TSB Rail investigation report R16T0111 (MacMillan Yard) - Opening remarks
Faye Ackermans, Board member, TSB
Rob Johnston, Manager, Railway Investigations, Central Region & Headquarters
Richmond Hill, Ontario
27 June 2018
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On the evening of June 17, 2016, a CN train consisting of 2 locomotives and 74 cars ran uncontrolled along three miles of main track just east of CN's MacMillan Yard, which sits on the northern edge of Toronto. The cars and locomotives, known as "an assignment," reached a speed of nearly 30 miles per hour before an upward slope brought them to a stop.
Ever since the disaster at Lac-Mégantic in 2013, Canadians need no reminders of the dangers posed by uncontrolled or runaway trains. Moreover, over the past five years, the number of these "uncontrolled movements" has been on the rise. And although there was no crude oil involved in this case, nor was anyone injured, one of the cars contained a flammable mix of gasoline and ethanol.
During its investigation, the TSB identified training deficiencies with regard to conductors who work in rail yards, many of whom use a remote-control unit known as a "Beltpack" to take incoming trains, reassemble the individual cars, and create new departing trains. What we learned is that the regulations that govern employee qualification standards have not kept pace with the significant changes in railway operations over the years. As a result, some railway employees working in key positions may lack the training or experience to safely perform their duties.
That's why today the TSB is issuing a recommendation, calling on Transport Canada to update the regulations and address qualification standards for employees in safety-critical positions.
I'll talk more about that recommendation in a few minutes, but first I'll turn things over to the Regional Manager, Rob Johnston. He'll walk you through the details of what happened that evening, explaining the specifics of how—and why—the crew lost control of the train in this occurrence.
Thank you, Faye.
Like most railway yards, MacMillan Yard is shaped like a bowl. Yards are designed that way on purpose, to minimize the chance of cars running away onto the main track. In this case, at the south end of the yard, the edge of that bowl rises and, beyond the crest, the tracks descend toward the York Subdivision and the city of Toronto.
On the day in question, the crew in that area of the yard consisted of a foreman and a helper. Although both were qualified conductors and Beltpack operators, and each had about two years of yard experience, neither had a lot of experience working in this area of the yard. The foreman therefore requested a job briefing from the Mac Yard trainmaster. They actually received two briefings—and while these were useful, there was still a misunderstanding regarding the availability and use of air brakes.
What you need to know is that trains have two types of air brakes: independent brakes and automatic brakes. Independent air brakes are available only on each individual locomotive, in this case, the two at the head of the movement. Automatic air brakes are used to slow or stop the entire train, and are controlled by means of an air brake pipe that is connected to each car.
Following the job briefings, the trainmaster understood that the cars were to be connected to the automatic air brakes—whereas the foreman and helper understood that only the independent air brakes on the two locomotives would be needed initially. Connecting the air hoses and charging the automatic brakes on the rest of the cars would be done once they were delivered to the customers.
By about 11:30 pm, the crew had assembled all the cars at the south end of Mac Yard. In total, the assignment was over 4500 feet long and weighed over 9000 tons. In order to take all the cars in a single move, the crew needed extra room, so they received permission to move the cars beyond the edges of the Mac Yard "bowl," and partway onto the York Subdivision main track.
Initially, this move went as planned. While the foreman remained on the ground in the yard, the helper stood on the locomotive platform at the front of the lead locomotive, controlling the cars using a Beltpack. With only about one-third beyond the crest of the bowl, the assignment was able to come to a controlled stop, to allow an oncoming train to pass by.
Afterward, the crew moved it farther onto the main track, so that roughly two-thirds of the cars were moving forward down the descending grade. At that point, with only the locomotives' independent brakes available, they did not have enough effective braking force, and the cars began to accelerate. As mentioned, the train moved uncontrolled, reaching a speed of nearly 30 mph before eventually coming to a stop three miles later.
Following the incident, CN conducted a risk assessment, which included a review of topography and air brake use at all its yards, nationwide. As a result, new minimum braking requirements are now in place for each yard—including how many cars require charged air brakes prior to being allowed on main track. But more must still be done. To discuss exactly what, I'll turn things back to Faye Ackermans.
As Rob mentioned, both the foreman and the helper were qualified train conductors, and each had worked in Mac Yard for nearly two years. But there were some key differences between the work they were tasked with and the duties they were used to performing—differences that left them without sufficient operational experience to do the job safely.
For instance, both crew members were used to working in other areas of Mac Yard—areas where most switching operations are performed without the use of automatic air brakes. This contributed to the misunderstanding with the trainmaster regarding the use of automatic air brakes. Second, although the crew was aware of the assignment's significant size, they lacked the knowledge to fully understand how that influenced the way it "handled." That is, how the cut of cars would move—or stop and start—based on characteristics such as length, tonnage, and weight distribution.
Finally, the crew did not recognize the significance of the territory they would be travelling, specifically, the descending grade outside the crest of the bowl. Yes, they were initially able to come to a controlled stop, but that was because two-thirds of the cars were still inside the yard on the upslope of the bowl. Once the majority of the cars were heading downhill, toward the main track and York Subdivision with no air brakes on the cars, the train lacked sufficient braking force.
Here's the problem in a nutshell: although the crew was qualified according to the regulations that govern employee qualification standards, those regulations do not cover the way work is carried out today. That's because, in the 31 years since those regulations were first issued, work has evolved. Beltpack technology now allows crews to assemble and move assignments without the services of a Locomotive Engineer — yet that is the only person who is required to have recurrent training in subjects such as locomotive operation and train handling, during which they are thought how to anticipate and negotiate changes in terrain.
Again, allow me to be clear: the problem is not the technology. Beltpack has been around for years, and it allows for all sorts of efficiencies, especially in terms of the reduced number of crew required to carry out a job. But this investigation identified gaps between what is mandated by the regulations, and what is required for some employees to do the job safely.
So long as these gaps in regulations remain, Transport Canada won't be able to fix the problem, either; they won't be able to conduct effective oversight, nor will they be able to enforce training programs for safety-critical positions. And that means the risk of uncontrolled movements and other accidents will continue.
Transport Canada has been promising a regulatory update for years—as far back as 2003. Now is the time for action. A cut of cars rolled uncontrolled away from a rail yard, downhill onto a main track, in the largest city in Canada. The employees tasked with moving it lacked the knowledge or experience to properly control it.
There can be no more delays. Transport Canada must update the Railway Employee Qualification Standards Regulations to address the existing gaps for employees in safety critical-positions related to training, qualification and re-qualification standards, and regulatory oversight.
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