Chair says recent derailment highlights need for physical fail-safe defences
Transportation Safety Board of Canada (TSB) warns that a long-standing safety gap in Canada’s railway system continues to expose passengers, workers, and communities to preventable risks. Following the release of its investigation into the 2023 Montreal train collision, the agency issues a new recommendation urging Transport Canada to act immediately.
On November 21, 2023, a Canadian National (CN) freight train collides with a stationary exo commuter train at the St-Léonard–Montréal-Nord station. Investigators find the CN crew fails to comply with a restricting signal, accelerating instead of slowing down. The resulting collision injures six people and derails multiple cars.
“The crew likely assumed the block ahead was clear,” says Luc Régis, Investigator-in-Charge at the TSB. “They did not slow down. Instead, they accelerated to 41 miles per hour—26 over the limit.”
By the time the commuter train becomes visible—just 500 feet away—the collision is unavoidable. An emergency brake is applied, but it is too late.
TSB analysis reveals that the in-cab voice and video recorders (LVVR) on the freight train had been tampered with. “Both cameras inside the cab had been intentionally obstructed by sheets of paper,” says Régis. “This hindered the ability to fully analyze what was happening inside the cab before the collision.”
While the microphones still function, the video is compromised—raising concerns about equipment integrity and safety culture.
Decades-old safety gap
This incident marks at least the eighth investigation since 2023 involving absent or insufficient physical fail-safe defences. For nearly 25 years, the TSB has pushed for the implementation of systems that can automatically slow or stop trains when crews fail to respond to signal indications.
“Without strong physical safeguards, the risk of collisions remains alarmingly high,” says Yoan Marier, Chair of the TSB. “Relying solely on human performance leaves Canada’s railways vulnerable.”
Marier points to the United States, where following a deadly 2008 crash in California, Positive Train Control (PTC) becomes mandatory on high-risk corridors. Canadian trains crossing into the U.S. must be equipped with the system, but Canada has yet to deploy a nationwide equivalent.
“The industry continues to rely solely on administrative defences—regulations, instructions, and procedures—leaving safety dependent on human performance,” Marier says.
New recommendation: R25-01
In response to the Montreal incident, the TSB issues Recommendation R25-01, calling on Transport Canada to implement immediate interim safety measures to mitigate signal compliance risks until permanent fail-safe systems are in place.
“This is a serious gap in safety—one that, even in the best-case scenario, will remain for many years. It cannot be ignored,” Marier states.
The recommendation emphasizes that full implementation of Canada’s enhanced train control system is still years away, with key steps such as corridor risk assessments still incomplete.
What interim measures could look like
Though the Board avoids prescribing specific technologies, it highlights available options already in use. Marier cites QNS&L Railway in Quebec, which uses a GPS-based system to alert crews when locomotives get too close to another train.
“Technology in recent years—especially GPS—has become very affordable and accessible,” Marier says. “These kinds of systems can act as a buffer until permanent solutions are ready.”
Other interim measures could include:
- Redundant verification of signal compliance among crew members.
- Speed restrictions in complex operating zones.
- Enhanced fatigue management and distraction-reduction protocols.
A cautionary tale for safety leaders
For health and safety professionals, the TSB’s findings underscore a broader principle: administrative controls alone are not sufficient in high-risk environments.
“The frequency of occurrences involving crews not following standard indications is not decreasing,” Marier warns. “We strongly urge Transport Canada to prioritize the deployment of these critical safety systems.”
The TSB’s firm position—and its public rebuke of inaction—highlights the growing expectation that regulators and employers share responsibility in bridging safety gaps during long-term system overhauls.
Until permanent controls are in place, the risk of signal misinterpretation, human error, and equipment non-compliance remains a live threat to railway workers and passengers alike.
