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Manitoba Train Collision in 2019 Due to Crew Fatigue, Inexperience: Safety Board

August 24, 2022 12:27 PM | The Canadian Press

By Brittany Hobson, The Canadian Press

CN Train Crash

Damage to the north side of lead locomotive CN 3009 on train 318. (TSB / HANDOUT)

WINNIPEG — The Transportation Safety Board says a 2019 train collision and derailment west of Winnipeg was the result of crew fatigue and inexperience and has made recommendations to prevent similar accidents in the future.

“If Transport Canada and the railway industry do not act more quickly to implement physical fail-safe defences to reduce the consequences of inevitable human errors, the risk of collisions and derailments will persist with a commensurate risk to people, property and the environment,” board chair Kathy Fox said Wednesday.

Two freight trains, both carrying dangerous goods, derailed near Portage la Prairie, Man., in January 2019. The investigation found the train travelling eastbound collided with the tail end of the train heading westbound after the crew failed to follow signals to stop in time.

Two locomotives and eight freight cars went off the tracks.

The agency said a diesel leak was detected at the time, but it was contained.

Crew members from the train travelling east had to jump from the locomotive and were treated for minor injuries.

The board found the engineer on the eastbound train had missed a signal to stop because of fatigue and the conductor on the same train deferred to the engineer because of inexperience on the job.

Fox said the engineer was fatigued due to inconsistent rest periods during the two days leading up to the accident.

“Fatigue management has been an issue of concern on the Transportation Safety Board watch list since 2016.”

The Transportation Safety Board said Transport Canada should implement physical fail-safe train controls more quickly on Canada’s high-speed rail corridors, which would act as backup safety defences against human error.

“When a crew does not follow signal indication, the administrative defence fails. In the absence of a physical defence, there’s no automatic intervention to slow or stop a train, as was the case in this accident,” said Fox.

Having enhanced train control measures means a system would automatically intervene to bring the train to a controlled stop if a crew goes past the signal indication when they’re not supposed to, said Rob Johnston, a manager with the board.

“Essentially, it would prevent an accident, something like this.”

The agency also recommends Transport Canada require railways to bolster their training for employees.

They suggest a formal crew resource management training model become a requirement for railway operating employees. This model focuses on crew communication, situational awareness and problem solving.

“When there’s a difference in experience between operating crew members … a less experienced crew member may not always intervene to ensure compliance with all of the rules,” said Fox.

The board said it has investigated eight other rail occurrences since 1996 in which similar practices were identified factors.

The agency has also been pushing Transport Canada for physical fail-safe measures for the past two decades.

“We feel there’s a sense of urgency that’s lacking,” said Fox.

In a statement Wednesday, Transport Canada said it is reviewing the safety board’s investigation report and the minister of transport is to respond within 90 days.

“Transport Canada monitors railway companies for compliance with rules, regulations and standards made under the Railway Safety Act through risk-based audits and inspections,” it said.

“The department conducted over 35,000 rail safety inspections last year and does not hesitate to take enforcement actions in the interest of public safety.”

The department said it is working with other government agencies and industry for the rollout of enhanced train control technology.

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