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Condition or Hazard observed:

Engineering crews operating track units for extended hours could reasonably be subject to fatigue, which has resulted in collisions and harm to employees and damage to property.

HBR, for all HBR Engineering Service employees, including HBR supervisors and contractors, to:

• Restrict a maximum on-duty time of no more than 12 hours in a 24 hour period and restrict employees to not exceed 100 total work hours in any 10 consecutive days; or 200 total work hours in any 28 consecutive days, excluding for:
  • deadheading at the end of a shift defined as the authorized transportation of an employee, as a passenger, from one location to another at the direction of the railway company;
  • completing administrative duties defined as paperwork, filing, job briefings, reporting and work related to human resources obligations; and
  • emergencies defined as a sudden or unforeseen situation where injury or harm has been sustained, or could reasonably be sustained to employee(s), passenger(s), the public or the environment such as those involving a casualty or unavoidable accident, an Act of God, severe storms, major earthquakes, washouts, derailments or where there has been a delay resulting from a cause not known to the railway company at the time employees leave the terminal and which could not have been foreseen.
• Implement the following fatigue management steps when working more than 12 hours in a 24-hour period during emergencies as aforementioned in this Notice and Order:

1. A designated and rules qualified Safety Watch person, must accompany the employee within the same Track Unit/Machinery in the lead position including for single Track Unit/Machinery operations;
2. Communicate with coworkers or rail traffic control by broadcasting over a recorded radio channel the operator’s name and track unit designation as well as and the speed of travel in miles per hour at every mile post location ending on "0" and "5" in the direction of travel and the speed of travel in miles per hour; and
3. Rotate equipment operator every two hours with another rules qualified employee.

• Keep record of hours and provide me, on the first of every month, with a report showing:
  • the total daily hours worked, including for those having to work in all 3 exclusions (deadheading, administrative duties and emergencies) separated individually, as aforementioned in this Notice and Order.
  • Written confirmation demonstrating the fatigue management steps were taken in each instance when working more than 12 hours in a 24 hour period during emergencies as aforementioned in this Notice and Order.

Condition or Hazard observed:

Failure to effectively protect railway movements and the public against known trespassing on the railway right-of-way creates a situation where fatalities have occurred and reasonably could be expected to occur again.

CN was ordered to: between Miles 71 and 74 of the Yale Subdivision:

1. reduce the speed of any and all trains to 30 mph with the added requirement to be on “lookout” for trespassers on the railway right-of-way.
2. operate all movements with the engine bell rung before entering and until fully through these limits
3. apply a 3 second continuous whistle for westbound. movements at Miles 70, 71, 72, 73 and 74 and for eastbound movements at Miles 75, 74, 73, 72 and 71.
4. provide a written corrective action plan to Transport Canada by July 5, 2024.

Condition or Hazard observed:

Failing to identify and remediate unsafe track conditions and ensure that track is safe for all movements at the authorized speed could result in a derailment situation where a person could be injured, or damage could be caused to the environment or property.

CP was ordered to: under the responsibility of a professional engineer overseeing the line of track between Field and Revelstoke, BC, for the entire Mountain Subdivision:                                        

1. Inspect and assess the track structure including rails, ties, ballast and fastening systems as well as turnouts on all main tracks by conducting, but not limited to, visual inspections and using track testing technology.

2. Review and assess any findings of inspections conducted by certified Track Inspectors and inspection data from any track testing technology inspections used to inspect the track structure outlined in item 1.

3. Assess the management oversight, quality and adequacy of track inspections and maintenance activities being conducted, including factoring in the available track time allocated to conduct those activities.

4. Provide a preliminary report, by March 3, 2023, that includes inspection and assessment findings from the activities listed under items 1, 2 and 3, as well as short term actions taken or planned to be taken in addressing any deficiencies identified.

5. Provide a final report, on or before May 31, 2023, to allow for a detailed evaluation of the track structure when it is clear of snow, that includes at a minimum, a summary of the activities listed under items 1, 2, and 3, and all actions taken or planned to ensure the line of track remains safe for movements at the authorized speed.

Condition or Hazard observed:

Continually leaving a train standing in a manner that obstructed a public crossing created a situation where a pedestrian took a risk by crossing between stopped railcars, which can reasonably be expected to lead to a person being injured.

CP was ordered to: ensure the train with lead locomotive CP 8200 does not move until CP has physically verified that it is clear of pedestrians.

