Two Watchlist issues highlighted in October 2014 VIA Rail train going through stop signal near Newtonville, Ontario
Richmond Hill, Ontario, 2 November 2015 – The Transportation Safety Board of Canada (TSB) today released its investigation report (R14T0294) into a VIA Rail passenger train passing a Stop signal near Newtonville, Ontario.
On 28 October 2014, VIA Rail Canada Inc. passenger train No. 62 (VIA 62) was proceeding eastward from Toronto to Montreal on the south track of the Canadian National Kingston Subdivision near Newtonville, Ontario. At 1015 Eastern Daylight Time, VIA 62 passed signal 2784S which was displaying a Stop indication, while travelling at about 68 mph. The train was brought to a stop and an emergency radio call was broadcast. The lead locomotive passed the Stop signal by approximately 900 feet. There were no injuries, and there was no derailment or track damage.
The investigation determined that the crew had misidentified the advance signal's indication (2808S) as being more permissive than the actual indication. The top (yellow) aspect of the advance signal (meaning the crew should be prepared to stop at the next signal) had been obscured for about 1 second by a green hue, as the light from the signal passed through a green glass insulator on the decommissioned pole line. Immediately after calling the misidentified signal within the cab, the crew focused their attention on other operational activities including the presence of a track unit on the north track ahead and discussing the next controlled location. The audible repeat of the misidentified signal by other crew members served to confirm the error as correct and the presence of the hi-rail vehicle ahead on the north track likely interrupted the crew's scanning behaviour necessary to correct the error. It was likely that the combination of these events resulted in the crew's loss of situational awareness.
On the day of the incident, a third operating crew member was in the cab. When a third crew member is present in the locomotive cab, particularly during training or territory familiarization, crew interaction and communications between the crew members will be altered, increasing the risk of loss of situational awareness. Further, there is no requirement for on-board voice and video recorders to capture any crew communications and as such, this important information is not being captured in the case of an occurrence.
Following railway signal indications and on-board video and voice recorders have been identified as key risks to the transportation system and are included on the TSB's 2014 Watchlist. The Board has called for additional physical safety defences to be implemented to ensure that railway signal indications governing operating speed or operating limits are consistently recognized and followed. Also, in the absence of locomotive in-cab voice and video recorders, operational and human performance issues cannot be fully validated and there is an increased risk that safety deficiencies will not be identified or addressed. The Board has called on the railway industry to ensure that communications and interactions in locomotive cabs are recorded.
In response to this occurrence, on 3 November 2014, Transport Canada (TC) issued a Notice to VIA Rail relating to the recent increase in VIA Rail trains exceeding authorized speeds and limits on the Kingston Subdivision. In response to the Notice, VIA Rail increased monitoring on the Kingston Subdivision to ensure that train crews are complying with speed restrictions. VIA Rail also implemented an oversight program to ensure that this monitoring is conducted regularly.
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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