TSB releases report into death of CN employee in Melville in 2017

The Transportation Safety Board of Canada (TSB) is recommending rail companies reduce the number of uncontrolled movements in rail yards.

The TSB also said it was concerned that, because of employee turnover in the industry, relatively inexperienced employees are working together in rail yards.

The findings are a result of the TSB’s investigation into the death of a CN employee in the Melville Yard on Dec. 22, 2017.

The 26-year-old woman suffered fatal injuries when she was pinned between cars while she and another employee were moving a group of cars without using air brakes — a practice known as “switching without air.”

In its report into the incident, the TSB said Transport Canada, rail companies and their labour representatives should work together to develop strategies to limit uncontrolled movements in rail yards.

According to the TSB, a foreman — the woman — and another employee were performing switching operations in the Melville yard at the time of the incident.

They were moving the cars using a remote-controlled locomotive, which released the cars and let them roll under their own momentum to their intended track without the use of air brakes on any of the cars. It’s known as “kicking cars.”

When the workers tried to move three loaded cars up a small grade without sufficient speed, the cars lost momentum and started rolling back downhill uncontrolled.

The foreman climbed onto the lead car and tried to put on the hand brake, but it didn’t work effectively and the cars didn’t slow down. They then collided with other cars, pinning her between two of them.

The TSB determined the workers were qualified to perform the task, but their limited experience likely contributed to the decision to move the cars at an insufficient speed up the hill. The employees also didn’t have the proper training to develop the necessary co-ordination and communication.

“Switching cars without use of air brakes in rail yards is a routine railway industry practice, but one that requires a certain degree of skill, experience and judgment to do safely,” TSB chair Kathy Fox said in a media release.

“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.”

Since the accident, CN has altered the track configuration at the Melville Yard and has prohibited the practice of kicking cars uphill.