2016 train collision in Toronto due to human error, transport safety board finds
Investigation into August 2016 collision concluded crew missed stop signals, possibly due to fatigue
Houses hugging the rail corridor along Dupont Avenue tend to shake, so the rumbling one resident felt on a morning last August didn't faze her.
But that morning, the rumbling grew louder. And louder.
"There was this crescendo of sound," D!ONNE Renée recalled. "I looked out my window and there was this plumage of red."
Renée says she called 911 but didn't venture outside, fearing a terror attack or gas leak. A few minutes later, she bucked up the courage to open her front door.
"That's when I realized it was a train," she said.
At about 5:20 a.m. on August 21, two Canadian Pacific Railway trains collided at a junction after the westbound train's crew missed a signal that would have warned them to slow down — and prepare to stop — for another train soon to cross their path.
Human error had been suspected in the collision, but Canada's Transportation Safety Board (TSB) confirmed Tuesday that the distraction of the westbound train's crew led them to miss that signal, which caused the crash.
The TSB assesses risks and provides recommendations to the rail industry and its regulator, Transport Canada. It cannot change legislation or pressure governments or the rail industry.
The report found "operating the train, reviewing the timetable, observing the eastbound train, and searching for a reported trespasser" diverted the crew's attention from that all-important warning signal.
Renée says the explosion was a wake-up call for the community around the rail corridor, which is exposed daily to trains carrying crude oil and other potentially dangerous materials.
"All our first responders should know what's going through the city to prepare just in case something happens," Renee said. "Because nobody was prepared for that just-in-case-it-happens on August 21 of last year."
Safe Rail Communities, an advocacy group that fights for the protection of residents like Renee, has been outspoken about safety regulations for trains passing through densely populated areas.
Patricia Lai, Safe Rail's founder, says the findings in the report don't surprise her; she's seen them before.
"This is part of an ongoing problem," Lai said. "It's about ending self-regulation of the railways and industry."
Lai points to the need for more government leadership in rail safety, claiming that the framework now in place means the industry can largely make its own rules.
"It really allows rail companies to decide for themselves what is suitable and what is safe," she said.
Three possible factors were identified in the TSB's report: fatigue, unfamiliarity with the route, and distraction.
Both the engineer and the conductor had less than six hours of continuous sleep in the 24-hour period before the crash, leading investigators to suspect both had a "sleep debt" that might have affected their ability to concentrate on signals.
The conductor had also been sleeping in his car in the days leading up to his shift, the report said.
Investigators also outlined the conductor's complicated employment history with CP Rail. The conductor had been laid off and rehired three times in the 14 months before the accident.
The morning of the crash was the conductor's first shift after a five-week layoff.
Crews are regularly tested for their fitness to operate trains. In the 18 months preceding the collision, the engineer was tested 80 times; the conductor, 24.
However, the conductor did not have a familiarity run before being assigned to the westbound route on August 21.
CP Rail doesn't have to change its policy or procedure based on these findings, but Don Mustard, the primary investigator for the crash, suggested it's in everybody's interest to mitigate risks.
"Nobody sets out to have an accident," said Mustard. "In my experience, usually the safest practices are also the best practices."