and task interruption among factors that led to a 2017 railway employee fatality in Montréal, Quebec
Dorval, Quebec, 6 May 2019 — In its investigation report (R17D0123) released today, the Transportation Safety Board of Canada (TSB) found that the lack of a risk assessment following a significant change in operations, in addition to fatigue and task interruption, were factors that led to a 2017 employee fatality in St-Luc Yard in Montréal, Quebec.
On 8 November 2017, during the hours of darkness, a Canadian Pacific Railway (CP) yard assignment (a crew operating with 2 locomotives) was performing switching operations in St-Luc Yard. The crew consisted of a locomotive engineer, a yard foreman and a yard helper.
While the assignment was switching cars into their designated tracks, the yard helper briefly left his position near a crossover switch and entered a nearby building. When he returned to continue his duties, he instructed the locomotive engineer by radio to stop the assignment north of the crossover switchwhich wasfurther than necessary for the next switching movement. The yard helper then incorrectly placed the crossover switch in the reverse position, inadvertently aligning the movement away from the intended destination track. He then placed the destination track’s switch in the reverse position and instructed the locomotive engineer to move the yard assignment into the destination track. Because the crossover switch was in the incorrect position, the assignment diverted onto the crossover track. The assignment struck and fatally injured the yard helper and collided with a cut of cars on the track.
The investigation found that when switching operations in St-Luc Yard were changed significantly in 2012, with most switching moved to the diamond area, a risk assessment of the changes had not been conducted. As CP’s safety management system (SMS) had not considered a risk assessment necessary, the opportunity to identify and mitigate any new hazards created by the changes was missed. If risk assessments are not completed when a change to railway operations occurs, new hazards might not be identified, increasing the risk of accidents. Safety management and oversight is an issue on TSB Watchlist 2018.
The existing levels of lighting in the diamond area of the yard made it more difficult for the yard foreman to visually determine the location of the yard helper and to distinguish the direction of travel of the yard assignment. If railway yards are not adequately illuminated for night switching operations, the visibility of employees, yard tracks and railway equipment can be compromised, which can lead to accidents.
Furthermore, the short absence of the yard helper created a task interruption that shifted the yard helper’s focus away from his duties. This led to the yard helper incorrectly aligning the yard assignment away from the destination track. It is likely that the yard helper’s fatigue also contributed to the incorrect alignment of the crossover switch.
Following the occurrence, Transport Canada (TC) conducted an investigation into the employee fatality. As a result, TC issued a direction regarding lighting at St-Luc Yard. CP has until May 2019 to address the items in the direction. CP conducted employee awareness campaigns focusing on the hazards present when working on or near tracks and the associated risk mitigation processes.
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
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