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Reassessment of the response to TSB recommendation R20-01

Reducing the frequency and associated risks of uncontrolled movements while switching without air

 Recommendation R20-01
in PDF [184 KB]

Background

On 22 December 2017, at about 1800 Central Standard Time during hours of darkness, a Canadian National Railway Company (CN) foreman and a helper were performing switching operations at CN’s Melville Yard in Melville, Saskatchewan. The foreman was operating extra yard assignment Y1XS-01 using a remote control locomotive system (RCLS) when the foreman became pinned between the assignment and the lead car of an uncontrolled movement while applying a hand brake. The foreman received fatal injuries. There was no derailment and no dangerous goods were involved.

The Board concluded its investigation and released the report R17W0267 on 10 June 2020.

TSB Recommendation R20-01 (June 2020)

In this occurrence, a foreman was controlling a yard assignment using an RCLS while switching without air in Melville Yard. During switching operations, the foreman became pinned between the assignment and the lead car of an uncontrolled movement while attempting to stop the movement by applying a hand brake. As a result, the foreman received fatal injuries.

Uncontrolled movements generally fall into 1 of 3 broad causal categories: loss of control, switching without air, and securement. Since 2016, the TSB has completed 3 investigations,Footnote 1 including this one, involving switching without air. This category of uncontrolled movement uses the locomotive independent brakes only, with no air brakes available on the cars being switched or kicked. The vast majority of these occur in yards.

Similar to this occurrence, TSB occurrence R16W0074 involved relatively inexperienced operators who were conducting switching operations without air in Canadian Pacific Railway (CP)’s Sutherland Yard in Saskatoon, Saskatchewan. The investigation determined that, despite Transport Canada (TC) and industry initiatives, the desired outcome of significantly reducing the number of uncontrolled movements had not yet been achieved. Consequently, the Board was concerned that the current defences were not sufficient to reduce the number of uncontrolled movements and improve safety.

Between 2010 and 2019, 589 unplanned/uncontrolled movements occurred. There has been an upward trend during this 10-year period. The average increase per year for all categories was 2.33 occurrences, with 71% of the overall increase associated with switching without air. Of the 202 occurrences involving switching without air, 74 (37%) occurred as a result of rollbacks and 60 (30%) involved dangerous goods. The major outcomes of these occurrences were collisions (137, or 68%) and derailments (85, or 42%). Two of the occurrences (1%), including this occurrence, involved an employee fatality.

While switching without air is routine and occurs every day in the railway industry, the practice has some inherent risks that can result in serious consequences. If effective strategies are not taken to improve safety while switching without air, uncontrolled movements will continue to occur, increasing the risk and severity of adverse outcomes.

The railway industry is responsible for having rules, instructions, procedures, and processes in place to safely manage operations. Railway employees who are directly involved in these operations have the greatest knowledge of how the work actually gets done and are the most affected when accidents occur. However, the regulator also has a responsibility to have adequate regulations, rules, and enforcement in place in order to provide effective regulatory oversight to ensure safe operations.

Safety action taken by TC and the railway industry to date has focused on securement practices. However, the desired outcome of significantly reducing the number of uncontrolled movements has not yet been achieved.

The underlying causes of uncontrolled movements that occur while switching without air can vary greatly. Consequently, developing a comprehensive strategy to deal effectively with all of the underlying factors and associated risks in order to reduce the number of such uncontrolled movements is proving to be difficult. Therefore, the Board has recommended that

The Department of Transport work with the railway industry and its labour representatives to identify the underlying causes of uncontrolled movements that occur while switching without air, and develop and implement strategies and/or regulatory requirements to reduce their frequency.
TSB Recommendation R20-01

Transport Canada’s response to Recommendation R20-01 (September 2020)

Transport Canada agrees with Recommendation R20-01, and is taking immediate steps to address identified and future gaps in the rail safety regulatory regime by the following actions:

Action #1

Action #2

The initiatives will provide opportunities for further engagement and discussions, including the requirements under Railway Safety Act for the industry to consult with labour organizations when drafting a new rule. Ultimately, this is to better understand the underlying causes of uncontrolled movements and provide nationally consistent standards to mitigate the risks of uncontrolled movements that occur during switching activities, and reduce their frequency.

TSB assessment of Transport Canada’s response to Recommendation R20-01 (December 2020)

Transport Canada (TC) agrees with the recommendation and has proposed a two-step action plan. The first step, to issue a Ministerial Order (MO), was completed on 29 September 2020 – MO 20-09. It directed the railway industry to revise the Canadian Rail Operating Rules to address three key risks during switching operations as follows:

  1. Requirements for location of switching operations
  2. Requirements when performing switching operations
  3. Requirements for switching with remote control locomotives

The MO requires industry to meet and discuss the proposed rules with affected associations and organizations and to file the proposed rules with the Minister of Transport by 01 June 2021.

While switching without air is routine and occurs every day in the railway industry, the practice has some inherent risks that can result in serious consequences. TC has recognized that these risks and their potential for severe outcomes need to be addressed as quickly as possible. The rapid issuance of the MO brings needed attention to this matter and clearly demonstrates TC’s interest in reducing the safety deficiency highlighted under Recommendation R20-01.

