DORVAL, Quebec — The Transportation Safety Board of Canada on Thursday released an investigation report into a February 2023 incident on the Quebec North Shore & Labrador Railway that the agency says highlights the importance of proper supervision for newly qualified employees.
The Feb. 22 incident occurred about 9:33 p.m. at Mai Station, Quebec, and involved a train of two locomotives and 127 empty ore cars overrunning a stop signal. No collision or derailment occurred, and no injuries occurred. According to the final report, the TSB found that, while the stop signal was visible from three-quarters of a mile away, the engineer did not undertake braking until he was within about 50 feet of the signal, at which time he applied full dynamic braking and the emergency brakes. The train came to a stop 73 feet past the signal.
The investigation found that the engineer, a railroad employee since October 2021 and qualified as an engineer since September 2022, was in the habit of stopping just past the signal to facilitate crew changes at Mai Station, and had likely acted in accordance with that habit. His vigilance in observing stop signals was also affected by his habit of not broadcasting stop signal indications, as required by railway operating rules. The TSB also found that engineer and rail traffic controller on duty at the time both had limited work experience, and as a result did not take the necessary measures to ensure protection on the main track in the wake of the incident.
The TSB also found that this was one of 12 incidents in the last 10 years in which a QNS&L train passed a stop signal, with human performance and experience a factor in all 12.
As a result, the TSB recommended that the QNS&L consider reviewing its engineer training program to ensure ongoing supervision of new employees in the post-qualification period; the railroad subsequently decreased the time period between field evaluations for apprentice engineers from 300 hours to 200 hours, and for qualified engineers with less than two years of experience from every eight months to every four months.
The TSB highlighted the incident in part because issues with following signal indications is part of the TSB Watchlist, which details matters the agency considers to be key issues for Canadian transportation safety.
Things that make you say “Hmmm.”
The text says, “his habit of not broadcasting stop signal indications, as required by railway operating rules.” So – they didn’t enforce THAT operating rule; maybe it was there to satisfy some bureaucrat in Ottawa. Which other rules were optional?
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Quite interesting. Here in the US the engineer would be immediately removed from service per FRA rules and dismissed from the carrier.