Release of investigation report R23D0108

Yoan Marier, TSB Chair
Luc Régis, Regional Senior Investigator

Ottawa, Ontario
16 September 2025

Check against delivery.

Yoan Marier – Introduction

Good morning and thank you for joining us.

We are here today to present the findings of our investigation into the 2023 main-track collision and derailment of a Canadian National Railway Company light engine train and a Réseau de transport métropolitain commuter train in Montreal, Quebec.

As a result of this investigation, we are reiterating one existing recommendation and issuing a new one to Transport Canada to mitigate the risks associated with train crews failing to comply with railway signals.

I’ll turn it over to Mr. Régis, who will walk you through the sequence of events surrounding the occurrence.

Luc Régis – Investigation findings

On November 21, 2023, CN train 376 was travelling south on the St-Laurent Subdivision when it collided with the tail end of a stationary commuter train, EXO 1212, at Saint-Léonard–Montréal-Nord station. Four of the eight passengers and two crew members on board the EXO train were injured.

Prior to the collision, the CN train had passed a restricting signal, meaning that the crew had to be prepared to stop short of another train anywhere in the block ahead, up to a maximum speed of 15 mph until the next signal.

In railway operations, signals work in sequence, meaning that each one provides an indication based on what the next signal is expected to display.

The CN crew likely assumed that the block ahead was clear and expected that the next signal would be permissive. Possibly acting on this assumption, they didn’t slow down. Instead, they accelerated to 41 mph… which is 26 mph over the limit.

This expectation, however, proved to be incorrect.

Due to the station’s ambient lighting and the railway signals beyond it, the end of train marker lights on the EXO commuter train only became visible when the CN lead locomotive was just over 500 feet away. The locomotive engineer initiated an emergency brake application, however, at that distance and speed, the collision was unavoidable.

Our investigation determined that while the crew verbally acknowledged signal indications among themselves, they did not adhere to the restricted speed and did not discuss the restriction as required by operating procedures.

When TSB investigators reviewed the locomotive voice and video recorder, they found that both cameras inside the cab had been intentionally obstructed by sheets of paper. This hindered the ability to fully analyze what was happening inside the cab before the collision.

The safety issues identified in this investigation are not isolated—they reflect longstanding, systemic vulnerabilities in Canada’s rail transportation system that have persisted for over two decades. Since 2023, the TSB has launched eight investigations into occurrences involving the absence of additional physical fail-safe defences.

This occurrence is yet another example of the risks that arise when there are no safeguards in place to protect against signals not being followed.

I will now turn to Mr. Marier, who will speak about the Board’s recommendation.

Yoan Marier – Recommendation

For nearly 25 years, the TSB has called for the implementation of physical fail-safe defences for trains operating in Canada.

These defences automatically intervene to slow or stop a train when a crew doesn’t respond to signal indications. They can also protect against overspeed derailments, incursions into work zones, and main track switches left in the wrong position.

The United States took concrete action after a serious train collision in California in 2008, mandating a physical fail-safe train control system on high-hazard routes. Canadian trains that go to the US must be equipped to work with this system.

Yet here in Canada, the industry continues to rely solely on administrative defences, such as regulations, instructions, and procedures, leaving safety dependent on human performance.

Without strong, physical safeguards, the risk of collisions remains alarmingly high.

In 2000 and 2013, the TSB issued recommendations urging Transport Canada to mandate physical fail-safe defences.

It wasn’t until 2022 that Transport Canada announced its intent to require such technology, known as enhanced train control, on our country’s highest-risk corridors. While that was a step forward, progress since has been limited.

The same year, following a 2019 main track collision between two CN trains in  Manitoba, the TSB issued a recommendation calling on Transport Canada to require major Canadian railways to expedite the implementation of physical fail-safe train controls on Canada’s high-speed rail corridors and on all key routes [R22-04].

To date, Transport Canada has not yet completed many of the key steps, including critical actions such as conducting corridor risk assessments.

That’s why we are here today to stress the importance of this recommendation. The frequency of occurrences involving crews not following signal indications is not decreasing; therefore, we strongly urge Transport Canada to prioritize the deployment of these critical safety defences.

Given the complexity of the work that remains, full implementation of a physical fail-safe system is still years away. More concerning, however, is that there are no government-mandated interim safety measures in place while the system is being developed—leaving trains at risk of collision or derailments when other defences, such as signal compliance, fail.

This is a serious gap in safety, one that, in the best case scenario, will remain for many years, and it cannot be ignored.

Therefore, the Board recommends that

Yoan Marier - Conclusion

This collision occurred on a key route—one that carries both daily passenger traffic and freight trains transporting dangerous goods. And yet, no physical backup safety defences were in place to stop it. The outcome could have been far more devastating. This incident is a stark reminder of the risks at stake and the urgent need for stronger safeguards. We cannot continue relying solely on human performance. Even if a physical fail-safe system is still years away, Canadians cannot afford to wait.

Thank you.