Condition or Hazard observed:

Failure to identify installation or design deficiencies while commissioning locations, and placing such locations in revenue service, could result in a signal system failure leading to a less restrictive signal than the condition warrants whereby a person can be injured, or damage can be caused to the environment or property.

CP was ordered to: between Miles 2 and 5 inclusively, on the Vaudreuil Subdivision

• operate all movements at restricted speed.
• complete a full set of commissioning tests as per company procedure under the responsibility of a professional engineer, to ensure that no wiring or component issues are present.

• reaffirm the design of all locations by a professional engineer.

Alteration # 4 of the Order, issued on December 18, 2022, removed speed restrictions and CP was ordered to, between Signals 21, 29, 33 and 50, on all tracks, on the Vaudreuil Subdivision:

• reaffirm the design of all locations by a professional engineer and provide a signed and sealed certificate attesting the compliance as per industry standards and best practices by February 24, 2023

Provide a list of any anomalies and/or changes that were applied following the commissioning tests and the reaffirmation of the design of all locations by February 24, 2023

Condition or Hazard observed:

The failure to implement reliable physical means to prevent pedestrians from unlawfully accessing the railway property creates a situation where a person could be injured or cause a derailment, resulting in damages to the environment or property.

CN was ordered to: within the limits of Mile 124.6 and Mile 125.17 on the Springhill Subdivision

1. Repair, or ensure repairs are carried out, and where needed, install new fencing to maintain the condition of the fence within 72 hours, and have responsible personnel present until all repairs are completed or new fencing can be installed.
2. Inspect the fence on both sides of the right-of-way twice weekly, not to exceed three consecutive calendar days without an inspection, to maintain, identify any breaches and carry out repairs.
3. Keep records of all inspections, repairs and/or installations made to the fence by logging the time, date, location and details of the inspections, repairs and/or fence installations.
4. Install fencing by Friday October 28, 2022, along the railway’s property on the South East corner where no fencing currently exists, up to the Main Street Overpass.
5. Issue a General Bulletin Order that applies to all movements to:
   • operate not exceeding 15 Miles per hour (MPH) with the added requirement to have a member of the operating crew posted on the leading piece of equipment in a position to observe trespassers and provide instructions to stop, as necessary; and
   • not operate within these limits unless the locomotive bell is activated.

On October 27, 2022, CN orders #1 and 2 were altered to:

1. Repair, or ensure repairs are carried out, and where needed, install new fencing to maintain the condition of the fence within 72 hours.
2. Inspect the fence on both sides of the right-of-way twice weekly, not to exceed three consecutive calendar days without an inspection, to identify and repair any breaches prior to the next inspection.

VIA Rail was ordered to: within the limits of Mile 124.6 and Mile 125.17 on the Springhill Subdivision

• Lock all gates and doors in the fencing providing access along its platform when not in use by VIA employees or contractors.
• Have responsible personnel present at the VIA station in a position to observe and deter any trespassers upon arrival and departure of trains during scheduled stops.

The City of Moncton was ordered to:

Have security or peace officers present onsite on the North and South side of the right-of-way one (1) hour before and after each event taking place at the Avenir Centre to ensure that no person is accessing the right-of-way or breaching the fencing along the railway’s right-of-way to traverse the railway tracks.

Condition or Hazard observed:

Due to insufficient vehicular storage space and a narrow road approach, larger vehicles stopped at the crossing are at risk of being struck by railway equipment or by oncoming road traffic.

CP was ordered to:

Provide a stop and proceed on the crossing at Mile 95.92 of the CP Cascade Subdivision until such time that there is no longer evidence of vehicles queuing over the crossing.

Condition or Hazard observed:

By not implementing reliable physical means to prevent pedestrians from unlawfully accessing the railway property, and not considering the known trespassing activity to protect against train movements, a person could be injured.

The City of Montreal was ordered to:

• inspect the fence, along the multiuse path between the limits of Saint-Denis and Clark Streets, every week under the city's responsibility, not to exceed 9 consecutive calendar days without an inspection, to identify any breaches,
• carry out repairs to the fence within 48 hours of having identified any breaches, and
• keep records of all inspections and repairs made to the fence by logging the time, date, location and details of repairs in a registry for the period this Order is in effect.

