Investigation report: 2018 collision between a train and a track machine near Crysler, Ontario
Richmond Hill, Ontario, 25 November 2019 — In its investigation report (R18H0105) released today, the Transportation Safety Board of Canada (TSB) determined that a gap in track clearing procedures prevented the timely sharing of safety-critical information among railway engineering employees who were engaged in track work, contributing to a collision between a train and a track machine in October 2018 near Crysler, Ontario.
Shortly after midnight on 2 October 2018 (EDT), a Canadian National Railway Company (CN) freight train was travelling westward through a work site area protected under Rule 42 of the Canadian Rail Operating Rules (CROR) near Crysler, Ontario, when it came into contact with a track machine (Unimat tamper). The tamper had its work heads (tamping tools) extended horizontally, foul of the adjacent track used by the train. The tamper sustained damage to its tamping tools. The train sustained damage to safety appliances on both locomotives and three cars. Seven other cars sustained minor damage. There were no injuries.
At the time of the occurrence, the tamper was being operated by a trainee under the supervision of a trainer. The investigation determined that the trainer was not aware that a train was approaching or that the tamping tools had been lifted and extended toward the adjacent track. The applicable CN engineering notice did not include the Unimat tamper in the list of equipment for which work heads must be pulled in, and work stopped, when trains operate on adjacent tracks. As the tamper was not on the sub-foreman’s clearing list, the sub-foreman did not call the tamper when the Rule 42 foreman required him to clear the track for the train. If safety-critical information is not accurate and disseminated effectively to all railway engineering employees, these employees may be unaware of changes to safe working practices, increasing the risk that they will inadvertently put themselves in harm’s way.
Following this occurrence, the TSB issued Rail Safety Advisory 09/18 to Transport Canada (TC) indicating that, given the potential risks when trains operate through work sites, TC might wish to review the application of CROR Rule 42 that allows ongoing work activities when a train is passing on the adjacent track.
In addition, the Unimat tamper was added to CN’s clearing procedures for track services, and the procedures were circulated among engineering production employees working in the Eastern Region. The company also posted labels inside the cab of machines that are restricted from working during the passage of a train on an adjacent track.
See the TSB investigation page for more information.
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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