Safety communications related to TSB investigation R23D0108: November 2023 train collision in Montréal, Quebec

The occurrence

On November 21, 2023, a Canadian National Railway (CN) train and an exo commuter train collided at the St-Léonard-Montréal-Nord station in Montréal, Quebec. The investigation found that the CN train crew had passed a Restricting signal requiring them to limit their speed and be prepared to stop. However, believing the track ahead was clear, the train accelerated. By the time the stationary commuter train became visible, it was too late to avoid the collision and subsequent derailment.

Board recommendations

Physical fail-safe train controls

The Canadian railway system relies primarily on administrative defences, such as regulations, instructions, and procedures, to ensure the safety of operations. These administrative defences depend on train crews complying with the rules. In situations where a train crew misperceives, misinterprets or fails to comply with a signal indication, all of these defences fail.

As demonstrated by this occurrence and other recent occurrencesTSB railway transportation safety occurrences R24D0070, R24T0064, R24C0020, R23V0205, R23E0079, and R23H0006. involving failure to obey signal indications, when an administrative defence fails and there is no additional physical defence built into the system, a preventable accident can occur. This occurrence took place on a subdivision considered a key route for commuter, passenger, and freight trains, some of which carry dangerous goods. There was no automatic intervention to stop train CN 376 after it exceeded the allowable speed in the block before colliding with the tail end of train EXO 1212.

Since December 2020, the United States has made it mandatory to use positive train control (PTC), an automatic control system that can intervene to stop a train if it fails to comply with train operating requirements, thereby preventing collisions, derailments, and other accidents.

In Canada, the TSB made 2 recommendations in 2000 and 2013 (R00-04 and R13-01, respectively) urging TC to adopt physical, fail-safe defences. Although several initiatives and projects were launched to design and develop such a system in Canada, few meaningful steps have been taken. In 2022, following its investigation into a collision between 2 CN trains in 2019 near Portage la Prairie, Manitoba, the TSB recommended that

On 17 April 2024, following 3 other occurrences under investigation, the TSB sent a letter to the Minister of Transport regarding the absence of physical fail-safe controls for trains operating in Canada. In its letter, the TSB urged the Minister of Transport to accelerate the implementation of such a system in Canada’s high-speed rail corridors and on all key routes across the country. As of the release of this report, the TSB had not yet received a response.

In February 2022, TC issued a notice of intent indicating that it intended to require Canada’s most at-risk corridors to be equipped with an automatic train protection system (known as enhanced train control, or ETC) in accordance with the objectives of its strategic plan entitled Transportation 2030: A Strategic Plan for the Future of Transportation in Canada (Transportation 2030 strategic plan). In December 2024, TC announced that it planned to draft regulations in 2025 for publication in Part I of the Canada Gazette in 2026. However, details regarding the specific rail corridors and routes that would require an ETC system and the final configuration of such a system have not yet been determined, and safety regarding rail traffic in Canada continues to rely solely on administrative defences.

As a result, if train control systems rely solely on administrative defences, trains cannot be automatically stopped in the event of non-compliance with signal indications, which increases the risk of accidents.

Given recent events involving crews not following signal indications that continue to occur in Canada, the TSB urges TC to expedite efforts to adopt fail-safe physical defences for trains, particularly on high-speed corridors and key routes, to better protect passengers, property, and the environment.

Accordingly, the TSB is reiterating Recommendation R22-04.

Additional interim measures

In response to Recommendation R22-04 and other TSB recommendations regarding fail-safe physical defences, TC developed the ETC concept and reported that it had begun working with industry partners on several measures to advance its implementation. In February 2022, TC published a notice of intent outlining the next steps for implementing ETC technologies in Canada.

In 2023, a risk assessment methodology to guide the implementation of ETC in Canada was developed, and consultations on this issue were undertaken. This methodology assesses various factors, including passenger service, annual gross tonnage, and the status of key routes. The same year, guidelines for the interoperability of ETC applications were published by the Canadian Standards Association (CSA).

According to TC, draft regulations for the implementation of ETC technologies in Canada are expected to be pre-published in the Canada Gazette, Part I, in 2026. TC also stated that the ETC implementation schedule will depend on the development of regulations.

Current administrative defences rely solely on train crews recognizing and complying with signal indications. However, numerous TSB investigations have identified various circumstances in which these administrative defences have failed. As highlighted in Rail Safety Advisory 01/24 and the letter to the Minister of Transport, the risks associated with failure to comply with signal indications remain high, and it is unlikely that the level of risk will be significantly reduced before physical fail-safe defences are implemented.

However, in recent years, several railway companies operating in Canada have, on their own initiative, introduced measures to partially compensate for the absence of such regulations by TC. Some companies have added additional administrative defences, while at least one other has integrated satellite geolocation technology (GPS).

For example, in order to reduce and eliminate distractions when a movement approaches a safety-critical situation, VIA Rail Canada Inc. and Canadian National Railway Company (CN) have each implemented the CFZ. This is a set of special procedures to be applied when crew vigilance is of the utmost importance. When a CFZ is in effect, employees in the cab of a controlling locomotive must cease all communication and other tasks not related to the immediate operation of the train.

Following this occurrence, CN extended CFZ conditions to include situations where trains are required to operate at restricted speed. To be effective, however, CFZs require team members to recognize the conditions that place them in these situations. CFZs are therefore subject to the same limitations as other administrative defences in place.

CN also introduced a new special instruction under CROR Rule 411.Rule 411: Clear to Stop - Proceed, preparing to stop at next signal. From now on, freight trains must reduce their speed by 10 mph below the maximum allowable speed when approaching a Clear to Stop signal, starting before passing the signal.

For its part, the QNS&L Railway has implemented a combined administrative and physical defence system, introducing proximity detection devices (PDDs) in 1997. PDDs are equipped with GPS to determine the position, direction, and speed of locomotives and maintenance vehicles equipped with these devices. They are configured to receive alerts of approaching movements. The conductors of both movements must confirm on a screen that they have acknowledged the alert and must communicate with each other by radio to verify their respective positions. A penalty brake is automatically applied to the locomotive of a train whose crew has not acknowledged receipt of the alert. Despite this technology, a PDD will not prevent a collision if the train crew acknowledges receiving an alert without reducing speed or stopping the train in time.

These examples of initiatives implemented by some railway companies are a step in the right direction pending the implementation of the ETC, which TC has stated it intends to implement in accordance with the objectives of its Transportation 2030 strategic plan.

As of the release of this report, TC had not yet completed many of the necessary steps to implement the ETC in Canada, including corridor risk assessments. Given the scope and complexity of some of these critical actions, it is unlikely that such a system will be developed and implemented within the next few years. If train control systems rely solely on administrative defences, there will be no automatic intervention to stop trains if train crews fail to follow signals or misinterpret them, increasing the risk of accidents.

Pending the implementation of the ETC in Canada, no interim measures are required or planned by TC to reduce the risk of train collisions. Consequently, in the coming years there will be few or no regulatory physical defences to stop a train when a crew fails to follow a signal indication.

The Board therefore recommends that