CP was ordered to, within the limits of Saint-Denis (mile 4.7) and Clark streets (mile 5.3):

• operate at « Restricted speed » with the added requirement to “be on lookout” for trespassers on the railway right-of-way,
• not operate any railway equipment within these limits, unless it always has a leading locomotive with the headlight at full power in the direction of travel,
• between sunrise and sunset, as per weather.gc.ca, not operate any railway equipment within these limits, unless the locomotive bell is activated,
• inspect the fence under CP's responsibility every week, not to exceed 9 consecutive calendar days without an inspection, to identify any breaches,
• carry out repairs to the fence within 48 hours of having identified any breaches, and
• keep records of all inspections and repairs made to the fence by logging the time, date, location and details of repairs in a registry for the period this Order is in effect.

Condition or Hazard observed:

Due to insufficient vehicular storage space at a grade crossing, larger vehicles stopped at the crossing are at risk of being struck by railway equipment or by oncoming road traffic.

Municipality of Merrickville-Wolford and the United Counties of Leeds and Grenville were ordered to:

• Restrict access to the portion of road approach, which lies over the grade crossing on Kilmarnock Road, including at the intersection of County Road 17 (Jasper road) and the crossing , to vehicles no larger than Medium Single Unit Truck classification (MSU, 10 meter) until  measures are implemented to ensure longer vehicles can be stopped safely at the crossing.

Condition or Hazard observed:

By leaving train 309-498 on a grade, in emergency and unsecured, as per regulatory requirements, train 309-498 could have moved uncontrolled.

CP was ordered to:

Equipment left on main track, subdivision track, siding or high risk locations without:

• at least one qualified employee physically on the controlling locomotive, and;
• the controlling locomotive coupled to the equipment and the air source cut in

must be considered unattended in the application of Canadian Railway Operating Rules 112 regardless of employee proximity.

Condition or Hazard observed:

1. The increased number of defective rails year over year, found both ultrasonically and visually, indicates a deteriorating situation and an increased risk of derailment due to a broken rail.
2. A combination of defective joint ties and fouled ballast conditions further increase the potential of rail break at a joint.

CMQR was ordered to:

• Increase the number of ultrasonic rail inspections on the Sherbrooke Subdivision between Mile 0 to Mile 125.46 and the result of these inspections to be conveyed to Transport Canada

Condition or Hazard observed:

The continued failure to adequately control movements operated by employees working within the Greater Edmonton Terminal, has resulted in seven (7) collisions since January 20, 2019.  This creates an immediate threat to safe railway operations where the risk of recurring collisions could cause harm to the employees and cause damage to the environment or property.

CN was ordered to:

not operate any movement on non-main track within the Greater Edmonton Terminal, which includes Walker Yard, Bissell Yard, Clover Bar Yard and Scotford Yard, unless such movements operate under the following conditions:  

• Restrict to a maximum speed of 10 mph;
• Restrict to a maximum coupling speed of 2 mph;
• Operate at a speed that will allow stopping within 1/3 the range of vision of equipment;
• Report any incident directly to Transport Canada within 24 hours of the occurrence taking place; and
• Have at least one on-Job-Trainer, who has been qualified under CN's On the Job Trainer Training Program, positioned at all times in Walker Yard, Bissell Yard and Clover Bar Yard to provide coaching and mentoring to all assignments.

Condition or Hazard observed:

The lack of sufficient safeguards during switching practices at the east end of Alyth classification yard created an immediate threat to safe railways operations where the risk of cars rolling uncontrolled could have caused harm to employees and damage to the environment or property.

CP was ordered to:

Not conduct switching operations from the west end of Alyth classification yard until sufficient safeguards were put in place to ensure that switching operations at this location are safe.

The corrective measures taken by CP were deemed satisfactory to mitigate the immediate threat to safety.

Condition or Hazard observed:

The road approaches to this crossing have stop signs installed on the railway signage which are located three (3) meters from the field side of the rail line. The sightlines from the stopped position are insufficient for road users to assess if an oncoming train is approaching and therefore, safely decide to cross the tracks. The recently installed signal bungalow restricts the sightlines in the northeast quadrant for the stopped vehicles to the point the drivers may not be able to see westbound train traffic. The absence of sightlines further creates a situation where vehicle operators stopped at the crossing may advance over the tracks and not have the reaction time to stop before a collision occurs.

CN was ordered to:

Until full sightlines are provided in the northeast quadrant of the grade crossing, limit the speed at Mile 136.98 to ten (10) miles per hour until the crossing is fully occupied.

