Richmond Hill Ontario - In its Investigation Report R16T0162 released today, the Transportation Safety Board of Canada (TSB) found that the August 2016 collision between two Canadian Pacific Railway (CP) trains occurred when one of the trains was operated past a stop signal.
In the early morning of 21 Aug 2016 an eastbound CP freight train with two locomotives and 24 loaded cars was crossing over from the north track to the south track along the North Toronto Subdivision in Toronto, Ontario.
At around the same time, a westbound train, composed of two locomotives, was approaching the same location on the north track.
When it reached the crossover, the westbound train collided with the tail end of the eastbound train and the westbound train's two locomotives derailed upright.
Four of the intermodal cars (10 platforms) at the tail-end of the eastbound train were struck and damaged, with four of the platforms derailing upright.
The fuel tank on the lead locomotive of the westbound train was punctured, resulting in the release of about 2,500 litres of diesel fuel.
Several small fires were extinguished on the site.
The conductor of the westbound train was injured.
The investigation determined that the crew of the westbound train had proceeded past an advance signal that required the crew to be prepared to stop at the next signal, without slowing or preparing to stop.
Approaching the accident location, the train crew had about 42 seconds to view and respond to the upcoming stop signal.
However, tasks such as operating the train, reviewing the timetable, observing the eastbound train, and searching for a reported trespasser diverted the crew's attention from the high-priority task of signal recognition.
Consequently, braking was not initiated until it was too late to safely stop the train, resulting in the collision and derailment.
This investigation highlights the need for on-board voice and video recorders, which is a TSB Watchlist issue.
An on-board recording could have provided investigators with better information to understand why the westbound train crew did not respond appropriately to the signal indications.
Since 1998, the TSB has investigated 12 occurrences when a train exceeded its limits of authority, including the 2012 Burlington VIA Rail Canada derailment (R12T0038), which resulted in three fatalities and 47 injuries.
The Minister of Transport has recently tabled legislation in Parliament to require the installation of voice and video recorders in all lead locomotives.
Systemic risks related to following railway signal indications, is also a Watchlist issue.
If train control systems rely only on administrative defences rather than physical defences to ensure safe train operations, signal recognition errors may not be adequately mitigated, increasing the risk of train collisions and derailments.
The TSB has investigated 13 similar occurrences and issued two recommendations (R13-01 and R00-04) calling for implementation of physical train controls and additional backup safety defences to ensure that signal indications are consistently followed.
Transport Canada responses to both recommendations have been assessed Satisfactory in Part.
Following the occurrence, CP issued bulletins to clarify speed reduction requirements when passing railway signals and to clarify the need for a radio broadcast of the signal indication being displayed at certain locations.
Transport Canada conducted an administrative investigation into railway signal rules violations and issued an administrative monetary penalty to CP as a result.