New documents disclose disturbing details

Chuck Strahl, Canada's minister responsible for rail safety

By Jack Locke

Newly disclosed documents shed more light on the Turcot Train Tragedy and the VIA Rail train that hit three young men in Montreal at 3 A.M., Oct. 31, 2010. Not very pleasant light.

The bundle of documents reveal the Transportation Safety Board of Canada(TSB), Canadian National Railways Ltd.(CN), Transport Canada, and VIA Rail all repeatedly call the 3 dead youths, Dylan Ford, Mitchell Bracken-Guenet, and Ricardo Conesa, “trespassers.”

The various event reports place blame for the incident almost instantly upon the dead teens and nothing in the documents suggest any responsibility for the deaths be placed on the shoulders of VIA Rail. The lack of questioning in the documents by various investigators is remarkable.

A CN Incident Report written at 4:58 A.M, Oct. 31—the morning of the incident—shows this clearly.

“P66831-30 proceeding eastward at 70 mph on south track at mile 4.7 Montréal sub(subdivision), hit 3 trespassers walking between the rails. Never moved. 3 fatalities.”

Never moved.

The author of the incident report does not question why they never moved.

The document confirms a surviving witness’s story that the youngsters were given no warning by the train. This raises at least three important questions.

Was the train being driven with due care and attention? Were existing safety devices operating? Was VIA’s safety management system adequate?

Without further information, these questions cannot currently be positively answered. But it is becoming apparent that there was a major failure by VIA Rail. VIA has decided to withhold requested information.

According to one document, believed to be a VIA Rail accident summary form, the author suggests the incident occurred in the Turcot Tunnel and repeats placing blame on the teens.

“Train struck and fatally(word missing) 3 male trespassers aged 17-19 in tunnel. 2 other trespassers were not injured.”

Another important part of the report discloses an area that requires greater investigation.

In the report a box titled, CauseCodeCategory, lists a rather inspecific answer.

“MISCELLANEOUS CAUSES NOT OTHERWISE LISTED,” reads the form.

The detail about the location of the impact is contradicted in an Oct. 31 email from Transport Canada investigator Sal Pizzanelli to his colleague.

Pizzanelli identifies the location of the tragedy at 500 feet west of the tunnel.

“It was clear that the south most track had paint strewn along the track for about 150 paces or 500 feet from the west right up to the entrance of the tunnel.

“This clearly meant that the impact was at that point as the officers indicated that the 5 boys were walking from the west towards the tunnel but were hit before. The ties for a distace(sic) of 300 to 400 feet indicate that something was dragged over it. There is at least one 20 litre can of paint along the ditch and other stuff I cannot mention here.”

Regardless whether the young men were carrying paint or other stuff, regardless of whether the young men were trespassing or working for the railway, it is unacceptable for three people to be killed by a train.

The investigation continues.

Investigation: Initial summary findings

by Jack Locke

File photo showing Turcot tunnel area where VIA train came to rest

1. The train that killed Dylan Ford, Mitchell Bracken-Guenet, and Ricardo Conesa on Oct. 31, 2010 was travelling at a high speed through the Turcot area of Montreal, estimated at 113 kilometres per hour(70 mph);

2. The five young men who were on, or near, the track received no warning of the train’s approach;

3. The engineer of a train driving at night with a headlamp and ditch lights should be able to see a man 800 feet ahead of the train. Travelling at 70 mph, this should have given the VIA engineer 8 seconds visual warning prior to impact;

4. The Montreal Police Service will not confirm whether or not the engineer of the train was tested for drugs or alcohol;

5. The Transportation Safety Board of Canada notes that 427 persons have been struck and killed by trains in the past five years. The calling of these people ¨trespassers” is inaccurate and is a matter that needs to be addressed by the TSB. They have investigated none of these deaths;

6. VIA Rail will not disclose any information regarding their investigation, nor will they disclose information recorded by the Locomotive Event Recorder(which records important train activity);

7. A gyrating light that allows greater awareness and visibility is not a required piece of equipment on Canadian trains.

8. VIA Rail has not assumed responsibility for the tragedy.

MORE DETAILS ARE FOUND IN BLOG ENTRIES BELOW

VIA Rail cover-up halts investigation

by Jack Locke

I don’t know how I am going to tell Dylan Ford’s mother.

