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Rail Safety Advisory Letter 01/21

18 January 2021

Director General, Rail Safety
Transport Canada
14th floor, Enterprise Building
427 Laurier Avenue
Ottawa ON K1A 0N5

Subject :

Rail Safety Advisory Letter 01/21 (occurrence R19T0191)
Second-train events at multi-track level grade crossings

On 13 November 2019, at about 1450 Eastern Standard Time, Metrolinx transit commuter train GO 3919 (GO 3919) was proceeding westward on the main track of the Metrolinx Guelph Subdivision near Kitchener, Ontario. As GO 3919 approached the Lancaster Street West public crossing at Mile 62.08 (the crossing), CN freight train L56831-13 (CN 568) was slowly shoving eastward on a siding track that was adjacent to and north of the main track.

A small group of pedestrians on the west sidewalk arrived at the north side of the crossing and waited for CN 568 to clear. After occupying the crossing for just under 9 minutes, CN 568 was just about to clear the east end of the crossing when the group began walking past the activated roadway automatic grade crossing warning devices (GCWD) and onto the crossing. Unaware of GO 3919’s approach, an adult and a school age child from the group walked quickly over the tracks and into the path of GO 3919. Subsequently, they were both struck and sustained serious injuries. Both pedestrians were transported to hospital and were later released. TSB investigation R19T0191 is ongoing.

The Lancaster Street West crossing consists of 2 sets of railway tracks, both owned by Metrolinx. The south track is the Guelph Subdivision main-track while the north track is a siding that provides access to a CN yard located northeast of and adjacent to the crossing. Metrolinx commuter trains, VIA Rail Canada Inc. passenger trains, CN freight trains and CN switching assignments all operate over the crossing. Since the CN rail yard is just east of the crossing, CN trains and switching assignments frequently occupy the crossing. It is not uncommon to have a train occupying each track near or on the crossing, at the same time.

Lancaster Street West is a paved 4-lane roadway (Figure 1), oriented in a north-south direction, that intersects the Guelph Subdivision at approximately 80 degrees.

Figure 1. Lancaster Street West crossing over the Metrolinx Guelph Subdivision (Source: Google Maps with TSB annotations)
Figure 1. Lancaster Street West  crossing over the Metrolinx Guelph Subdivision (Source: Google Maps with TSB  annotations)

Sidewalks are located parallel and adjacent to the road and extend past the GCWD up to the crossing. The crossing is protected with standard reflectorized crossing signs, flashing lights, bells and gates. Some of the flashing lights are mounted on a cantilevered structure extending over the outside lanes of Lancaster Street West. The crossing was designated as an anti-whistling crossing, which prohibited trains from sounding their horn upon approach. The crossing was compliant with all regulatory requirements.

At the time of the accident, other than the automatic GCWDs, there were no pedestrian gates to protect pedestrians using the sidewalks. There were also no roadway signs or alternate warning devices located at or approaching the crossing to warn pedestrian or roadway crossing users that a second train may approach or occupy the crossing at any time. While these types of additional defences are not required by the Transport Canada Grade Crossings Regulations (GCR), there is nothing that precludes a railway and/or a road authority from taking additional measures to improve crossing safety for roadway users and pedestrians at public crossings.

Following this occurrence, Metrolinx reduced the allowable operating speed over the crossing for its GO train service from a maximum of 30 mph to a maximum of 15 mph and issued instructions to GO train crews approaching the crossing to sound their horn when a second train is in the vicinity of the crossing.

The Transport Canada Grade Crossings Regulations (GCR) apply in respect of public grade crossings and private grade crossings.

GCR Section 97. (2), Obstruction of public grade crossing, states:

It is prohibited for railway equipment to be left standing on a crossing surface, or for switching operations to be conducted, in a manner that obstructs a public grade crossing
— including by the activation of the gate of a warning system — for more than five minutes when vehicular or pedestrian traffic is waiting to cross it.

GCR Section 98. (1), Collaboration, states:

If railway equipment is operated in a manner that regularly causes the obstruction of a public grade crossing, including by the activation of a warning system, and the municipality where the grade crossing is located declares in a resolution that obstruction of the grade crossing creates a safety concern, the railway company and the road authority must collaborate to resolve the safety concern.

In June 2020, Metrolinx installed 2 eastward-facing cameras at the crossing that focused on the north and south gates and road approaches. The video recording for the times during which the Metrolinx commuter trains operate was reviewed (the 5 weekdays between 23 and 29 June 2020, from approximately 0400 until 2300). The review identified that, during these time periods, the automatic GCWDs were activated 195 times. Of these 195 GCWD activations:

In 2005, the TSB investigated a crossing accident involving a second train in Brockville, Ontario, where 2 pedestrians were struck by a CN train.Footnote 1 The pedestrians were preoccupied by their conversation and, after observing the passage of a westbound train, walked into the path of an eastbound train; one of the pedestrians sustained fatal injuries and the other received serious injuries. The crossing was protected with flashing lights, bells and gates.

Between 2005 and 2019, there have been at least 12 additional occurrences involving a second train on federally regulated public crossings that resulted in 4 injuries (2 serious, 2 minor) and 6 fatalities. Second-train events are considered to be low-frequency/high-risk events because, when they do occur, they often have serious consequences.

Traditional level crossing GCWDs (flashing lights, bells and gates) are designed to inform roadway vehicle drivers and other users that railway equipment is in or is about to enter a crossing. However, at multi-track crossings, these warning devices do not provide specific information regarding the potential for a second train, which may not be readily visible, to be approaching nearby.

As demonstrated in this occurrence, when a multi-track crossing is located next to a rail yard, slow-moving trains or stationary switching assignments may frequently occupy the crossing and sometimes delay crossing users in excess of the 5-minute regulatory limit. When these delays involve a slow-moving switching assignment, crossing users may incorrectly assess the risks and enter into the crossing before the GCWDs deactivate, and proceed into the path of an oncoming second train.

Crossing safety is based on a collaborative approach and a shared responsibility between the regulator, the railways and the road authorities. Besides this occurrence crossing, there are 788 other multi-track federally and provincially regulated public crossings in Canadian urban settings. Therefore, it may be prudent for the parties involved to identify those multi-track crossings that experience frequent and extended crossing signal activations, and that have a high level of pedestrian/cyclist traffic, assess the likelihood of a second-train event to occur and consider additional safety measures to minimize the risks of an accident.

The TSB would appreciate being advised of any action that is taken in this regard. Upon completion of investigation R19T0191, the Board will release its investigation report.

Yours sincerely,

Original signed by
Paul Treboutat
Director, Investigations (Rail/Pipeline)
Transportation Safety Board of Canada


  • Vice President, Transit Operations

  • Director, Transportation Policy Branch
    Ministry of Transportation

  • Senior Advisor
    Railway Association of Canada

  • Assistant Vice President, Safety
    Canadian National Railway
  • Chief Operating Officer
    VIA Rail Canada Inc.

  • Policy Advisor, Policy and Public Affairs
    Federation of Canadian Municipalities

  • Manager, Transportation Engineering
    Region of Waterloo

  • Assistant Vice President, Safety and Sustainability
    Canadian Pacific Railway