Canada: TSB issues report in respect of pedestrian fatality

28 Jan

Canada’s Transportation Safety Board investigation report into the December 1st, 2012, death of an 11-year-old girl on the Third Street automatic half-barrier level crossing of Canadian Pacific Railway (CP) in London, Ontario has been published. The findings of the TSB investigation are detailed below:

Findings as to causes and contributing factors

1.Pedestrian 1 was struck by the train and sustained fatal injuries while attempting to traverse the crossing ahead of the train.
2.It is likely that the pedestrians were motivated to traverse the crossing to avoid having to wait for the train.
3.Given the pedestrians’ familiarity with the crossing, it is likely that previous observations of individuals traversing the crossing in front of a train further reduced the perception of the risks.
4.In the absence of sufficient visual and auditory cues, the pedestrian incorrectly decided that there was enough time to cross before the arrival of the train.

Findings as to risk

1.While roadway automatic warning device (AWD) protection may reduce the risk of vehicle accidents, there is an increased risk to pedestrians at public crossings equipped solely with roadway AWD in locations where there is a high level of pedestrian traffic.
2.Without specific education, such as Operation Lifesaver material delivered to schools near railway property, there is an increased likelihood that school-age children will remain uninformed of the dangers associated with railway crossings or trespassing on railway property and continue to take risks that can have fatal consequences.
3.Ineffective enforcement of crossing and trespassing laws increases the probability that the public will continue demonstrating unsafe behaviours that put them at risk.

Safety actions taken since the accident are:


On January 23rd, 2013, the TSB issued Rail Safety Information letter (RSI) 01/13 entitled “Trespassing in the Vicinity of Third Street Public Crossing in London, Ontario.” The RSI outlined that approximately 60 pedestrians and cyclists per hour traversed the crossing using the sidewalks. Several trespassers were also observed on the railway right of way east of Third Street. The trespassers likely accessed the right of way through openings cut into the railway fence in a number of locations. Pathways observed extending from the railway fence to the track suggest that a high frequency of trespassing occurred in this vicinity. The RSI suggested that since trespassing accidents usually result in serious injury or fatality, railway inspection, maintenance, and enforcement programs must be sufficiently robust to ensure that trespassing activity is identified and proactively deterred.

On February 25th, 2013, Transport Canada (TC) responded that in areas where there are known access control issues, it conducts regular monitoring activities, informs the railways of any safety deficiencies and, if required, takes appropriate action. In this case, the TC Ontario Surface Regional Office followed up with Canadian Pacific Railway (CP). CP advised that the area was being monitored closely by their engineering officers, fencing was repaired, and signage was erected. TC will continue to work with the railway, the municipality, and other stakeholders to provide education and awareness about access control on railway properties in the City of London.

City of London

The City of London ordered the removal of brush along the right-of-way in the vicinity of crossings within city limits.

Transport Canada

TC is currently updating the Pedestrian Safety at Grade Crossing Guide in order to provide improved guidance to municipalities on pedestrian crossing safety.

Through its Rail Safety Education and Awareness (E&A) program, TC works with municipalities, railway, and provincial levels of government to promote, encourage, and facilitate discussions around railway safety. In conjunction with this program, TC has spearheaded railway crossing blitzes with the Ontario Provincial Police (OPP), local police forces, and railways in some towns to educate drivers and pedestrians on railway safety.

From February 12-14th, 2013, TC Rail Safety attended the Federation of Canadian Municipalities (FCM) conference in Windsor, Ontario, to educate municipalities on railway safety roles and responsibilities.

In February 2013, TC Rail Safety officials contacted CP police and the City of London regarding their involvement with rail safety in London and the surrounding area. TC spoke to both parties to inquire if the municipality and railway had plans to mitigate the risks identified in the TSB information letter.

On August 18-19th, 2013, TC Rail Safety attended the Association of Municipalities of Ontario (AMO) conference to educate municipalities on railway safety roles and responsibilities. On 05 September 2013, TC Rail Safety and various other stakeholders attended a meeting on railway emergency management hosted by the City of London to review and reinforce roles and responsibilities and brainstorm on proactive measures to promote railway safety. Similar meetings have been held in the City of Oshawa.

On November 7th, 2013, TC hosted a railway crossing blitz in the City of London with local police and CP Rail to continue to educate drivers and pedestrians on railway safety.

Canadian Pacific Railway

CP has committed to give Operation Lifesaver (OL) presentations in all schools situated within 1 km of its property. Since this accident, CP police have delivered OL presentations in 13 schools within the London area, including the school attended by the victim in this accident. Additional presentations were planned during the fall of 2013.

Since 2011, CP police have entered into 27 agreements with municipal police agencies permitting these agencies to act as CP agents in the enforcement of crossing and trespassing laws on CP property. The agencies are briefed on railway safety and the procedures to be adopted when enforcing trespassing prohibitions on CP property. CP entered into such an agreement with the City of London Police in August 2013.

CP police have met with representatives of the City of London to review grade crossing safety and to raise awareness of the City’s role in respect of rail safety in general.

As of September 15th, 2013:
•CP police have laid 43 trespass charges in the City of London.
•Joint enforcement operations with the City of London Police at grade crossings have resulted in 52 charges being laid in 2013. Additional joint operations are planned for the future.

The TSB report can be found at:

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