Dylan was one of three boys killed by a VIA Rail train on Oct. 31, 2010 in Montreal.

My 12-part investigation has looked into many aspects of rail safety. I’ve spoken to a person who was aboard that fateful train. I’ve been in touch with a young man  who was inches from being killed himself. And I have been in regular communication with Jamie, Dylan’s mother.

Now, I must tell Jamie that I cannot answer why her son was killed because VIA Rail, a federal crown corporation, subject to the Access to Information Act, will not disclose information that is in their possession.

In the email below is VIA’s explanation. I am truly sorry Jamie and Dylan, Mitch and Ricardo.
– – – – – – – – – – – – – – – – – – – – – – – – – – –
from Elizabeth_Huart@viarail.ca
to “Jack J. Locke” <jjlocke1957@gmail.com>
date Fri, Jan 14, 2011 at 5:08 PM
subject Re: Please advise: VIA’s intentions

Dear Mr. Locke:

There is no doubt that the accident that took place on October 31 is extremely tragic and has affected many people, including the families and friends of the three young men who lost their lives.

Safety is of the utmost importance at VIA Rail which is why following any accident, all aspects are thoroughly investigated. The investigation following this incident allowed us to conclude that all train equipment and track warning systems were functioning properly, and that all rules and regulations were respected. No irregularities were found.

VIA offers its full cooperation to all other authorities that are involved in investigations of this type. These authorities include Transport Canada, the coroner, the local police, the owner of the property and VIA Rail.

It is not our policy to publicly release the kind of detailed information you requested. That being said, I trust you will find these explanations helpful and reassuring.

Sincerely,

***************************************************************
Elizabeth Huart, M. Adm
Conseillère, Relations avec les médias et les collectivités
Advisor, Media and Community Relations
VIA Rail Canada
3, Place Ville Marie, suite 500
Montréal, Québec H3B 2C9
Tel.: 514-871-6119
elizabeth_huart@viarail.ca
http://www.viarail.ca

A letter for listening, healing

In installment 10 of the investigation into the Turcot Train Tragedy, I have asked friend Rev. Jan Jorgensen for some advice on dealing with the trauma. Here’s what she writes:

Dear Jack,

I think one of the most healing things that can be done for people who have suffered trauma is to have a compassionate person simply listen to them tell their story. It probably won’t be coherent, most likely it will be painful to speak and painful to listen to — but part of the healing comes from speaking and being heard –
no platitudes, no judgment, just the kind of listening that makes the person feel like they are seen and heard and cared about.

People in fields that deal with loss and trauma may have developed coping stratagems
(Some grief counselors speak of “sterbs” “short term emotional release behaviours”… these could be drinking, running, watching intense movies or playing games that get the adrenaline going, shopping.)

But at the end of the day, the story will want to get out — and it helps if one is “heard”
heard and not misquoted,
heard and not misinterpreted,
heard and not told “It’s time to get on with your life…”

We need to give people time to grieve, to feel all of their emotions as hard as that is…

It doesn’t help anyone to hear: “I know how you feel” or “You’ll have to be brave.”
In the first instance, no one ever knows how another person feels, even if they have similar losses …
The second is useless because the person is probably being the bravest they’ve ever been.

Listening without pushing the traumatized person to speak and act according to the listener’s timetable or agenda is very important.

To help someone who has been traumatized one needs to reach into one’s heart and acknowledge the pain the other is in … and then just listen / and if they can not speak, to simply “be with” that other person.

One follows the cues of the other, if they need to make a joke – fine; if they need to cry – fine; if they are silent – fine.

One thing is absolutely essential in attending to those who are bereaved or traumatized and that is to be real — you can’t pretend compassion, you can’t pretend to listen as you think to yourself, I wish this person would get over it… you can’t drift off to think about how you are going to get home –
people can feel distraction, they can feel authenticity.

This is a time for heart to speak to heart.

I don’t know if this is helpful or not …

But this is what comes to mind on first reflection…

peace, Jack,

with love,
jan

Don’t ask, don’t know

In installment 9 of The Turcot Train Tragedy, the investigation asks whether alcohol played a role in the deaths of three teenagers killed by a VIA Rail train on Oct. 31, 2010 in the Turcot area of Montreal?

by Jack Locke

“Did the SPVM conduct drug and alcohol tests on the drivers of the VIA Rail train involved in the deaths of three young men on Oct. 31?” I asked Montreal Police Service media officer Raphael Bergeron by email.

