Rail Safety Advisory Letter 617-02/19
Securement of cars that are considered “attended” during yard switching operations
Place du Centre
200 Promenade du Portage, 4th Floor
Gatineau QC K1A 1K8
21 March 2019
Safety advisory letter 617-02/19
Related occurrence: R18M0037
Letter addressed to Transport Canada
Subject: Rail Safety Advisory Letter – 617-02/19: Securement of cars that are considered “attended” during yard switching operations
On 04 December 2018, at about 0825 Atlantic Standard Time, a Canadian National Railway Company (CN) yard assignment (assignment) was switching cars at Edmundston Yard in Edmundston, New Brunswick. The assignment crew consisted of a locomotive engineer, a conductor and a conductor trainee (trainee). During switching operations, 2 cars that had been placed on track EA14 (west-end yard lead) started to roll uncontrolled back towards the assignment, resulting in a collision with the assignment’s trailing locomotive (Figure 1). The trainee, who was standing on the side ladder of the trailing locomotive, sustained fatal injuries (TSB Occurrence No. R18M0037).
The 2 cars had been placed on the west-end yard lead near the Track 5 switch. As per normal practice at this yard, the crew had left the cars with emergency brakes applied before continuing the work. After uncoupling from the 2 cars, the assignment (now consisting of 2 locomotives only) proceeded westward for about 200 feet, just passed the Track 4 switch. The trainee then lined the Track 4 switch to allow the assignment to reverse eastward into this track. Upon re-boarding the trailing locomotive, the trainee was positioned on the northeast ladder, next to the locomotive platform where the conductor (who was coaching him) was positioned. The trainee then instructed the locomotive engineer to back up 20 car lengths in order to pick up a car positioned further east on Track 4.
Shortly after the assignment began reversing towards Track 4, the conductor noticed that the 2 cars on the west-end yard lead were rolling uncontrolled towards them. The conductor immediately instructed the locomotive engineer to stop the assignment, and attempted to warn the trainee. The assignment was placed into emergency, but was not able to stop before side-colliding at about 9 mph with the uncontrolled cars. The trainee, who was still positioned on the ladder of the trailing locomotive, sustained fatal injuries.
During yard switching operations, cars that are set off are considered to be “attended” if the crews are continuing their work in the vicinity of the cars. As such, when these cars are set off on a track in Edmundston Yard, they are typically secured with air brakes only.Footnote 1
Canadian Rail Operating Rules (CROR) Rule 112 states (in part):
Equipment is considered unattended when an employee is not in close enough proximity to take effective action to stop the equipment should it move unintentionally.
The rule implies that an employee in the “proximity” would be able to intervene effectively to stop an unintentional movement of the equipment. However, as in this occurrence, employees are normally engaged in other work activities and may not always be able to take effective action to stop the equipment, should it move unintentionally. Furthermore, if equipment does roll unintentionally, the crew members may have to climb onto the moving equipment to take action, placing them in a hazardous situation.
In 2016, the TSB investigated a similar occurrence involving an uncontrolled movement at the Co-op Refinery Complex in Regina, Saskatchewan (TSB Occurrence No. R16W0059). In that occurrence, tank car GATX 67963 (loaded with asphalt) had been secured only with an emergency brake application. The tank car was considered to be “attended,” as the crew was continuing its work in the general vicinity. About 10 minutes later, the tank car rolled away uncontrolled. The crew was unable to take effective action to stop it before it exited the yard.
In 2018, there were 16 TSB-reportable occurrences (including this occurrence) involving cars that had been left in the yard and considered “attended,” which then rolled unintentionally and resulted in a collision or derailment (Annex A). In each of these occurrences, while the cars were considered to be “attended,” the crew members were not able to take effective action to stop the uncontrolled movement. As written, CROR Rule 112 may not be sufficiently clear with respect to when cars can be considered as being “attended.” Given the risks associated with cars rolling unintentionally, Transport Canada may wish to review, clarify and update the definition of “unattended” as it pertains to CROR Rule 112 to ensure that this rule is appropriately (and consistently) applied during yard switching operations.
Original signed by
Investigation Operations, Rail/Pipeline
- Canadian National Railway
- Railway Association of Canada
- Canadian Pacific Railway
Annex A – Uncontrolled movements in yards involving cars that were considered “attended” (2018)
|The Canadian National Railway Company (CN) east lead assignment with locomotive CN 7279 had cars listed for track PF30. By mistake, the crew shoved past track PF30, towards track PF31, and stopped just short of going onto track PF31. At the same time, the conductor decided to remove the hand brake in track PF30 and allowed the cars to roll towards the movement. The cars rolled foul of the lead (at the east end), resulting in car CN 412224 colliding with car WC 22176 as the crew began pulling back to clear the PF30 switch. Car CN 412224 was pulled eastward, derailing the A-end set of trucks. The safety appliances on car WC 22176 sustained damage. There were no injuries and no dangerous goods were involved.
|A CN train crew, while preparing to lift cars from track HA10, applied hand brakes on the south end and released the hand brakes on the north end when the cars began to roll northward, striking the derail and derailing car AEX 19628 (1 set of trucks on the A-end). There were no injuries and no dangerous goods were involved.
|The Canadian Pacific Railway (CP) Winnipeg Yard Beltpack assignment, while pulling east out of track NW03, derailed cars COER 880187 (load of lumber - on its side), TTGX 700045 (loaded automobile flat car - on its side) and SOO 115068 (empty covered hopper car - upright). This was an uncontrolled movement and collision between TTGX 700045 that had been left in track NW01, rolled out of the track, and contacted the Beltpack assignment.
