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Rail transportation safety investigation R17D0123

The TSB has completed this investigation. The report was published on 6 May 2019.

Table of contents

Employee fatality

Canadian Pacific Railway
Yard assignment FS23
Mile 46.9, Adirondack Subdivision
St-Luc Yard
Montréal, Quebec

View final report

The occurrence

On , Canadian Pacific Railway yard assignment FS23 was performing switching operations in St-Luc Yard at Mile 46.9 of the Canadian Pacific Railway Adirondack Subdivision, in Montréal, Quebec. At about 0600 Eastern Standard Time, while reversing southward in the dark at approximately 10 mph, the yard assignment struck and fatally injured the yard helper.


Media materials

News releases

2019-05-06

Absence of risk assessment, fatigue, and task interruption among factors that led to a 2017 railway employee fatality in Montréal, Quebec
Read the news release

Deployment notice

2017-10-04

TSB deploys a team of investigators to the site of a railway accident at Saint-Luc Yard in Montreal, QC

The Transportation Safety Board of Canada (TSB) is deploying a team of investigators to the site of a Canadian Pacific railway accident at Saint-Luc Yard in Montreal, Quebec. The TSB will gather information and assess the occurrence.


Investigation information

Map showing the location of the occurrence


Investigator-in-charge

Photo of Jennifer Philopoulos

Jennifer Philopoulos has 15 years of experience in the Oil and Gas industry. She joined the TSB in 2015 as Pipeline engineering expert and senior investigator based out of the Dartmouth, NS regional office. She holds a bachelor’s degree in Metallurgical Engineering from Dalhousie University.

Prior to joining the TSB, Jennifer began her career with Shell at their Oil Sands Upgrading facility, as a site materials and corrosion engineer. Most recently, she has worked as a consulting engineer, providing materials and corrosion expertise to the Oil and Gas industry.

Her experience has focused on corrosion assessments evaluating the conditions of materials in refineries and pipelines in order to prevent premature failures. This includes performing and developing risk based inspection programs, preventative maintenance programs and supporting fitness for service assessments. She has also preformed and supported metallurgical forensic work on various failed components.


  Download high-resolution photos from the TSB Flickr page.

Class of investigation

This is a class 3 investigation. These investigations analyze a small number of safety issues, and may result in recommendations. Class 3 investigations are generally completed within 450 days. For more information, see the Policy on Occurrence Classification.

TSB investigation process

There are 3 phases to a TSB investigation

  1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
  2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
  3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

For more information, see our Investigation process page.

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.