RAIL TRANSPORTATION SAFETY INVESTIGATION REPORT R18T0058 TRESPASSING ACCIDENT Canadian Pacific Railway Freight train 141-17 Mile 16.82, Galt Subdivision Mississauga, Ontario 18 March 2018 II | TRANSPORTATION SAFETY BOARD OF CANADA ABOUT THIS INVESTIGATION REPORT This report is the result of an investigation into a class 3 occurrence. For more information, see the Policy on Occurrence Classification at www.tsb.gc.ca The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. 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Materials under the copyright of another party Some of the content in this investigation report (notably images on which a source other than the TSB is named) is subject to the copyright of another party and is protected under the Copyright Act and international agreements. For information concerning copyright ownership and restrictions, please contact the TSB. Citation Transportation Safety Board of Canada, Rail Transportation Safety Investigation Report R18T0058 (released 24 September 2019). Transportation Safety Board of Canada Place du Centre 200 Promenade du Portage, 4th floor Gatineau QC K1A 1K8 819-994-3741 1-800-387-3557 www.tsb.gc.ca [email protected] © Her Majesty the Queen in Right of Canada, as represented by the Transportation Safety Board of Canada, 2019 Rail transportation safety investigation report R18T0058 Cat. No. TU3-11/18-0058E-PDF ISBN: 978-0-660-32595-8 This report is available on the website of the Transportation Safety Board of Canada at www.tsb.gc.ca Le présent rapport est également disponible en français. RAIL TRANSPORTATION SAFETY INVESTIGATION REPORT R18T0058 | III Table of contents 1.0 Factual information ................................................................................................. 1 1.1 The accident ................................................................................................................................................. 2 1.2 Subdivision and track information ...................................................................................................... 5 1.3 Trespassing on railway property .......................................................................................................... 5 1.3.1 Enforcement of trespassing offences by railway police constables ....................... 6 1.3.2 Enforcement of trespassing offences by local police services ................................. 7 1.3.3 Enforcement of trespassing offences by Transport Canada inspectors ............... 7 1.4 Trespassing at Howland Avenue .......................................................................................................... 7 1.5 Risk perception by individuals trespassing ...................................................................................... 9 1.6 Decision making .......................................................................................................................................10 1.6.1 Decision-making process for teenagers .........................................................................10 1.6.2 Effects of psychoactive substances on decision making ..........................................10 1.7 Rail trespassing awareness programs ..............................................................................................11 1.7.1 Operation Lifesaver .................................................................................................................12 1.7.2 Direction 2006 ...........................................................................................................................12 1.7.3 Canadian Pacific Railway’s safety program ....................................................................13 1.7.4 Rail safety awareness campaign by Metro Trains (Melbourne, Australia) .........13 1.8 Trespassing occurrences reported to the Transportation Safety Board of Canada .......13 1.8.1 Other recent trespassing occurrences in southern Ontario ....................................15 1.9 Railway Safety Act review panel .........................................................................................................16 1.9.1 Trespassing occurrences .......................................................................................................16 1.9.2 Proximity ......................................................................................................................................18 1.9.3 Railway Safety Act review panel recommendations ...................................................20 1.9.4 Minister of Transport response to the Railway Safety Act panel report ............22 1.10 Trespassing and pedestrian studies and tools..............................................................................23 1.10.1 Canadian Rail Atlas and Geospatial Data Extraction tool .........................................23 1.10.2 United States trespassing demographic studies .........................................................23 1.10.3 Volpe Center geographical information systems map for trespassing occurrences ................................................................................................................................24 1.10.4 Collaborative European project on the reduction of suicides and trespassing on railway property .................................................................................................................24 1.11 Forward-facing camera on head-end locomotives .....................................................................25 1.12 Critical Incident Response Program for employees....................................................................25 2.0 Analysis ................................................................................................................... 26 2.1 The accident ...............................................................................................................................................26 2.2 Factors influencing the decision to trespass .................................................................................26 2.3 Trespassing at the Howland Avenue crossing ..............................................................................27 2.4 Mitigating the hazards associated with trespassing ..................................................................27 2.4.1 Engineering strategies and proximity issues .................................................................28 2.4.2 Enforcement strategies ..........................................................................................................29 2.4.3 Education strategies ................................................................................................................29 2.4.4 Demographic and geographic data..................................................................................30 2.5 Availability of recordings from forward-facing cameras ..........................................................30 IV | TRANSPORTATION SAFETY BOARD OF CANADA 3.0 Findings ................................................................................................................... 31 3.1 Findings as to causes and contributing factors ............................................................................31 3.2 Findings as to risk .....................................................................................................................................31 3.3 Other findings ............................................................................................................................................32 4.0 Safety action ........................................................................................................... 33 4.1 Safety action taken ..................................................................................................................................33 4.1.1 Transportation Safety Board of Canada ..........................................................................33 4.1.2 Canadian Pacific Railway .......................................................................................................33 RAIL TRANSPORTATION SAFETY INVESTIGATION REPORT R18T0058 | 1 RAIL TRANSPORTATION SAFETY INVESTIGATION REPORT R18T0058 TRESPASSING ACCIDENT Canadian Pacific Railway Freight train 141-17 Mile 16.82, Galt Subdivision Mississauga, Ontario 18 March 2018 The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. Summary On 18 March 2018, shortly after 0115 Eastern Daylight