New TSB recommendation aims to reduce frequency of uncontrolled movements in rail yards
Gatineau, Quebec, 10 June 2020 — The Transportation Safety Board of Canada (TSB) is recommending that Transport Canada (TC), railway companies, and their labour representatives work together to reduce the number of uncontrolled movements in rail yards, specifically those caused by rail cars being moved without using air brakes – a routine task known as “switching without air.” This recommendation stems from the TSB’s investigation (R17W0267) into a 2017 employee fatality following the uncontrolled movement of a rail car at Melville Yard in Saskatchewan.
On 22 December 2017, two Canadian National (CN) employees, a foreman and a helper, were operating a yard assignment and performing switching operations at a rail yard in Melville, Saskatchewan. The switching was done by shoving the cars with a remote-controlled locomotive, releasing the cars and then letting the cars roll under their own momentum to their intended track, without the use of air brakes on any of the cars. This is an industry operation known as “kicking cars.” After an attempt to kick a group of three loaded cars up a short ascending grade with insufficient speed, the cars lost momentum and began rolling back downhill, uncontrolled. The foreman, who was operating the assignment, ran toward the cars, climbed on the lead car, and attempted to apply the hand brake, but the braking efficiency of the hand brake was compromised. As a result, the cars did not stop or slow down, but continued to roll back down the track, colliding corner-to-corner with the stationary group of cars, pinning the foreman between them. As a result of the collision, the foreman sustained fatal injuries.
The investigation found that the crew’s limited experience likely contributed to a decision to kick three loaded cars at insufficient speed up an ascending grade. It was also determined that there was a lack of communication between the two employees. If crew members do not receive enhanced crew resource management training to develop skills in crew coordination and communication, there is an increased risk that inadequate crew communication will lead to unsafe operations. In this case, neither crew member had received formal crew resource management training. They also had not discussed kicking the cars uphill or expectations of how this task would be performed.
“Switching cars without use of air brakes in rail yards is a routine railway industry practice, but one that requires a certain degree of skill, experience and judgment to do safely”, says TSB Chair Kathy Fox. “Since 2009 there have been 185 occurrences involving switching without air, and these are on an upward trend. This tells us that current defenses are not sufficient to reduce the number of uncontrolled movements”.
In light of this investigation, the Board recommends that Transport Canada work with both 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.
In this occurrence, both crew members were found to be qualified, but relatively inexperienced. Due to extensive employee turnover in the railway industry in the past few years, it is not unusual for the two most junior, and least experienced, employees to be working together in a yard. In light of this ongoing turnover and the potential adverse outcomes when inexperienced employees are paired together working in yards, the Board is concerned that, without additional mitigation, inexperienced personnel will continue to be paired together in yards, with a commensurate risk of ongoing adverse outcomes.
Since the accident, CN has made changes to the track configuration at Melville Yard, and prohibited the kicking of cars uphill. CN also identified 857 similar open-top hopper cars in its rail car fleet and inspected them all, particularly in the area of the bell-crank bracket, to ensure safe operation.
See the 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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