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Inadequate safety watch training contributed to railway employee injury in Delta, BC in December 2016

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Richmond, British Columbia, 14 May 2018 – In its investigation report (R16V0195) released today, the Transportation Safety Board of Canada (TSB) determined that inadequate safety watch training contributed to an employee injury at the Roberts Bank Yard in Delta, British Columbia in December 2016.

On 18 December 2016, a Toronto Terminals Railway (TTR) locomotive engineer and a conductor were shoving 66 empty intermodal platforms onto the east leg track at the Roberts Bank Yard in Delta, BC. The conductor was driving a vehicle beside the lead platform while providing instructions to the locomotive engineer who was positioned at the opposite end of the movement. At the same time, two track workers employed by a track maintenance contractor (PNR RailWorks) were clearing snow from a switch on the same track. As the movement approached the switch, the conductor saw the workers and activated the oscillating beacon on top of the vehicle to alert them to the approaching movement. When no reaction was observed, the conductor attempted to sound the vehicle's horn, but it was inoperative. The conductor then instructed the locomotive engineer to stop the movement. However, the movement was unable to stop before the leading platform struck and seriously injured one of the track workers.

The investigation found that the conductor's instruction to the locomotive engineer to stop was not made in time to allow the movement to be stopped before reaching the switch. The attentional focus required to monitor the movement's progress while driving the vehicle, combined with the expectation that the track workers would clear the track, likely contributed to the late call to stop the movement.

Deficiencies with the use of safety watch protection by the track workers were also identified in the investigation. Safety watch is a form of track protection that requires one of the members of a track work crew to be assigned with the sole task of continuously monitoring the work site for oncoming trains or other on-track equipment. In this occurrence, neither of the track workers was solely performing the duties of safety watch. The track workers had not been adequately trained in its use and did not have an accurate understanding of how to apply such protection. In addition, as the use of safety watch and the associated processes were not specifically audited, the inadequate application of this form of track worker protection was not apparent.

Safety management and oversight is a TSB Watchlist issue. As demonstrated in this occurrence, gaps in training, supervision, and efficiency testing of employees can decrease the effectiveness of a company's safety management system (SMS).

Technical Safety BC (formerly BC Safety Authority) issued a Safety Advisory to notify all provincially certified railways operating in BC of the risks associated with shoving equipment. It recommended that railways review their processes to ensure compliance with all applicable rules and regulations regarding shoving equipment.

BCR Properties Ltd., the owner of the Roberts Bank Yard, completed a risk assessment and incorporated a number of protection measures into its SMS. BCR also followed up with the contractor to ensure its employees receive appropriate training and certifications.

employee injury at the Roberts Bank Yard in Delta, British Columbia in December 2016.

On 18 December 2016, a Toronto Terminals Railway (TTR) locomotive engineer and a conductor were shoving 66 empty intermodal platforms onto the east leg track at the Roberts Bank Yard in Delta, BC. The conductor was driving a vehicle beside the lead platform while providing instructions to the locomotive engineer who was positioned at the opposite end of the movement. At the same time, two track workers employed by a track maintenance contractor (PNR RailWorks) were clearing snow from a switch on the same track. As the movement approached the switch, the conductor saw the workers and activated the oscillating beacon on top of the vehicle to alert them to the approaching movement. When no reaction was observed, the conductor attempted to sound the vehicle's horn, but it was inoperative. The conductor then instructed the locomotive engineer to stop the movement. However, the movement was unable to stop before the leading platform struck and seriously injured one of the track workers.

The investigation found that the conductor's instruction to the locomotive engineer to stop was not made in time to allow the movement to be stopped before reaching the switch. The attentional focus required to monitor the movement's progress while driving the vehicle, combined with the expectation that the track workers would clear the track, likely contributed to the late call to stop the movement.

Deficiencies with the use of safety watch protection by the track workers were also identified in the investigation. Safety watch is a form of track protection that requires one of the members of a track work crew to be assigned with the sole task of continuously monitoring the work site for oncoming trains or other on-track equipment. In this occurrence, neither of the track workers was solely performing the duties of safety watch. The track workers had not been adequately trained in its use and did not have an accurate understanding of how to apply such protection. In addition, as the use of safety watch and the associated processes were not specifically audited, the inadequate application of this form of track worker protection was not apparent.

Safety management and oversight is a TSB Watchlist issue. As demonstrated in this occurrence, gaps in training, supervision, and efficiency testing of employees can decrease the effectiveness of a company's safety management system (SMS).

Technical Safety BC (formerly BC Safety Authority) issued a Safety Advisory to notify all provincially certified railways operating in BC of the risks associated with shoving equipment. It recommended that railways review their processes to ensure compliance with all applicable rules and regulations regarding shoving equipment.

BCR Properties Ltd., the owner of the Roberts Bank Yard, completed a risk assessment and incorporated a number of protection measures into its SMS. BCR also followed up with the contractor to ensure its employees receive appropriate training and certifications.

TSB

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