It was not a pleasant question for me to ask. Maybe, not a question Bergeron was permitted to answer?

First, if the police did not fully determine the locomotive engineer’s status in relation to these substances, it would appear to me to be an improper investigation. Similarly, by not testing the engineer, the engineer may not gain the benefit from having proof of his state at the time of the incident.

Also, as Bergeron had previously said the police had closed their investigation and no charges would be laid, it appears that no incriminating evidence had been found.

The answer to my question came from Bergeron’s superior, Sergeant Ian Lafrenière—a somewhat inconclusive answer.

“If we had reason to believe, we would have done a test,” said Sgt. Lafrenière. He neither confirmed nor denied whether the police had conducted such tests. He did confirm that the police concluded the tragic event was an accident and therefore is a matter for the coroner.

In investigating why Dylan Ford, Mitchell Bracken-Guenet, and Ricardo Conesa were unable to avoid the three-hour-late, VIA Rail passenger train travelling at 113 kph, many possibilities must be explored in order to eliminate those details that played no part in the mishap.

“The law related to drunk driving for a car is the same that applies to other modes of transportation,” says Transport Canada’s Mélanie Quesnel in an email.

“Every one commits an offence who operates a motor vehicle or vessel or operates or assists in the operation of an aircraft or of railway equipment or has the care or control of a motor vehicle, vessel, aircraft or railway equipment, whether it is in motion or not, while the person’s ability to operate the vehicle, vessel, aircraft or railway equipment is impaired by alcohol or a drug,” states Canada’s Criminal Code.

Railway companies—such as Canadian National Railway(CN)—have identified workplace alcohol and drug problems as an area of serious concern.

“Possession, distribution or sale of beverage alcohol, and the use of any form of alcohol, is prohibited while on duty (including during breaks on or off CN property), on company business, or on company premises, including vehicles and equipment…In any situation where employees are to be tested with reasonable cause including after an accident or incident, they are prohibited from using alcohol within eight hours of the accident or incident, or until tested or advised that a test will not be necessary,” CN’s policy states.

This policy alludes to possible testing after an accident, but in no way makes testing mandatory following an accident. Transport Canada likewise does not insist on mandatory testing following an accident.

“Transport Canada does not require mandatory drug or alcohol testing after a rail accident,” writes Quesnel.

It’s a heavy responsibility to drive a train, whether it’s a VIA Rail train carrying passengers or a CN train consisting of 100 cars of toxic chemicals. The locomotive alone weighs about 118,000 kilograms(260,000 pounds.) It’s why there should be no tolerance for drug or alcohol use while working a train.

In CN’s 2009 Safety Management System guide they note alcohol and drug use is declining. But it is far from elimination.

“In 2008 in Canada, continued emphasis on the Alcohol and Drug Policy resulted in a 4% decrease in positive alcohol and drug tests in post accident/incident situations,” admits CN, now a privately-owned railway company.

Reaction time for locomotive engineers can mean the difference between a close call and a major catastrophe.

When VIA Rail’s engineer Don Blain in 1999 reacted to an improperly set rail switch, he had just 5 seconds to act. He warned an oncoming train to stop, shut his locomotive engine, and applied emergency brakes before perishing in the Thamesville, Ontario mishap (see Dec. 21 Lockeblog post, Eight seconds to Forever.)

An impaired engineer would not have had the ability to act as swiftly, as professionally, as Blain.

I emphasize, I am NOT suggesting drugs or alcohol were a factor in the Turcot train tragedy of Oct. 31 that took the lives of 3 Montreal-area teens. But until I have more information, this question must be asked. Unfortunately, asking does not guarantee an answer.

“As operating any motor vehicle while impaired falls under the Criminal Code of Canada, please contact local police for further information,” suggests Transport Canada’s Quesnel.

Police exchange

by Jack Locke

Had a nice conversation yesterday with Sergeant Ian Lafrenière of the Montreal Police Service(Service de police de la ville de Montréal) media relations division.

He expressed concern over what I had written in the LOCKEBLOG post of Dec. 18. I had concerns also, for different reasons.

I’m glad we talked.