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News release

Associated links (R19T0191)

Kitchener crossing accident raises concerns about Ontario’s safety oversight of its provincially regulated railways

Richmond Hill, Ontario, 9 February 2023 — Today, the Transportation Safety Board of Canada (TSB) issued a safety concern following the release of its investigation report (R19T0191) into a 2019 accident in which a GO Transit commuter train struck an adult and a child at a public crossing in Kitchener, Ontario. As a result of the investigation, the Board is concerned that the Province of Ontario does not provide effective safety oversight of provincially regulated railways.

“This accident illustrates the critical and pervasive issue of railway crossing safety, which is the second leading cause of fatalities in the railway sector,” explains TSB Chair Kathy Fox. “Crossing safety is a shared responsibility. Pedestrians and motorists need to obey the rules at crossings; and the railways, road authorities and regulator need to communicate with each other when risks are identified and take appropriate action to improve safety and prevent further crossing accidents.”

The occurrence

On 13 November 2019, a group of 11 pedestrians, consisting of six adults and five children, were waiting to cross at the Lancaster Street West public grade crossing in Kitchener, Ontario. The crossing gates, warning bells and flashing lights were activated, as a Canadian National Railway (CN) freight train was performing switching operations on the siding track and occupying the multi-track crossing.

On the main track, a GO Transit commuter train was travelling westward on the Metrolinx Guelph Subdivision destined for Kitchener. Unaware of the approaching train, two adults from the group, both accompanied by a child, began to cross. The first adult and child ran across the crossing. As they cleared the crossing, the second adult and child pair, who followed about 15 feet behind them, were struck by the train. They both sustained serious injuries and were airlifted to a local hospital.

Investigation findings

The investigation found that four of the 11 pedestrians from the group traversed the crossing despite being aware of the activated grade crossing warning devices (GCWD), as they were unable to see the approaching GO train and therefore associated the crossing warning solely with the CN freight train exiting the crossing. The pedestrians also did not receive an early warning of a second train approaching due to the anti-whistling designation at that crossing.

The investigation also determined that CN’s use of the crossing for switching activities resulted in the GCWD being frequently activated, sometimes in excess of the five-minute regulatory limit, which influenced some users to adopt the risky behaviour of entering the crossing while the GCWD were activated in order to avoid delays.

Safety concern

Although the Ministry of Transportation of Ontario (MTO) is responsible for the safety oversight of provincially regulated railways such as Metrolinx, it has no overall provincial regulatory framework in place and relies on inspection agreements with Transport Canada (TC) and Metrolinx to aid in complying with the standards set out in federal rules and regulations. Moreover, the MTO does not have employees with technical railway knowledge, experience and expertise.

While the MTO can outsource inspections to TC, it cannot outsource the responsibility for the safety of rail operations. Meaning, while TC inspectors can identify safety hazards and aid Metrolinx in mitigating the risks, they do not have the authority to compel them to take remedial action.

Despite the clear need for thorough safety oversight, as it is vital in identifying and addressing risks present at crossings, none of the parties involved – CN, Metrolinx, the Region of Waterloo, and the MTO – were aware of the observed hazards that existed at the crossing.

Given the complexity of multiple separate agreements with different parties, this accident demonstrates that there are gaps in the Province of Ontario’s regulatory surveillance of its provincially regulated railways.

Safety actions taken

In 2021, the TSB issued Rail Safety Advisory 01/21 to TC regarding second-train events at multi-track level-grade crossings that have a high level of pedestrian traffic and experience frequent and extended grade crossing warning device activations. The advisory suggested assessing the likelihood of second train events and implementing additional safety measures to minimize the risk of accidents.

Following the accident, Metrolinx made several physical safety improvements at the Lancaster Street West crossing, and now requires train operators approaching the crossing to sound the horn if it is occupied by another train.

Since the accident, the MTO identified a need to update the oversight framework for urban and regional rail transit that would better support the province’s growing rail network and the diversity of operators. In January 2022, the MTO updated its agreements with both TC and Metrolinx. In making these updates, the MTO worked closely with TC to strengthen the MTO’s accountability role in the agreement, with respect to Metrolinx, to verify that non-compliances and deficiencies that may arise are appropriately addressed.

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
Media Relations
Telephone: 819-360-4376