TSB Recommendation R22-05

On 03 January 2019, about 0610 Central Standard Time, Canadian National Railway Company (CN) eastbound freight train M31851-01 (train 318) began following eastbound CN train Q11651-30 (train 116) near Rivers, Manitoba, on the CN Rivers Subdivision. Both trains were destined for Winnipeg, Manitoba. Train 318 was a key train^{Footnote 1} operating on a key route,^{Footnote 2} as defined by the Transport Canada (TC)–approved Rules Respecting Key Trains and Key Routes. At 0906:54, train 318 was travelling at 42 mph, with Trip Optimizer (TO) engaged and the throttle in position 7, as it passed a Clear to Stop signal indication at Mile 52.2. The conductor had called out the signal in the locomotive cab and identified the Clear to Stop indication. However, the conductor did not hear the locomotive engineer (LE) verbally respond to acknowledge the signal, and the LE appeared to be staring straight ahead. At this point, conversation in the cab ceased. TO remained engaged, and the train continued at track speed.

As CN train 318 was proceeding on the south track, a westbound CN freight train M31541-03 (train 315) was transitioning from single track to the north track while exiting the equilateral turnout (Mile 50.37) at Nattress near Portage la Prairie, Manitoba. At Mile 51.13, while travelling at 46 mph, train 318 passed the head end of train 315. The train 318 conductor then reminded the LE that they were operating under a Clear to Stop indication. Once reminded, the LE disengaged TO and made a full service brake application at 0908:34; 24 seconds later, he inadvertently placed the brake handle into the suppression position (rather than the emergency position), and then applied the locomotive independent brake.

Ten seconds later, as Stop Signal 504S came into view, the LE placed the train in emergency and the crew evacuated the locomotive cab. Train 318 side-collided with train 315 while travelling at 23 mph. Shortly thereafter, the train 318 crew members jumped from the locomotive to the south side of the track and sustained minor injuries. As a result of the collision, the 2 head-end locomotives on train 318 and 8 cars on train 315 derailed. Although no cars loaded with dangerous goods were involved, the head-end locomotives on train 318 lost a combined total of about 3500 imperial gallons of diesel fuel. The released diesel fuel was contained locally and cleaned up with no waterways affected.

Railway operations are governed by rules and instructions that place equal responsibility for safe train operations on all crew members. Safe railway operations are predicated on all crew members following all of the rules, all of the time. In the rail industry, operating rules require that crew members verbally acknowledge signal indications displayed in the field to each other. When a train encounters a signal indication displayed in the field, 1 crew member must communicate the signal indication aloud within the locomotive cab to the other crew member. While the other crew member is required to repeat the message back, there is no requirement for the original sender to confirm that the message was received accurately or understood by the other crew member. As a result, this communication can fail.

The railway rules do not specify a closed-loop communication method, meaning there is no requirement for the original sender of the message to acknowledge, and therefore confirm, that it was received accurately. Moreover, when there is a significant difference in level of experience between operating crew members, an authority gradient may develop in which the less experienced crew member may not always intervene to ensure compliance with all of the rules. In these situations, there is a danger that safety-compromising behaviour will be overlooked because a less experienced employee may be reluctant to question the actions of a more senior employee or intervene in the operation of the train even when it may be critical to do so.

In this occurrence, the investigation determined that communications between the 2 crew members were not always closed-loop. The callouts of signal indications by the conductor were not always acknowledged or repeated back by the LE. The conductor did not confirm that the LE had understood the communication nor was he required to do so. The inexperience of the conductor on the subdivision, and with locomotive operations, also deterred him from trying to intervene and stop the train.

Crew resource management (CRM) is a concept introduced in the aviation and marine industries to limit or eliminate human errors by recognizing the importance of cognitive and interpersonal skills, thereby improving safety. CRM targets a crew’s skills, abilities, attitudes, communication, situational awareness, problem solving, and teamwork. Crew members must successfully interact with each other, their equipment, and their environment to effectively manage threats, errors, and unexpected conditions that may be encountered.

In order to perform in a coordinated, efficient, and safe manner, crew actions need to be based on a common understanding of the current state of the equipment, the intended route to be taken, and any other potential threats. When this understanding is consistent, crews are better able to effectively anticipate and coordinate their actions to achieve their common goal. This common understanding between crew members is referred to as team or shared situational awareness.

Shared situational awareness is developed and maintained by a crew through a number of discrete and continuous behaviours. These behaviours include in-trip briefings, the identification of key points throughout the trip, threat and error management (TEM), callouts to any change in the state of the equipment, the instrument setting or mode, and the communication of any change in plans to ensure that all crew members have a common understanding of activities.

TEM stresses the principles of anticipation, recognition, and recovery when addressing threats, errors, and undesirable equipment states, and is based on the proactive detection of threats that could reduce safety margins. Effective error management is associated with specific behaviours by the crew, the most common being vigilance, a propensity to ask questions or provide feedback, and assertiveness.

A 2015 study entitled Human Factors Analysis of “Missed Signals” in Railway Operations,^{Footnote 3} when addressing team training, indicated that CRM training

emphasizes non-technical skills such as communication, briefing, backing-up behaviour,^{Footnote 4} mutual performance monitoring, team leadership, decision making, task-related assertiveness (e.g., a junior operator speaking up to a dominant colleague), and team adaptability.

The report went on to state that CRM training includes aspects of team situational awareness such as “perception” and “information sharing, coordination and crosschecking information” and instructed crews to “become vigilant for losses of [situational awareness]; both one’s own and by others.”

CRM focuses on providing crews with the interpersonal skills required to carry out their tasks safely: “CRM training typically consists of an ongoing training and monitoring process through which personnel are trained to approach their activities from a team perspective rather than from an individual perspective.”^{Footnote 5} 

Significant safety benefits were experienced in the aviation and marine industries with the introduction of CRM. Given the prevalence of human factors issues in rail accident statistics, this type of training could yield significant safety benefits in the rail industry.^{Footnote 6}

Since 2017, CN has delivered a course called “Looking out for each other” as part of its operating crew requalification programs delivered every 3 years. While the CN training is insightful, it is broadly focused and does not specifically deal with train crew interaction within a locomotive cab or the authority gradients that may exist in that environment. While Canadian Pacific Railway Company (CP) provides CRM training to its new operating employees, it does not provide formal dedicated recurrent CRM training.

The Railway Employee Qualification Standards Regulations have no requirement for operating crews to complete a separate module on CRM when they qualify or re-qualify. Consequently, the adoption of CRM training in the rail industry has been sporadic and the approach differs between railways. Although railway training touches on CRM principles, neither CP nor CN provide dedicated, recurrent CRM training that explores all aspects of CRM. Recurrent CRM training would seek to improve non-technical skills that deal with in-cab communication, job briefings, backing up behaviour, mutual performance monitoring, team leadership, decision making, task-related assertiveness (e.g., a junior operator speaking up to a dominant colleague), team adaptability, as well as concepts of TEM and team situational awareness.

The TSB has investigated 8 other rail occurrences, dating back as far as 1996, in which ineffective CRM practices were identified as a factor that contributed to the accidents.^{Footnote 7}

If operating crew members do not receive enhanced initial and recurrent CRM training to develop skills in crew communication, the coordination of decision making and activities, and dealing with authority gradients that may exist within a locomotive cab environment, there is an increased risk that inadequate crew communication will lead to unsafe operations.

Therefore, the Board recommended that

The TSB will monitor TC’s progress on its planned actions.

This deficiency file is Active.