Ontario failed to properly monitor railroad safety in 2019 when pregnant mother, 6-year-old, was hit by a train: TSB

An investigation by the Transportation Safety Board of Canada into an incident involving a GO Transit train that struck and seriously injured a pregnant woman and six-year-old child in Kitchener in 2019 has found that the Ontario Department of Transportation lacks effective safety oversight of the province offers regulated railroads.
In its report released Thursday, the TSB said the department has no overall provincial regulatory framework and relies on inspection agreements with Transport Canada (TC) and Metrolinx to help meet federal safety standards. The MTO also lacks employees with railway engineering knowledge, experience and expertise, the report said.
The findings come more than three years after the GO Transit train struck the woman and child at a Kitchener crossing, leaving them seriously injured. They were flown to a local hospital. The woman was discharged from the hospital in December 2019. The status of the child is not immediately known.
Metrolinx commuter trains, Via passenger trains and CN freight trains all operate at the junction, according to TSB.
The woman and child were hit on rails owned by Metrolinx, an Ontario government agency.
1 million passengers travel on GO trains every week
TSB Chair Kathy Fox told CBC News on Thursday that the Department of Transportation has not received inspection reports from Transport Canada because the Department does not have staff with the background to properly evaluate those reports.
“The [MTO] has the authority to direct Metrolinx, through its board of directors, to take certain mitigating actions,” Fox said.
“But the problem is that if MTO … doesn’t receive inspection reports from Transport Canada and doesn’t have the expertise or staff to verify or validate what they hear from TC and ensure Metrolinx takes the appropriate action, then there is a gap in supervision.
“For this reason, [MTO] cannot provide effective oversight of provincially regulated railroads in Ontario,” Fox added.
Approximately 337 kilometers of railroad tracks are owned by Metrolinx, which operates commuter trains and buses from GO Transit. GO Transit is the regional public transit service for the greater Toronto and Hamilton areas. According to the GO Transit website, around a million passengers ride GO trains every week.
MTO needs “appropriate regulatory framework”
Fox said while the MTO has the right to outsource inspections to Transport Canada inspectors, the department cannot outsource the responsibility for overseeing the safety of its railroads.
She said while Transport Canada inspectors can point out areas of non-compliance or standards, since the route is regulated by the MTO, they cannot compel Metrolinx to take action.
“Whoever carries out the inspections, even if it is a third party, MTO is still responsible for effective oversight and in order to do that they need a proper legal framework with rules covering safety-related provisions and the possibility to Taking enforcement action when those provisions are in place is disrespectful,” Fox said.
Since the 2019 incident, according to the TSB’s report, the MTO has “identified the need to update the regulatory framework for urban and regional rail services to better support the province’s growing rail network and diversity of operators.”
In January 2022, the Department updated its agreements with Transport Canada and Metrolinx and worked closely with Transport Canada to strengthen the Department’s accountability for Metrolinx and “verify that any non-compliances and deficiencies that may arise are adequately addressed.”
In an emailed statement to CBC News, an MTO spokeswoman said Transportation Secretary Caroline Mulroney had directed staff to conduct a review prior to the release of the TSB report to “strengthen oversight of railway safety in the province and to improve”.
“Actions taken so far include changing the process for receiving inspection reports and continuing to work with Metrolinx and communities to ensure safety at level crossings,” the spokesman said.
“As part of our ongoing work, MTO will continue to work closely with its agencies, including Metrolinx and the Ontario Northland Transportation Commission, to ensure the safety of our regulated railroads.”
CBC has reached out to Metrolinx via email but has not heard back at the time of publication.
Wife and child met in 2019
On November 13, 2019, the 30-year-old pregnant woman and six-year-old boy from Guelph suffered life-threatening injuries after they were struck by the westbound GO train trying to cross the city to the tracks the intersection of Lancaster Street and Victoria Street in Kitchener.
The boy is not related to the woman. She worked for BitKIDS Behavior Consulting, a center that provides autism therapy for children, and he was in her care at the time of the incident.
The intersection consists of two tracks running east and west, and is owned by Metrolinx, according to the report.
Metrolinx officials said staff were notified just before 3:00 p.m. ET that two people had been hit by a GO train out of Guelph.
The woman was later charged by regional police in December 2019 for “failing to yield to railroad equipment at a road junction.”
At that time, the level crossing had crossing signs, flashing lights, bells and gates. It is also designated as an anti-whistle crossing, meaning trains are not allowed to honk on approach, the TSB said.
The TSB added that there were no pedestrian gates to protect pedestrians or alternative warning devices to warn them of a second train coming at the time of the accident.
The report also found that MTO, CN, Metrolinx and the Waterloo area were unaware of the dangers at the Kitchener Junction.
During its investigation, the TSB found that Metrolinx had installed two east-facing cameras facing the gates in June 2020. Officials reviewed footage taken between 4 a.m. and 11 p.m. between June 23 and June 29 and found that the intersection’s warning devices were triggered 195 times. 129 of them with CN freight trains or shunting orders.
Of those 129 times, in 17 incidents, vehicles, pedestrians and cyclists were delayed by more than five minutes, in violation of level crossing regulations, the TSB said. On three occasions the delays were longer than 10 minutes, with 18 minutes being recorded as the longest delay.
Reviewing the footage, Metrolinx also found that pedestrians and cyclists entered the intersection while the intersection arms (also called intersection gates) were down nearly 25 percent of the time.
Since 2019, Metrolinx has installed additional safety measures at the Kitchener level crossing, as well as additional signs warning of a second train.
Metrolinx also reduced the speed for GO trains to go through the crossing from 48 km/h to 24 km/h and has instructed crews to sound their horns when a second train is near the crossing.