TSB incident investigation finds issues with engineer training, signal rules

The Transportation Safety Board of Canada (TSB) has released its investigation report into an incident involving a Quebec North Shore and Labrador Railway (QNS&L) train carrying ore last year in Quebec. 

On Feb. 22, 2023, the train passed a stop signal indication at Mai Station while another train was proceeding towards Mai in the opposing direction. The incident caused no collision, derailment or injuries.

The investigation determined that the locomotive engineer’s mental state was likely affected due to routinely stopping the lead locomotive of his train in front of the camp located after the signal. The engineer also had developed a habit of not always broadcasting stop signal indications on the train's radio as required by Canadian rail operating rules, TSB officials  said in a press release.

Including the incident, there had been 12 occurrences of QNS&L trains passing stop signals in the past 10 years, the investigation found. Human performance and experience were considered as factors in all the occurrences, TSB officials said.

In September 2023, the TSB sent a safety information letter to QNS&L regarding the supervision of newly qualified locomotive engineers. As a result, QNS&L made changes to its evaluation program for apprentice engineers and increased the frequency of evaluations by supervisors in the field for engineers with less than two years of experience.

Following railway signal indications is a TSB Watchlist issue because signals are not consistently recognized and followed, which poses a risk of train collisions or derailments, TSB officials said.