News release

The Transportation Safety Board of Canada (TSB) is calling on Transport Canada to strengthen its oversight of how railways assess whether employees in safety-critical roles are medically fit for duty. The call comes after an investigation (R23E0079) into a 2023 collision between two Canadian National Railway (CN) trains near Wainwright, Alberta, found that a locomotive engineer had been cleared to work despite incomplete medical assessments related to his diabetes. The findings of this investigation have led the Board to issue one recommendation and one safety concern. 

On August 8, 2023, CN train 115 was travelling west on the Wainwright Subdivision when it collided with the side of another CN train. The collision derailed the two lead locomotives and two cars on train 115, and six cars on the other train. 

The investigation found that train 115 passed a Stop signal while being operated by a trainee under the supervision of a locomotive engineer. As the train approached the signal, the locomotive engineer did not respond to the trainee’s repeated requests for guidance, delaying the trainee’s decision to brake. The locomotive engineer was experiencing a significant decline in cognitive functioning that affected his ability to control the train and coach the trainee. Without adequate guidance, the trainee did not apply sufficient braking to stop before the signal. A breakdown in communication and shared situational awareness among the crew further delayed their response. 

The locomotive engineer had type 1 diabetes. The investigation found that several required annual diabetes assessments were incomplete but were nevertheless accepted by CN or had not been conducted at all, leaving the company without all the information needed to determine whether the locomotive engineer’s medical condition was stable. 

The investigation also revealed that Transport Canada had not audited CN’s compliance with the Railway Medical Rules in the 12 years before the crash. Because no audits were conducted, the gaps in the locomotive engineer's medical assessments were not captured through regulatory oversight.  

Recommendation  

As a result of the investigation, the TSB is calling for Transport Canada to establish regular oversight activities of railways’ compliance with the Railway Medical Rules for Positions Critical to Safe Railway Operations to ensure that assessments of medical fitness for duty for employees in safety-critical positions are carried out as required (TSB Recommendation R26-01). 

Safety Concern 

The investigation also found that the guidelines railways use for assessing the medical fitness for duty of employees with diabetes are inconsistent with recommendations published by Diabetes Canada. Therefore, the Board is concerned that the guidelines in the Canadian Railway Medical Rules Handbook used to assess the medical fitness for duty of railway employees in safety-critical positions who are diagnosed with diabetes are not aligned with recommendations published by Diabetes Canada, or with the medical certification guidelines used in the air and marine transportation sectors that also fall under Transport Canada’s regulatory oversight. 

See the investigation page for more information.