With the release of investigation documents surrounding a 2019 accident in which a GO Transit train struck two people at a public crossing in Ontario, officials from the Transportation Safety Board of Canada are expressing concerns about the safety oversight of provincially regulated railways.
The TSB issued a safety concern Feb. 9 following the release of its investigation report into the 2019 incident that involved an adult and a child being struck in Kitchener, Ontario.
“This accident illustrates the critical and pervasive issue of railway crossing safety, which is the second leading cause of fatalities in the railway sector,” said TSB Chair Kathy Fox. “Crossing safety is a shared responsibility. Pedestrians and motorists need to obey the rules at crossings; and the railways, road authorities and regulator need to communicate with each other when risks are identified and take appropriate action to improve safety and prevent further crossing accidents.”
On Nov. 13, 2019, six adults and five children were waiting to cross the street at Kitchener, Ontario’s Lancaster Street West public grade crossing. A CN freight train was at the time completing switching operations on the siding track and occupied the multi-track crossing while the crossing gates, warning bells, and flashing lights were activated, a release said.
On the main track, a GO Transit commuter train was making its way to Kitchener on the Metrolinx Guelph Subdivision. Unaware of the oncoming train, two of the group’s adults with two children started to cross.
The first adult and child crossed the street quickly. The second adult and child—described by CBC as a 30-year-old pregnant woman and a 6-year-old child—crossed about 15 feet behind them and were hit by the train, a release said. They were both transported to a nearby hospital after sustaining critical injuries.
The investigation found that the four pedestrians who crossed the crossing despite the activated warning devices were unable to see the approaching GO train and associated the crossing warning solely with the CN freight train that was exiting the crossing.
Due to an anti-whistling designation at the crossing, the pedestrians also did not receive an early warning of a second train approaching, according to the TSB.
The investigation also found that CN frequently activated the grade crossing warning devices during switching activities, sometimes surpassing the five-minute regulation limit. This led some users to become accustomed to the warnings and engage in unsafe behavior by entering the crossing during warning device activation to avoid delays, TSB said.
Although Metrolinx and other provincially regulated railroads are subject to the Ministry of Transportation of Ontario’s safety oversight, TSB said the ministry lacks a comprehensive provincial regulatory framework and relies on inspection agreements with Metrolinx and Transport Canada to help maintain compliance with federal regulations. The MTO also does not employ anyone with technical railway expertise, TSB explained.
MTO can delegate inspections to TC, and while TC inspectors can identify safety problems and help Metrolinx reduce risks, TC authorities lack the ability to compel them to take corrective action, according to the Board.
The observed hazards at the crossing were not known to any of the parties involved—CN, Metrolinx, the Region of Waterloo, and the MTO, according to the TSB.
The incident illustrates gaps in the Province of Ontario’s regulatory oversight of its provincially regulated railways given the intricacy of numerous separate agreements with various parties, TSB said.
TSB said the authority took action to reduce similar safety risks in 2021, when the Board issued Rail Safety Advisory 01/21 to TC regarding second-train events at multi-track level-grade crossings with high pedestrian traffic and those which experience frequent and extended grade crossing warning device activations.
The advisory suggested evaluating the likelihood of second train events and putting additional safety measures in place to enhance safety.
Following the 2019 incident, officials said Metrolinx made a number of physical safety modifications at the Lancaster Street West crossing, and it is now mandatory for oncoming train operators to blast their horns.
The MTO has also identified a need to update the oversight structure for urban and regional rail transit that would support the area’s growing rail network and the diversity of operators, a release said.
The MTO updated its agreements with TC and Metrolinx in January of 2022. In order to ensure that any potential non-compliances are properly handled, the MTO worked closely with TC to reinforce the MTO’s accountability level in the agreement with relation to Metrolinx, according to a release.