Gaps in flagging procedures led to 2016 crossing collision near Saint-Norbert, Quebec
Dorval, Quebec, 31 October 2017 – In its investigation report (R16D0076) released today, the Transportation Safety Board of Canada (TSB) found that a lack of compliance with hand-signalling procedures and insufficient signalling equipment contributed to the August 2016 collision between a Canadian National Railway (CN) track unit and a tractor-trailer near Saint-Norbert, Quebec.
On 18 August 2016 at approximately 3:30 a.m. Eastern Daylight Time, a CN hi-rail track unit (TU) was travelling northward on the CN Joliette Subdivision when it approached a public crossing on Highway 347 near Saint-Norbert, Quebec. Because the track unit could not activate the crossing warning system, the crossing was manually protected. The CN flag-person positioned at the crossing signalled the TU operator to proceed. When the TU was approximately 400 feet (122 m) from the crossing, the flag-person saw the headlights of a road vehicle approaching from the west. The flag-person attempted to signal the driver of the vehicle to stop by waving a white headlamp while continuing to indicate to the TU operator to advance. However, the driver of the vehicle was unable to stop before the TU entered the crossing. The TU struck the vehicle (a tractor-trailer) and derailed. The two employees on board the TU and both occupants of the tractor-trailer sustained minor injuries. Approximately 600 litres of petroleum products were released from the TU and the tractor trailer.
The investigation found that CN's General Engineering Instructions (GEI) instruct TU operators to give the right of way to road vehicles, except when the crossing is protected by an activated warning device or by a flag‑person. However, the GEI do not specify that a flag-person must give the right of way to road vehicles. In this occurrence, the right of way was given to the TU rather than to the road vehicle. If instructions are not clear, there might be confusion on the appropriate actions to take. The investigation also determined that the personal protective equipment and the white headlamp that the flag-person was using were not sufficiently compelling to alert the driver of the tractor-trailer to make him aware of the unusual situation at the crossing. Nor did the flag-person have a key to activate the warning system for the crossing. If the equipment necessary for signalling at crossings is not used, procedures cannot be carried out as intended, which increases the risk of accidents.
Following the accident, CN published a safety bulletin on flagging procedures for track units passing through crossings. The bulletin dictates a number of items that flag-persons must have, including a tool to access crossing warning devices. CN also distributed a Safety Flash to all of its Engineering Services personnel. The document describes the facts of the accident and specifies the guidelines to prevent such an accident from recurring.
See the investigation page for more information.
The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
For more information, contact:
Transportation Safety Board of Canada
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