Safety communications related to TSB investigation (R16T0111)

Safety communications related to TSB investigation (R16T0111) into the June 2016 uncontrolled movement of rolling stock at MacMillan Yard, Vaughan, Ontario

The occurrence

On 17 June 2016, a Canadian National Railway (CN) crew was performing switching operations using a remote control locomotive system in MacMillan Yard, located in Vaughan, near Toronto, Ontario. The crew was pulling 72 loaded cars and 2 empty cars southward from the yard toward the York 3 main track, in order to clear the switch at the south end of the Halton outbound track, when it lost control of the cars. The group of cars rolled uncontrolled for about 3 miles, reaching almost 30 mph before coming to a stop. There were no injuries. There was no release of dangerous goods and no derailment.

TSB recommendations

The Canadian Transportation Accident Investigation and Safety Board Act specifically provides for the Board to make recommendations to address systemic safety deficiencies posing significant risks to the transportation system and, therefore, warranting the attention of regulators and industry. Under the Act, federal ministers must formally respond to TSB recommendations within 90 days and explain how they have addressed or will address the safety deficiencies.

Recommendation made on 27 June 2018

The Railway Employee Qualification Standards Regulations came into force more than 30 years ago. Since that time, there have been significant operational changes in the rail industry, including the following:

• The size of crews has been reduced.
• Remote control locomotive system (RCLS) operations have been widely implemented.
• The periodic use of management crews has become more widely implemented.

Under the current regulations, locomotive engineers are required to receive recurrent training in locomotive operation and train handling. They are trained to recognize characteristics of the train, the characteristics of the territory, anticipate the train's response and must adapt its operation to negotiate changes in terrain as well as to comply with signal indications and rail traffic controller instructions.

Conductors, on the other hand, receive little training in locomotive operation or train handling, and the current regulations do not require such training. However, in Canada, conductors can transfer groups of cars (or assignments) in railway yards using remote control locomotive systems. These assignments can enter the main track and are allowed to travel as far as 20 miles at speeds of up to 15 mph, with no tonnage or train length restrictions.

Since 2002, TSB has conducted 6 investigations (including this occurrence) that were directly related to deficiencies in operating crew training and/or related gaps in the regulations.^{Footnote 1} Transport Canada (TC) has recognized the need to update the regulations on several occasions:

• In 2003, TC indicated that it was planning to review the regulations in fall 2003.
• In 2005, TC acknowledged that the regulations were outdated and should be revised; it considered creating a working group to revise the regulations.
• In 2009, TC approved the Rules Respecting Minimum Qualification Standards for Railway Employees (Rules), which were to come into force once the regulations were repealed. However, to date, the Rules are not in place, as the regulations have not been repealed.

In its Departmental Plan 2017-18, Transport Canada indicated its intention to strengthen the regulatory regime by updating the Railway Employee Qualification Standards Regulations, but there has been little progress to date.

The Railway Safety Management Safety Regulations, 2015 require railways to have processes for managing knowledge. Although sections 25-27 cover some aspects of crew training, they do not require individual plans and methods for each position and do not prescribe the training requirements for each position. Consequently, the approach varies among railways. For example, Canadian Pacific Railway (CP) does not include RCLS operators in its plan, whereas CN does.

As a result, significant regulatory gaps remain with respect to training and qualification standards. For example:

• Conductors receive no training in locomotive operation or train handling.
• Management crews do not have to meet the same requirements for duration of training, number of trips, and experience as unionized staff.
• There is no practical training required for requalification of locomotive engineers, transfer hostlers, or conductors.
• There is no occupational category and no corresponding training or requalification requirements for rail traffic controllers.
• There is no training requirement for RCLS and no requirement to requalify in RCLS operations.
• There are also important gaps in regulatory oversight. For example:
• The regulations contain no guidance for course training material, test content, or test delivery for railway employees in safety-critical positions.
• Transport Canada does not assess the adequacy of the training and provides no further oversight with regard to the training of railway employees in safety-critical positions.
• There are no requirements for mandatory familiarization or refresher training when railway employees in safety-critical positions return to work after a layoff.

If the gaps in the current Railway Employee Qualification Standards Regulations are not addressed, railway employees in safety-critical positions may not be sufficiently trained or experienced to perform their duties safely. Additionally, Transport Canada will not be able to conduct effective regulatory oversight and enforcement of training programs.

Therefore, the Board recommends that