The Transportation Safety Board of Canada (TSB) March 31 released its investigation report (R19C0015) into the 2019 derailment of two CP Rail locomotives and 99 cars of a 112 car grain train, in which the three crew members were fatally injured near Field.

As a result of the investigation, the TSB has issued three recommendations to make cold-weather train operations safer through mountainous territory.

The Board recommends that Transport Canada (TC):

• establish enhanced test standards and requirements for time-based maintenance of brake cylinders on freight cars operating on steep descending grades in cold ambient temperatures. (TSB Recommendation R22-01)
• require Canadian freight railways to develop and implement a schedule for the installation of automatic parking brakes on freight cars, prioritizing the retrofit of cars used in bulk commodity unit trains in mountain grade territory. (TSB Recommendation R22-02)
• require Canadian Pacific Railway Company (CP) to demonstrate that its safety management system can effectively identify hazards arising from operations using all available information, including employee hazard reports and data trends; assess the associated risks; and implement mitigation measures and validate that they are effective. (TSB Recommendation R22-03)

“This tragic accident demonstrates, once again, that uncontrolled movements of rolling stock continue to pose a significant safety risk to railway operations in Canada,” said TSB Chair Kathy Fox. “It is obvious that more must be done to reduce the risks to railway employees and the Canadian public, reduce preventable loss of life, and increase the safety and resilience of this vital part of the Canadian supply chain.”

The investigation findings also reflect the TSB’s ongoing concerns about unplanned/uncontrolled movements of rail equipment and safety management, both of which are issues on the TSB Watchlist.

The occurrence as per Transportation Safety Board of Canada

On February 3, 2019, a CP unit grain train with 112 loaded hopper cars was travelling from Calgary, AB to Vancouver, B.C. While descending the steep 13.5-mile-long Field Hill, the inbound train crew was not able to maintain the required speed and applied the brakes in emergency, bringing the train to a stop at 9:49 p.m.

The brake cylinder pressure retaining valves were set on 84 cars to retain residual air pressure, which would facilitate getting the train underway again, allowing the air brakes to recharge as it continued its descent.

A relief crew was called in to replace the inbound crew as they were at the end of their shift. During this time, the train’s air brake system had been leaking brake cylinder pressure, reducing the capacity to keep the train stopped on the grade. Shortly after the relief crew took over, at 12:42 a.m. on February 4, the train began to creep forward and accelerate uncontrolled down the steep grade.

The train reached 53 mph, and was unable to negotiate a sharp curve, resulting in the derailment of two locomotives and 99 cars, and the three relief crew members being fatally injured.

Investigation findings

The investigation found that the brake cylinders on the freight cars were leaking compressed air, a situation made worse by their age and condition, and exposure to extreme cold temperatures over time. It was determined that after being stationary on the hill for around 3 hours, air leakage reached a critical threshold and the brakes could no longer hold the train on the steep grade.

The inbound locomotive engineer had observed indications of brake system anomalies. Although these were discussed with the trainmaster, they were not recognized as problematic. Additionally, because the situation was the first emergency stop, critical factors were not considered, and only the pressure retaining valves were applied, rather than the retaining valves and hand brakes. In this instance, the trainmaster’s training and experience did not adequately prepare him to evaluate the circumstances or to make the decision he was tasked with.

The TSB also issued three Rail Safety Advisories to communicate safety critical information to Transport Canada as the investigation was unfolding. Those advisories urged Transport Canada to address the following deficiencies:

• the adequacy of braking performance of grain cars in CP’s fleet,
• residual risk for trains stopped in emergency on grades less than 1.8%,
• the need for an alternate approach to determine the effectiveness of freight car air brakes.

Following the occurrence, TC introduced several initiatives, and CP proceeded, among other things, to remove over 5,000 grain cars from service for repair. Safety actions taken by both parties are detailed in the investigation report.

See the investigation page for more information.

The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

Read: Rail transportation safety investigation report R19C0015

Transportation Safety Board of Canada photo and graphic

Transportation Safety Board of Canada

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