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Rail transportation safety investigation R21D0001

The TSB has completed this investigation. The report was published on 13 December 2021.

Table of contents

Employee fatality

Canadian National Railway Company
Yard assignment YPC011-06
Mile 1.9, Montreal Subdivision
Montréal, Quebec

View final report

The occurrence

On , a train of empty grain hopper cars was coming out of the Port of Montreal into the Pointe-Saint-Charles Yard. The train was backing up with the assistant conductor riding the side ladder on first car, COER 353680.

The last communication the assistant conductor had with the conductor and locomotive engineer, located in the locomotive at the other end of the train, was to instruct them to stop the movement as they were approaching a red signal. After having stopped the train, the conductor proceeded to walk the entire length of the train after unsuccessful attempts to contact the assistant conductor over the radio were made. The assistant conductor’s body was subsequently found under car COER 353680.

Media materials

News releases


Investigation report: Employee fatality near Pointe-Saint-Charles Yard
Read the news release

Deployment notice


TSB deploys investigator to railway employee fatality in Montreal, Quebec

Dorval, Quebec, 6 January 2021 — The Transportation Safety Board of Canada (TSB) is deploying an investigator following a railway employee fatality at the Canadian National Railway Pointe-Saint-Charles yard. The TSB will gather information and assess the occurrence.

Investigation information

Map showing the location of the occurrence


Photo of Luc Régis

Luc Régis joined the Transportation Safety Board of Canada (TSB) in 2019 as a Senior Regional Investigator with the Rail/Pipeline Investigations Branch.

Before joining the TSB, Mr. Régis gained considerable experience in the construction and maintenance of railway infrastructure, holding various supervisory positions within the Engineering Department at Canadian National Railway Company (CN) from 2009 to 2014. From 2014 to 2019, he worked at Transport Canada as a Railway Safety Inspector in the Quebec Region, and at Transport Canada’s Emergency Situation Centre (SitCen) as rail safety expert. He lives in Montreal, Quebec.


Class of investigation

This is a class 4 investigation. These investigations are limited in scope, and while the final reports may contain limited analysis, they do not contain findings or recommendations. Class 4 investigations are generally completed within 220 days. For more information, see the Policy on Occurrence Classification.

TSB investigation process

There are 3 phases to a TSB investigation

  1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
  2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
  3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

For more information, see our Investigation process page.

The TSB is an independent agency that investigates air, marine, pipeline, and rail 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.