Blog Post #1040 – Lack of Risk Assessment Cited at a Rail Yard

Excerpt from the OH&S Canada magazine

The lack of a risk assessment, in addition to fatigue and task interruption, led to the death of a railway employee in Montreal in 2017.

A Canadian Pacific Railway (CP) yard-assignment crew consisting of a locomotive engineer, a yard foreman and a yard helper were performing switching operations is St. Luc Yard on November 8, 2017, according to an investigation report that the Transportation Safety Board of Canada released on May 06, 2019.

While the crew was switching cars into their designated tracks, the yard helper left his position briefly. When he returned, he instructed the locomotive engineer by radio to stop the assignment north of the crossover switch.

The yard helper incorrectly placed the crossover switch in the reverse position, aligning the movement away from the intended destination track. He then placed the destination track’s switch in the reverse position before instructing the locomotive engineer to move the yard assignment into the destination track. Due to the incorrect position of the crossover switch, the assignment diverted onto the crossover track and fatally injured the yard helper.

The investigation found that switching operations had been changed significantly in 2012, but a risk assessment of the changes had not been conducted.

The existing levels of lighting in the diamond area of the yard made it more difficult for the yard foreman to visually determine the location of the yard helper and distinguish the direction of travel of the yard assignment, hence heightening the likelihood of accidents. The yard helper’s fatigue and his short absence were also contributing factors.

Following the occurrence, Transport Canada issued a direction regarding lighting at St-Luc Yard. CP also conducted worker awareness campaigns on the hazards when working on or near tracks and the risk-mitigation processes.

My opinion

A completed JHA (job hazard analysis or assessment) is a must in most of today’s workplace. The Ministry of Labour (MOL) in Ontario, is a great watchdog ensuring that all workplaces understand the associated hazards with any job that is to be started/completed.

Canadian Pacific Railway is a large enough company to know this. CP needs to change the work culture to one of SOPs and supervisory monitoring of workplace operations. Practicing “Due Diligence” is the only way!

HRS Group Inc. has a great team that can help you with all your health and safety needs. Contact Deborah toll free at 1-877-907-7744 or locally at 705-749-1259 We can also be reached at 

Ensure your workplace is a safe place.

Remember – In Ontario, “ALL Accidents are Preventable”

HRS Group Inc. has a great team that can help you with all your health and safety needs including ‘Due Diligence’ and ‘Standard Operating Procedures’. Contact Deborah toll free at 1-877-907-7744 or locally at 705-749-1259.

We can also be reached at 

‘Work’ and ‘Play’ safe.

Daniel L. Beal

CHSEP – Advanced Level
VP & Senior Trainer
HRS Group Inc.


Leave a Comment