Crew inexperience cited in death of railway worker
REGINA After investigating the death of a Canadian National railworker near Melville, The Transportation Safety Board of Canada (TSB) is recommending the industry look into why uncontrolled movements of rail cars occur, and expressed concern over crews made up of inexperienced workers.
On Dec. 22, 2017, two CN employees were performing switching operations at the rail yard. This was done by shoving the cars with a remote-controlled locomotive, then letting them roll onto the intended track without the use of air brakes.
The operation is known in the industry as “kicking cars.”
After an attempt to kick a group of three loaded cars up an ascending slope, the cars lost momentum and began rolling downhill. The foreman climbed onto the lead car and tried to apply the handbrake, but a mechanical failure rendered it useless.
The cars rolled into a stationary group of cars, pinning the foreman between them. The foreman suffered fatal injuries.
The TSB is recommending Transport Canada work with the railway industry and labour unions to identify why uncontrolled movements occur while switching without air brakes, and develop strategies or regulations to reduce their frequency.
TSB chair Kathy Fox said switching cars without the use of air brakes is a routine practice in the industry, but one that requires a degree of experience to do safely. Its use also appears to be rising.
“Since 2009 there have been 185 occurrences involving switching without air, and these are on an upward trend. This tells us that current defences are not sufficient to reduce the number of uncontrolled movements,” Fox said in a press release.
The TSB’S report also raised concerns about the experience level of both workers who were present at the time of the accident.
“In fact, both employees were relatively inexperienced and wore a green vest to indicate less than two years of service. The helper was one of the employees with the least seniority at the yard, and this was just the foreman’s fifth shift in the role of foreman at Melville yard using the remote control system,” Glen Pilon, an investigator with the TSB, said in a video posted to the organization’s Youtube channel.
The investigation found the crew’s limited experience likely contributed to the decision to kick the three loaded cars at an insufficient speed up the hill.
The report said there was a lack of communication between the two workers, who had not discussed kicking the cars uphill or how the task would be performed.
The report also noted that neither worker had received formal crew resource management training, which is used to develop coordination and communication skills.
The TSB said ongoing turnover in the railway industry has made it more common for junior employees to be working together in a rail yard.
The TSB expressed concern over this trend, and said that it could result in “ongoing adverse outcomes.”
The TSB’S report said that since the accident, CN has prohibited kicking cars uphill and has made changes to the track configuration at the Melville rail yard. The company has also inspected 857 similar open-top hopper cars in its fleet to ensure the handbrakes are functioning properly.
In a statement, CN said it supported the TSB’S recommendation regarding uncontrolled movement of rail cars, and expressed condolences to the deceased foreman’s family.
“Safety is a core value at CN and it is a critical part of everything we do. We learn from every event on our network to make CN a safer railroad for our employees, the public and the communities where we operate,” read the statement.
A representative for Teamsters Canada said the union is currently analyzing the report, but declined to make any specific comments.
Both employees were relatively inexperienced and wore a green vest to indicate less than two years of service.