Transportation Safety Board finds employees were not following protocols when conductor died

Yoan Morneau, right, with his girlfriend, Catherine Magny

MONTREAL — On Jan. 6, CN Rail assistant conductor Yoan Morneau was performing "switching operations" at the Pointe-Saint-Charles railyard in Montreal when he lost his grip while standing on a ladder attached to the train.

Morneau fell onto the track and was run over by another train that was backing up.

Now, an investigation by the Transportation Safety Board of Canada (TSB) found the worker was riding on the ladder against protocol when he fell and the train should have stopped before entering a tunnel to allow him to get off.

"The train did not stop before entering the tunnel to allow the assistant conductor to get off the car and walk through the tunnel, even though this was required by regulations," the TSB wrote in its report.

It continues: "To ride the car through the tunnel and avoid being in the space between the side ladder of the car and the concrete wall, the assistant conductor repositioned himself on the end ladder of the leading car. This repositioning on the end ladder was contrary to CN’s instruction, which stipulates that personnel riding equipment must use the side ladder."

He was reportedly on the ladder after a bout of freezing rain.

The TSB says using the side ladder is required as employees are able to get off the car more easily in case of emergency.

When the locomotive engineer (LE) applied the independent brake, the resulting reverberations caused Morneau to lose his grip and fall.

"This rapid stop suddenly pulled on the train car couplers, the force of which spread to the leading car," the report notes. "The assistant conductor, who was still holding onto the ladder at the end of this car, lost his grip and fell on the track in front of the car before the train stopped. The assistant conductor was fatally injured."

Morneau also used his personal cell phone to communicate with the rail traffic controller which is "contrary to regulations," the report states.

Following the fatal fall, CN issued a circular to employees warning about the effects of using the independent brake, safety rules for riding equipment and communication between peers, and "the importance of remaining vigilant to protect oneself against sudden movements and shocks caused by slack action."

Transport Canada also sent CN a letter of non-compliance related to rules on employees riding equipment and "raised concerns about non-conformities with CN special instructions."