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TSB issues final report on collision between a freight train and track equipment near Fraine, British Columbia, in October 2017

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Richmond, British Columbia, 29 March 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (R17V0220) on the 2017 collision of a Canadian Pacific Railway (CP) freight train with a backhoe conducting track work, near Fraine, BC. The investigation found that the misapplication of CP’s planned protection procedures in a track work area resulted in misunderstandings among team members and important information being missed.

On 31 October 2017, at about 0600 Pacific Daylight Time, during the hours of darkness, a CP freight train, authorized to proceed eastward through work limits on the Connaught track of the Mountain Subdivision, struck a backhoe conducting track work. The backhoe operator suffered serious injuries. The backhoe and the lead locomotive sustained damage.

At the time of the accident, track work was being conducted in the area under Canadian Rail Operating Rules (CROR) Rule 42 (Planned Protection). The foreman had established with the rail traffic controller (RTC) that trains requiring passage would operate through the Macdonald track only. This information was transmitted during the job briefings. Later, the foreman realized that an eastbound train had been routed toward the work limits on the Connaught track. Although he told the supervisor and all sub-foremen and contract workers under his protection of the change in track routing, a formal job briefing was not conducted to inform all employees and contractors. Before authorizing the eastbound train through the work limits on the Connaught track, the foreman verified with and received confirmation from the employees under his immediate supervision, from the sub-foreman, and from the supervisor that all workers and track equipment had been cleared off the track.

The investigation found that the supervisor had assumed the responsibility of sub-foreman to protect some of the track workers without having acquired formal sub-foreman designation from the foreman. This adaptation created an ambiguity in the chain of command within the work limits that created an unsafe condition and contributed to the backhoe operator being instructed to resume work activities on an active track.

The investigation also determined that the foreman and sub-foreman had been using various ad hoc methods to keep track of employees. Reliance on working memory, rather than the use of the formal sub-foreman protection process, contributed to the foreman and the supervisor having a different understanding of the track on which the train would operate, the location of the backhoe, and the protection required for the backhoe operator.

Following the accident, CP issued a Safety Flash stating that all employees must ensure there is clear communication when clearing a movement through protected limits. This includes validating that all parties understand the direction and are aware of the limits being provided.

See the investigation page for more information.

freight train with a backhoe conducting track work, near Fraine, BC. The investigation found that the misapplication of CP’s planned protection procedures in a track work area resulted in misunderstandings among team members and important information being missed.

On 31 October 2017, at about 0600 Pacific Daylight Time, during the hours of darkness, a CP freight train, authorized to proceed eastward through work limits on the Connaught track of the Mountain Subdivision, struck a backhoe conducting track work. The backhoe operator suffered serious injuries. The backhoe and the lead locomotive sustained damage.

At the time of the accident, track work was being conducted in the area under Canadian Rail Operating Rules (CROR) Rule 42 (Planned Protection). The foreman had established with the rail traffic controller (RTC) that trains requiring passage would operate through the Macdonald track only. This information was transmitted during the job briefings. Later, the foreman realized that an eastbound train had been routed toward the work limits on the Connaught track. Although he told the supervisor and all sub-foremen and contract workers under his protection of the change in track routing, a formal job briefing was not conducted to inform all employees and contractors. Before authorizing the eastbound train through the work limits on the Connaught track, the foreman verified with and received confirmation from the employees under his immediate supervision, from the sub-foreman, and from the supervisor that all workers and track equipment had been cleared off the track.

The investigation found that the supervisor had assumed the responsibility of sub-foreman to protect some of the track workers without having acquired formal sub-foreman designation from the foreman. This adaptation created an ambiguity in the chain of command within the work limits that created an unsafe condition and contributed to the backhoe operator being instructed to resume work activities on an active track.

The investigation also determined that the foreman and sub-foreman had been using various ad hoc methods to keep track of employees. Reliance on working memory, rather than the use of the formal sub-foreman protection process, contributed to the foreman and the supervisor having a different understanding of the track on which the train would operate, the location of the backhoe, and the protection required for the backhoe operator.

Following the accident, CP issued a Safety Flash stating that all employees must ensure there is clear communication when clearing a movement through protected limits. This includes validating that all parties understand the direction and are aware of the limits being provided.

See the investigation page for more information.

TSB

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