Although TC’s past regulatory focus for reducing unplanned/uncontrolled movements has been largely directed at the securement of equipment, it is encouraging that the MO may improve the likelihood of solutions being put in place for increasing the lines of defence against hazards inherent with switching operations. The effectiveness of TC’s response, however, cannot yet be fully ascertained until the consultations with the railway industry and its labour representatives have occurred, the underlying causes of uncontrolled movements that occur while switching without air are better understood, and strategies have been developed and implemented to reduce their frequency. Therefore, until the consultations are complete and strategies to reduce the frequency of uncontrolled movements that result from switching without air have been identified and implemented, the response to Recommendation R20-01 is assessed as being Satisfactory in Part.

The second step in TC’s response makes reference to future stakeholder consultations on key aspects of the Railway Employee Qualification Standards Regulations. These are planned for fall 2020; however, they have not yet been initiated. The goal is to strengthen oversight requirements and address gaps related to training and experience of employees in the regulations to ensure that they can conduct their duties safely. This should address the Board safety concern issued at the same time as Recommendation R20-01.

The Board is encouraged that TC acknowledges the existence of gaps in the training and qualification for employees in safety-critical positions and that it is actively working in a number of areas to address these gaps, including amendments to the regulatory framework.

Transport Canada’s response to Recommendation R20-01 (December 2021)

Transport Canada reaffirms its agreement with this important recommendation. Taking action in this area, the department has implemented several measures to mitigate the risk of uncontrolled movements that occur while switching without air. Following the September 29, 2020 Ministerial Order (MO) 20-09 on this topic, Transport Canada approved changes to the Canadian Rail Operating Rules (CROR) to improve safety and prevent uncontrolled movements while conducting switching operations, and to ensure that equipment is properly secured while switching. These changes came into force on October 28, 2021. The amended CROR now prescribes:

In addition, Transport Canada held a workshop with industry and labour representatives on May 17, 2021 concerning uncontrolled movements. Participants reviewed analyses of the uncontrolled movement data, underlying causes, risks, and measures taken to date. Building on the outcomes of the workshop, the department will publish a call for proposals to research potential mitigation measures applicable to uncontrolled railway equipment movements. That research will look into:

In parallel, Transport Canada continues to move forward with updating the regulatory regime for railway employee training and qualification. Progress in this area has accounted for landmark reports on rail safety in Canada, such as the February 2021 Auditor General’s follow-up audit on rail safety oversight, extensive review of observations and findings from TSB investigation reports, as well as from Transport Canada inspections and audits. Drawing on these findings, the department has prepared proposed regulatory changes aligned with the TSB’s recommendations and findings, including with respect to training programs, crew resource management, on-the-job training, and re-certification. To support a consultative approach in this area, on November 16, 2021, Transport Canada published a discussion paperFootnote 2 that outlines key policy considerations (e.g. scope of application, training requirements, examinations and evaluations) for updating the Railway Employee Qualification Standards Regulations. The discussion paper has been posted on TC’s website for a 60-day consultation period and during this period, the department will also engage in targeted consultations with stakeholders. Pending the results of these consultations, publication of the regulatory proposal in Canada Gazette, Part I, is planned for spring 2022.

Building on this progress, Transport Canada will undertake the following actions to further mitigate the risks of uncontrolled movements:

Railway Association of Canada’s response to Recommendation R20-01 (November 2021)

In September 2020, TC issued MO20-09 requiring railway companies and local railway companies to revise the Canadian Rail Operating Rules (CROR) to incorporate provisions governing switching operations. CROR were revised and filed with the Minister on June 1, 2021. These rules were approved by the Minister on July 29, 2021 and came into effect on October 28, 2021.

TSB reassessment of the responses to Recommendation R20-01 (March 2022)

This recommendation is related to the TSB Watchlist 2020 key safety issue of “Unplanned/uncontrolled movements of rail equipment” that create high-risk situations that may have catastrophic consequences. It is also linked to Recommendation R14-04, in which the Board recommended that “the Department of Transport require Canadian railways to put in place additional physical defenses to prevent runaway equipment.”

In December 2021, Transport Canada (TC) reaffirmed its agreement with the recommendation. On 28 October 2021, following Ministerial Order (MO) 20-09, the Canadian Rail Operating Rules (CROR) were amended and now prescribe:

In spring 2021, TC held a workshop with industry and labour representatives on the subject of uncontrolled movements and published a call for proposals to research potential mitigation measures.
The Board looks forward to the results of these research initiatives.

TC also continues to move forward with updating the regulatory regime for railway employee training and qualification. To support a consultative approach in the area of training programs, crew resource management, on-the-job training, and re-certification, on 16 November 2021, TC published a discussion paper that outlines key policy considerations for updating the Railway Employee Qualification Standards Regulations and has identified that it intends to conduct industry consultations.

The Board notes that, pending these consultations, publication of the regulatory proposal in the Canada Gazette, Part I, is planned for spring 2022.

The Board further notes that, in 2022, TC

The publication of the regulatory proposal and additional strategies to reduce the frequency of uncontrolled movements that result from switching without air are imminent. However, until the details of the proposals are clear, the Board considers the response to Recommendation R20-01 as being Satisfactory in Part.

Next TSB action

The TSB will monitor TC’s progress on its planned actions.

This deficiency file is Active.