Condition or Hazard observed:

The continued failure to adequately control movements operated by employees working within the Greater Edmonton Terminal has resulted in four (4) collisions since October 30, 2017. Despite extensive lists of remedial actions, enhanced coaching, on the job training and educational Operating Notices intended to stop the trend, collision have continued to occur.

CN was ordered to:

Not operate any movement on non-main track within the Greater Edmonton Terminal, unless such movements are operated under the following conditions:

• restricted to a maximum speed of 10 mph;
• restricted to a maximum coupling speed of 2 mph;
• operate at a speed that will allow stopping within one-third the range of vision of equipment.

Condition or Hazard observed:

1. Vegetation and brush restricting the sightlines at many farm, private and passive crossings.
2. Non-compliant tie conditions between mile 213.0 and mile 224.1.
3. A combination of non-compliant geometry conditions at mile 201.4.
4. Sightlines restricted by vegetation growth on the south west quadrant of the private crossing at mile 218.75.

The CSX Transportation Inc. was ordered to:

1. Shall not continue operations at current Class 1 freight train speeds (10 mph) between Miles 213.6 and 214.1 unless detailed turnout inspections have been performed by a qualified track inspector.

Condition or Hazard observed:

1. Vegetation and brush restricting the sightlines at many farm, private and passive crossings.
2. Non-compliant tie conditions between mile 213.0 and mile 224.
3. A combination of non-compliant geometry conditions at mile 201.4.
4. Sightlines restricted by vegetation growth on the south west quadrant of the private crossing at mile 218.75.

The CSX Transportation Inc. was ordered to:

1. Not allow train or equipment movements to operate at speeds exceeding 10 mph until vegetation and brush is cut between Miles 183.2 to 189.3, Miles 190.1 to 190.8, Miles 194.8 to 196.7, Miles 197.7 to 199.2, Miles 200.7 to 206.0 and Miles 2016.8 to 207.8.
2. Not allow train or equipment movements to operate between Miles 213.6 and 244.1 unless track inspection frequencies are increased to 3 times per week and performed by a certified track inspector.
3. Shall not continue operations at current Class 1 freight train speeds (10 mph) between Miles 213.6 and 224.1 unless a walking inspection has been performed by a qualified track inspector.
4. Shall not continue operations at current Class 1 freight train speeds (10 mph) between Miles 213.6 and 214.1 unless detailed turnout inspections have been performed by a qualified track inspector.
5. Shall not allow train or equipment movements to operate at Miles 222.75 unless daily track inspections are performed until such time as a sufficient number of non-defective ties and joint ties have been installed.
6. Shall not allow northbound trains or equipment movements to operate at Miles 218.75 except under the provisions of "Stop and Proceed" instructions.

Condition or Hazard observed:

CP's kicking activities could have created a situation of unintended movement of cars that are a threat to other railway activities being conducted at this location. There was a threat of collision with other movement or track units that could have reasonably been expected to cause harm to employees, or damage caused to the environment or property. Employees attempting to secure runaway cars were also subject to a threat of injury, in attempting to mitigate the consequences of these events.

The Canadian Pacific Railway is ordered to:

In CP's St-Luc Departure Yard

• Not allow the kicking of cars unless a physical defense is in place to stop the motion of any runaway cars from occupying other lead.
• Not allow the kicking of cars when another movement or track unit is present in the lead on which cars are being released on.

Condition or Hazard observed:

CP's current practices associated with the use of skates in kicking cars create an immediate threat to safe railway operations, as the risk of cars rolling uncontrolled was high and could have, as a result, caused harm to employees or members of the public and caused damage to the environment or property.

The Canadian Pacific Railway was ordered to:

In CP St-Luc yard:

• Not use track skates as a means to stop the motion of cars that have been kicked.
• Secure with handbrakes any cars intended to receive cars cut in motion.
• Ensure that the crew or qualified employee, involved in the switching operations, visually verify the presence of equipment before cars are cut in motion.

CP filed a request for review at the Transportation Appeal Tribunal of Canada (TATC) on September 23, 2016.

Hearing was held on December 15, 2016 and continued on January 18 and 19, 2017.

The TATC rendered its decision and referred the matter to the Minister for review.

The Minister confirmed the Order on December 19, 2018. The Order remains in effect until CP has provided measures to resolve the immediate threat.

