Human error almost led to ‘catastrophic’ 2024 crash involving 2 GO Trains, TSB calls for bolstered safeguards

The Transportation Safety Board of Canada (TSB) says human error was behind a potentially “catastrophic” collision between two commuter GO Trains two years ago in Burlington, and it’s calling for bolstered safeguards to prevent similar incidents in the future.

The TSB released its investigation Wednesday into the near-collision on March 14, 2024.

The incident occurred when a train departed from Aldershot station, passing a signal displaying a Stop indication. The train then continued through a switch and entered a track occupied by another GO Train travelling in the opposite direction.

Crews managed to stop both trains, but not before they came approximately 549 feet from crashing head-on.

The two trains carried around 400 passengers.

“In this occurrence, a catastrophic collision involving 400 passengers was narrowly averted,” Chair of the TSB, Yoan Marier, said in a release.

Marier said the incident underscores “the need for physical fail-safe train controls that can intervene when signal indications are not followed.

“For more than 25 years, we have been calling on industry and regulators to expedite the implementation of physical fail-safe train control systems and put strong interim measures in place while these systems are being developed and installed.”

The investigation pointed out how errors in judgement and simple distractions can lead to potential tragedies.

“The investigation found that, based on past experience, the crew departing Aldershot station expected the opposing train to have already passed and that the signal would be permissive. During departure preparations, the conductor was focused on his tablet while the locomotive engineer was dealing with equipment issues in the cab, diverting attention from the signal. As a result, they did not observe the Stop indication.”

The TSB says the incident was not a one-off, and notes that it has investigated eight separate similar incidents across Canada since 2023 involving signal indications not being followed.

The TSB says the sheer number of near collisions demonstrates “the limits of administrative defences that rely on consistent human compliance.”

The TSB suggests physical fail-safe systems, such as positive train control (PTC) that automatically slow or stop a train when crews do not respond to signals.

“PTC has been fully implemented in the United States since 2020 on high-hazard routes, including those operated by Canadian National and Canadian Pacific Railway Company.”

Metrolinx responds to report

In a statement, Metrolinx told CityNews it is continually working with French rail company Alstom to assure safe practices.

Alstom is contracted to operate and maintain rail infrastructure and vehicles for Metrolinx, including track signalling.

“When an incident like this occurs, we work directly and immediately with Alstom to ensure that appropriate steps are taken to hold employees responsible and to reinforce training and safety procedures with everyone,” Metrolinx said.

“Following the 2024 incident, Metrolinx and Alstom have advanced a broad set of long term and interim actions designed to address human factors, procedural, and systemic contributors identified in the Transport Safety Board’s investigation report.

“Metrolinx and the Ministry of Transportation regularly review safety performance and incidents, while Metrolinx continues to meet all TSB reporting obligations and proactively share information with federal regulators.”

More broadly, the TSB says it has been urging Transport Canada to adopt its recommendations since 2000 and finds its response “unsatisfactory.”

“Since 2000, the TSB has issued three recommendations calling for such protections, most recently Recommendation R22-04, which urged Transport Canada to expedite implementation on high-speed corridors and key routes.

“While Transport Canada has cited progress, including proposed regulations targeted for 2026 or 2027 and interim measures, the TSB has assessed the response as Unsatisfactory, noting that meaningful risk reduction is unlikely before 2030.”