|The CN Thornton transfer assignment derailed 2 cars while switching in the yard. Car CN 371843 derailed upright (A-end), and car CNLX 10076 derailed upright (B-end). There were no injuries and no dangerous goods were involved.
|In CP Alyth Yard, the CE31 east-end switcher shoved a cut of 13 cars into the east end of track VT06. The switcher then pulled out to the lead. While the switcher was on the lead, the cut of cars that had been left in track VT06 rolled eastward, making contact with their locomotives.
|A CN train assignment, while servicing customer tracks, had set out car UTLX 902454 into customer track U221, and returned to their train on the adjacent track. While pulling on the adjacent track, car UTLX 902454 rolled uncontrolled and collided with the train, resulting in the derailment of cars UTLX 902454 (loaded, UN 2348 - butyl acrylates, all wheels on a 45-degree angle), PROX 23024 (loaded, UN 2055 - styrene monomer, derailed all wheels, upright), and UTLX 902486 (loaded, UN 2348 - butyl acrylates, derailed all wheels, upright). There were no injuries. The track sustained minor damage. No leaks or exposures were reported.
|A CN train assignment set out 2 cars onto track OR16, returned to their train on track OR17, and pulled to spot for their next cut. Rail car NCIX 173 (loaded covered hopper car) rolled out of track OR16 and struck car NCIX 6826, which was stopped on the lead coming out of track OR17. Car NCIX 173 derailed upright, with one axle on the A-end on the ground. There were no injuries and no dangerous goods were involved.
|A CN Walker Yard assignment at the east end of track CF74 shoved single car AEX 20057 onto track CF74 and made a light engine move onto track CF78. Upon exiting track CF78, locomotive CN 7504 sideswiped car AEX 20057 that had rolled uncontrolled eastward out of track CF74, causing car AEX 20057 to derail on its side. There were no injuries and no dangerous goods were involved.
|The CN Saskatoon Beltpack yard assignment, holding onto 24 cars on the east lead, was sideswiped by a cut of cars that rolled out of the east end of track SC30. Empty open gondola cars AIMX 15336 and AIMX 15284, both of which were in track SC30, derailed upright with damage to their safety appliances. These cars collided with GACX 6244 (empty potash car), causing damage to its safety appliances. There were no injuries and no dangerous goods were involved.
|A CN yard assignment, operating with locomotive CN 7265, set off 6 cars on a grade and cut away. Some cars cars rolled into a departing freight train. Car TFOX 1533, from the yard assignment, sideswiped cars BAEX 1249 and CNIS 417187 on the freight train. There was no derailment. There were no injuries and no dangerous goods were involved.
|A CN yard assignment, while switching in Senneterre Yard between tracks AS05 and AS06, shoved a cut of 31 cars westward at approximately 5 mph towards track AS06. Empty dangerous car PROX 16012 (residue, last contained sulfuric acid, UN 1830) from their movement collided (cornered) with empty centre beam car CN 626188, which rolled back out towards the lead from track AS05. There were no injuries and no leaks. Both empty cars sustained minor damage.
|CN Symington Yard assignment was shoving eastward into track WI03 with 26 cars and 2 locomotives when cars in track WI01 rolled uncontrolled westward and side-collided with car DTTX 759279. Car DTTX 759279 (5-pak) derailed upright, its west-end truck on the west-end platform. The following cars sustained damage to their safety appliances due to the sideswipe: DTTX 727134 (sodium hydroxide solution – UN 1824), DTTX 466263, GTW 675106, DTTX 657369, DTTX 745724, DTTX 475954, and DTTX 742268. The fuel tank on locomotive CN 7251 was punctured, but not leaking. Locomotive CN 252 sustained damage to its hand rail. There were no injuries and no leaks.
|A CP cut of cars rolled out of track BT14 at the east end of Coquitlam Yard and collided with a single box car as it was being kicked towards track BT16. There were no injuries and no dangerous goods were involved. There was no derailment. Some damage was reported.
|Three CP locomotives rolled uncontrolled while on the Fast Track diesel shop in Alyth Yard. A fourth locomotive had been disconnected just prior to the uncontrolled movement. As a result, locomotive CP 8519 collided with locomotives CP 3127 and CP 2315 that were secured on the Fast Track. Both locomotives (CP 8519 and CP 3127) sustained damage. There were no injuries and no leaks were reported.
|A CN Beltpack assignment, operating with 3 locomotives and 89 empty cars, set out a cut of cars on the main track and proceeded into track RA35 (customer facility). During the movement, cars on the main track began to roll uncontrolled and collided with the movement, resulting in car GATX 68294 (residue, last contained asphalt) derailing on its side and car DBUX 250296 (residue, last contained asphalt) derailing upright. There was an impact to main track operations. There were no injuries and no leaks.
|A CN train assignment, while reversing towards track 4 at the west end of Edmundston Yard, collided with a car foul of the track. The conductor stopped the movement with emergency broadcast as the conductor trainee, riding the side of car, was struck and fatally injured. Emergency Services and Coroner responded.
- Glen Pilon, Regional Senior Investigator, Head Office, Gatineau, Quebec
- Guy Laporte, Regional Senior Investigator, Dorval Regional Office, Quebec
- Manuel Kotchounian, Manager, Pipeline and Eastern Regional Operations – Rail, Head Office, Gatineau, Quebec