Condition or Hazard observed:

Two accidents, between June 30 and July 13, 2016 that were directly attributed to the practice of kicking cars, indicated that the measures in place were insufficient to ensure equipment will not move foul of another track.

The procedures in place related to switching in CN Taschereau yard were not sufficient to prevent uncontrolled movements.

The Canadian National Railway Company was ordered to:

1. Clearly identify locations on each track where the 2 "anchor" cars are to be secured prior to having cars kicked onto them;
2. Monitor and document the travel of the secured "anchor" cars from the identified location prior to the lifting of the cars;
3. Report to Transport Canada, via email, any instance where equipment has moved foul of another track in an uncontrolled fashion; and
4. Not allow kicking of cars in the classification yard if a crew is present at the opposite end, unless positive communications between the crews is established that includes the work to be done and that employees and equipment at the opposite end are in a position that they would not be affected by equipment that would become foul of the lead.

Condition or Hazard observed:

The practice of releasing cars under their own momentum, commonly referred to as "kicking" under the conditions observed during recent operations inspections could have led to uncontrolled and unprotected movements of equipment.

The Canadian Pacific Railway was ordered to:

In S-Luc yard, not allow the practice of "kicking" cars until such time that control measures are put in place to the Railway Safety Inspector's satisfaction so that the activity is performed safely.

Condition or Hazard observed:

Freight cars held in captive service with mechanical defects were traveling an undetermined distance prior to being inspected.

Trillium Railway was ordered to:

1. Visually inspect all track and provide a copy of the track inspection report to the undersigned by May 30, 2016.
2. Until (a) is completed to the satisfaction of the undersigned, not operate any equipment at a speed greater than the maximum allowable operating speed for Class 1 track;

Condition or Hazard observed:

Freight cars held in captive service with mechanical defects were traveling an undetermined distance prior to being inspected.

The Canadian National Railway was ordered to:

Perform a certified car inspection on freight trains departing Senneterre, Québec in the direction of travel going East and that defects found on these trains be reported to the railway safety inspector.

The Order will apply until such time as the railway safety inspector is satisfied that the risk associated with these cars is removed.

Condition or Hazard observed:

Trains blocking the public crossing at Mi.8.8 of the CN Halton Subdivision at Goreway Drive in Brampton Ontario, for an extended period of time, and the railway's unwillingness to immediately rectify the issue will create uncertainty for pedestrians and vehicular traffic. This situation is resulting in dangerous driver behaviour being taken at the crossing and could also delay the passage of emergency vehicles through the crossing in an emergency situation which could reasonably be expected to lead to a person being injured or made to be ill.

The Canadian National Railway was ordered to:

1. Ensure that all trains arriving at Brampton Intermodal Terminal are provided a clear route with all switches directly lined into their yard track, allowing for trains to pull continuously until the crossing is clear.

CN Rail to provide to TC on a weekly basis, copies of Event Recorder downloads from the Grade Crossing Warning System at Mi. 8.8, Halton Subdivision (Goreway Drive, Brampton, ON)

CN filed for review at TATC on March 9, 2016

Hearing held June 23, 2016

TATC rendered its decision on December 1, 2016 and referred the matter to the Minister.

Upon review of the Order, the Minister revoked the Order, effective July 7, 2017.

Condition or Hazard observed:

• CP operations, specific to Extended Service Run (ESR), are creating conditions which are causing fatigue to accumulate in operating crews, thereby reducing their alertness, while in care and control of trains. The operational conditions contributing to this are:
  • Not including transit time, to and from the away-from-home rest facility, and the away-from-home terminal as time on duty;
  • Not allowing crews to book rest at the away-from-home terminal after being cancelled for duty;

Not listing ESR trains on the train lineup for a sufficient amount of time. This does not allow crew members sufficient planning time for a sleep cycle prior to being on duty.

The Canadian Pacific Railway was ordered to:

At home, and away-from-home terminal of Kamloops, Roberts Bank, and Port Coquitlam (Greater Vancouver Area Terminals inclusive):

• Shall include all transit time to and from the rest facility at the away-from-home terminal as operating crews on-duty time;
• Shall allow ESR crews the ability to book up to eight hours undisturbed rest when cancelled;
• Shall have all ESR trains posted on the ESR specific train lineup or a general lineup if utilized, for a minimum of eight hours prior to call time, and up to a maximum call time of twelve hours.