Aviation.ca - Your Number One Source for Canadian Aviation News, Jobs and Information!

Canadian News

Dorval, Quebec, 6 May 2019 — In its investigation report (R17D0123) released today, the Transportation Safety Board of Canada (TSB) found that the lack of a risk assessment following a significant change in operations, in addition to fatigue and task interruption, were factors that led to a 2017 employee fatality in St-Luc Yard in Montréal, Quebec.

On 8 November 2017, during the hours of darkness, a Canadian Pacific Railway (CP) yard assignment (a crew operating with 2 locomotives) was performing switching operations in St-Luc Yard. The crew consisted of a locomotive engineer, a yard foreman and a yard helper.

While the assignment was switching cars into their designated tracks, the yard helper briefly left his position near a crossover switch and entered a nearby building. When he returned to continue his duties, he instructed the locomotive engineer by radio to stop the assignment north of the crossover switchwhich wasfurther than necessary for the next switching movement. The yard helper then incorrectly placed the crossover switch in the reverse position, inadvertently aligning the movement away from the intended destination track. He then placed the destination track’s switch in the reverse position and instructed the locomotive engineer to move the yard assignment into the destination track. Because the crossover switch was in the incorrect position, the assignment diverted onto the crossover track. The assignment struck and fatally injured the yard helper and collided with a cut of cars on the track.

The investigation found that when switching operations in St-Luc Yard were changed significantly in 2012, with most switching moved to the diamond area, a risk assessment of the changes had not been conducted. As CP’s safety management system (SMS) had not considered a risk assessment necessary, the opportunity to identify and mitigate any new hazards created by the changes was missed. If risk assessments are not completed when a change to railway operations occurs, new hazards might not be identified, increasing the risk of accidents. Safety management and oversight is an issue on TSB Watchlist 2018.

The existing levels of lighting in the diamond area of the yard made it more difficult for the yard foreman to visually determine the location of the yard helper and to distinguish the direction of travel of the yard assignment. If railway yards are not adequately illuminated for night switching operations, the visibility of employees, yard tracks and railway equipment can be compromised, which can lead to accidents.

Furthermore, the short absence of the yard helper created a task interruption that shifted the yard helper’s focus away from his duties. This led to the yard helper incorrectly aligning the yard assignment away from the destination track. It is likely that the yard helper’s fatigue also contributed to the incorrect alignment of the crossover switch.

Following the occurrence, Transport Canada (TC) conducted an investigation into the employee fatality. As a result, TC issued a direction regarding lighting at St-Luc Yard. CP has until May 2019 to address the items in the direction. CP conducted employee awareness campaigns focusing on the hazards present when working on or near tracks and the associated risk mitigation processes.

See the investigation page for more information.


Published in Transportation Safety Board of Canada
Written by
Read more...

Tags:

On March 8, 2019, the first of our 16 new CC-295 fixed-wing search and rescue aircraft rolled off the assembly line in Spain, bringing us one step closer

Published in Royal Canadian Air Force
Written by
Read more...

Ottawa, Ontario, 2 May 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18O0150) on the mid-air collision that occurred near the Ottawa/Carp Airport, Ontario, in November 2018.

The TSB conducted a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues.

See the investigation page for more information.


Published in Transportation Safety Board of Canada
Written by
Read more...

April 1st, 2019 – Ottawa – National Defence/Canadian Armed Forces

Canada has significantly increased its contribution to Operation ARTEMIS, the Canadian Armed Forces’ (CAF) ongoing contribution to counter-terrorism and maritime security

Published in Royal Canadian Air Force
Written by
Read more...

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.

Published in Transportation Safety Board of Canada
Written by
Read more...

Vancouver, British Columbia, 28 March 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18P0115) into a loss of control on initial climb and impact with the runway involving a vintage de Havilland DH-89A biplane at the Abbotsford International Airport, in British Columbia, in August 2018.

The TSB conducted a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues.

See the investigation page for further information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Dorval, Quebec, 29 March 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (R18D0067) on the main-track derailment that occurred near Delson, Quebec, in July 2018.

The TSB conducted a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues.

See the investigation page for further information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Toronto, Ontario, 25 March 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (A18O0134) on a September 2018 collision with terrain that involved a Robinson R44 II helicopter near the Toronto/Buttonville Municipal Airport, Ontario.

The TSB conducted a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues.

See the investigation page for further information.

Published in Transportation Safety Board of Canada
Written by
Read more...

Tags:

Current or former Federal Public Servants, Canadian Armed Forces (CAF) and Royal Canadian Mounted Police (RCMP) members who were affected by unfair federal policies due to their

Published in Royal Canadian Air Force
Written by
Read more...

Calgary, Alberta, 4 March 2019 – Today, the Transportation Safety Board of Canada (TSB) released its investigation report (R18C0076) on the main-track derailment that occurred near Stirling, Alberta, in July 2018.

The TSB conducted a limited-scope, fact-gathering investigation into this occurrence to advance transportation safety through greater awareness of potential safety issues.

See the investigation page for further information.

Published in Transportation Safety Board of Canada
Written by
Read more...
         
Aviation.ca is not responsible for the content of external Internet sites. Copyright © 1997-2015 Skytech Dynamics Corporation, All rights reserved exogenous-blank
exogenous-blank
exogenous-blank
exogenous-blank

Login or Register