TSB of Canada releases signal violation incident report and outlines importance of monitoring new employees on site

DORVAL, Quebec – The Transportation Safety Board of Canada released an investigation report Thursday into a February 2023 incident on the Quebec North Shore & Labrador Railway, which the agency said highlights the importance of proper supervision for newly qualified employees.

The Feb. 22 incident occurred around 9:33 p.m. at Quebec’s Mai station and involved a train of two locomotives and 127 empty ore cars that ran through a stop signal. There was no collision or derailment and no injuries occurred. According to the final report, the TSB found that although the stop signal was visible from three-quarters of a mile away, the engineer did not brake until he was within approximately 50 feet of the signal, at which point the full stop signal was visible Braking force used brakes and emergency brakes. The train came to a stop 73 feet behind the signal.

The investigation found that the engineer, who has been employed by the railway since October 2021 and trained as an engineer since September 2022, had a habit of stopping just after the signal to facilitate the change of personnel at the May station and that he was probably this had acted according to custom. His vigilance in observing stop signals was also compromised by his habit of not sending stop signal indications as required by railroad operating rules. The TSB also found that the engineer and rail traffic manager on duty at the time had limited professional experience and therefore did not take the necessary measures to ensure protection on the main line following the incident.

The TSB also noted that this was one of 12 incidents in the past 10 years in which a QNS&L train passed a stop signal, with human action and experience playing a role in all 12.

As a result, the TSB recommended that the QNS&L consider a review of its engineering training program to ensure continued support of new employees post-qualification. The railroad subsequently shortened the period between field evaluations from 300 hours to 200 hours for aspiring engineers and from every eight months to every four months for qualified engineers with less than two years of experience.

The TSB highlighted the incident in part because issues with the following signal indicators are part of the TSB watchlist, which details issues the agency considers key to Canadian transportation safety.