The Transportation Safety Board of Canada (TSB) says a lack of communication was among the factors that may have led to the head-on collison of two CN freight trains west of Winnipeg.
Two locomotives and eight freight cars went off the tracks in January 2019, east of Portage la Prairie, Man.
The agency says a diesel fuel leak was detected at the time but it was contained.
TSB regional operations manager Rob Johnston said fatigue also played a role in the crash.
“The engineer was fatigued due to disrupted sleep periods during the two nights preceding the accident,” Johnston said.
“Fatigue management has been an issue of concern on the TSB watchlist since 2016. This increases the risk of a train collision or derailment to occur.”
In the incident, eight cars on a westward train derailed and one car was damaged but did not derail.
A train conductor on one of the trains suffered minor injuries.
TSB chair Kathy Fox said the chief recommendation is for a physical fail-safe train system to be installed on all key routes in the country.
“The safety issues highlighted through this investigation are not new,” Fox said.
“This accident highlights major issues in the rail industry in Canada, and reinforces what the TSB has been saying now for over two decades — that physical fail-safe train controls are vital to improving rail safety in Canada and avoiding future rail disasters.”
With files from The Canadian Press
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